Category Grades
23C 22C-
Access to Emergency Care:
18C 6C+
Quality/Patient Safety:
27C 20C+
Medical Liability:
22C 45F
Public Health/ Injury Prevention:
42D- 46F
Disaster Preparedness:
18B 8B-

Missouri has a strong Disaster Preparedness system with plans, policies, and facilities in place for an effective disaster response and above-average Access to Emergency Care. However, the state also has a challenging Medical Liability Environment, worrisome chronic disease risk factors, and high rates of preventable deaths.

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Missouri has worked to improve its already strong Disaster Preparedness by instituting a statewide patient-tracking system and including patients dependent on dialysis in its medical response plan. These and other policies and procedures help ensure that the medically vulnerable are cared for in the event of a disaster and that disaster data are tracked and monitored to ensure a quick and nimble state response. Missouri also has high per capita rates of burn unit beds (13.1 per 1 million people) and intensive care unit beds (372.3 per 1 million people). The state has a demonstrated commitment to training, with an above-average number of drills and exercises conducted with hospitals. Missouri has the second highest rate of behavioral health professionals registered in the Emergency System for Advance Registration of Volunteer Health Professionals (74.6 per 1 million people) and is among the top 10 states for physicians and nurses registered, as well.

Missouri ranks sixth in the nation for Access to Emergency Care. An overall strong health care workforce bolsters this grade, with above-average per capita rates of many types of specialists. Missouri also has adequate hospital capacity, with high per capita rates of staffed inpatient beds (366.1 per 1 million people) and psychiatric care beds (52.6 per 1 million people). The state also has above-average rates of accredited chest pain centers, level I and II trauma centers, and emergency departments. Although Missouri's Medicaid fee levels for office visits need attention, at only 76.8% of the national average, they are at least trending in the right direction, with a 14.4% increase since 2007.


Missouri has fallen in the Medical Liability Environment rankings. Missouri's $350,000 cap on non-economic damages was struck down by the state Supreme Court in 2012, eliminating a key protection for health care providers in a state where the average malpractice award payments are almost $130,000 higher than the national average. The state's medical liability insurance premiums for physicians are also higher than average. In addition, Missouri has few other protections in place for its health care providers. It does not provide for pretrial screening panels, which can help prevent frivolous lawsuits, and does not have rules requiring expert witnesses in medical liability cases to practice in the same specialty as the defendant or to be licensed to practice medicine in the state.

Missouri faces several challenges in Public Health and Injury Prevention. The state has one of the lowest rates of funding for injury prevention ($13.36 per 1,000 people) in the nation, which may be reflected in higher-than-average preventable death rates in several areas, including homicides and suicides, traffic fatalities, poisoning-related deaths (which include drug overdoses), and fire- and burn-related deaths. Adults in Missouri have high rates of cigarette smoking (25.0%) and are more likely to be obese (30.3%) than adults in most states. Although Missouri's infant mortality rate is only slightly higher than average (6.6 deaths per 1,000 live births), the state has one of the highest infant mortality disparity ratios in the nation, with the non-Hispanic Black infant mortality rate being 3.6 times greater than that of the racial or ethnic group with the lowest rate.


Missouri must work to implement medical liability reforms to hold back rising medical liability insurance premiums that could jeopardize access to care. One important reform would be the implementation of additional liability protection for care mandated by the Emergency Medical Treatment and Labor Act, which is aimed at reducing the burden on emergency providers who serve high-risk patients, often with little or no knowledge of their medical histories. Given the loss of the medical liability cap, this reform would be an important step toward improving the state's liability climate, potentially encouraging more on-call specialists to provide services to the emergency department.

Missouri should work to discourage risky behaviors that can lead to preventable disease and injury. Distracted driving legislation and stronger enforcement of child safety belt and seatbelt laws could help reduce traffic fatalities. Passage of smoke-free legislation for restaurants, bars, and workplaces could help prevent secondhand smoke exposure and encourage current smokers to quit.

Despite high scores in Access to Emergency Care, Missouri falls behind with regard to financial barriers to care and has a shortage of primary care providers. In addition to low Medicaid reimbursement rates, it ranks among the 10 worst for the proportion of children with no health insurance (11.5%). Missouri should work to address these issues to ensure that the state's low-income and child populations can access the care that they need.

Access to Emergency Care

Title 2009
Report Card
Report Card
Board-certified emergency physicians per 100,000 pop 7.1 8.3
Emergency physicians per 100,000 pop 11.1 13
Neurosurgeons per 100,000 pop 2.2 2.4
Orthopedists and hand surgeon specialists per 100,000 pop 9.3 9.8
Plastic surgeons per 100,000 pop 2.3 2.6
ENT specialists per 100,000 pop 3.5 3.8
Registered nurses per 100,000 pop 964.3 1,125.5
Percent of children able to see provider 96.7
Level I or II trauma centers per 1M pop 3.1 2.7
Percent of population within 60 minutes of Level I or II trauma center 83.8 89.6
Accredited chest pain centers per 1M pop 2.7 3.3
Percent of population with an unmet need for substance abuse treatment 9.2 8.9
Pediatric specialty centers per 1M pop 3.1 3.3
Medicaid fee levels for office visits as a percent of the national average 82.5 76.8
Percent change in Medicaid fees for office visits (2004-05 to 2007/2007 to 2012) 18 14.4
Percent of adults with no health insurance 14.6 15.9
Percent of adults underinsured 7.8
Percent of children with no health insurance 9.1 11.5
Percent of children underinsured 17.8
Percent of adults with Medicaid 6 9.7
Hospital closures in 2006/2011 0 0
Staffed inpatient beds per 100,000 pop 387.8 366.1
Hospital occupancy rate per 100 staffed beds 64.9 63.3
Psychiatric care beds per 100,000 pop 54.6 52.6
Median time from ED arrival to ED departure for admitted ED patients 239
State collects data on diversion YES YES

Disaster Preparedness

Title 2009
Report Card
Report Card
Per capita federal disaster preparedness funds $9.72 $5.22
State budget line item health care surge NO
ESF-8 plan is shared with all EMS and essential hospital personnel NR NO
Emergency physician input into the state planning process YES, YES YES
Public health and emergency physician input during an ESF-8 response YES
Drills, exercises conducted involving hospital personnel, equipment, or facilities per hospital
Accredited by the Emergency Management Accreditation Program (EMAP) YES, ACCREDITED YES
Special needs patients included in medical response plan YES YES
Patients dependent on medication for chronic conditions in medical response plan YES YES
Medical response plan for supplying dialysis NO YES
Mental health patients included in medical response plan YES
Medical response plan for supplying psychotropic medications YES
Mutual aid agreements in place with behavioral health providers STATE LEVEL
State requires long-term care and nursing home facilities to have a written disaster plan YES
State able to report number of exercises involving long-term care facilities or nursing YES
Just-in-time training systems in place STATEWIDE COUNTY OR CITYWIDE
Statewide medical communication system with one layer of redundancy YES YES
Statewide patient tracking system NO YES
Statewide real-time or near real-time syndromic surveillance system YES YES
Real-time surveillance system in place for common ED presentations YES YES, STATEWIDE
Bed surge capacity per 1M pop NR 359.7
ICU beds per 1M pop 377.2 372.3
Burn unit beds per 1M pop 14.3 13.1
Verified burn centers per 1M pop 0 0
Physicians registered in ESAR-VHP per 1M pop 0 65.1
Nurses registered in ESAR-VHP per 1M pop 425.3 616.4
Behavioral health professionals registered in ESAR-VHP per 1M pop 74.6
Strike teams or medical assistance teams YES YES
Disaster training required for essential hospital/EMS personnel YES, YES NO
Percent of RNs that received emergency training 38.4 40.8

Medical Liability Environment

Title 2009
Report Card
Report Card
Lawyers per 10,000 pop 16.2 17.2
Lawyers per physician 0.6 0.6
Lawyers per emergency physician 14.5 13.2
ATRA judicial hellholes (2009 range 0 to -7/2014 range 2 to -6) -1 0
Malpractice award payments per 100,000 pop 1.4 2.8
Average malpractice award payments $255,805 $435,588
National Practitioner Databank reports per 1,000 physicians 19.7 28.1
Apology laws: Apology is inadmissible as evidence in a court of law YES
State has implemented a patient compensation fund NO NO
Number of insurers writing medical liability policies per 1,000 physicians 5 5.4
Average medical liability insurance premiums for primary care physicians $19,765 $15,688
Average medical liability insurance premiums for specialists $91,838 $56,001
Presence of pretrial screening panels NONE NO
Pretrial screening panel's findings admissible as evidence N/A N/A
Periodic payments are: required, granted upon request, at court's discretion UPON REQUEST OR AGREEMENT OF PARTY(IES) UPON REQUEST
Medical liability cap on non-economic damages $250,001-350,000 NONE
Additional liability protection for EMTALA-mandated emergency care NO NO
Joint and several liability abolished PARTIALLY PARTIALLY
Collateral Source Rule/Provides for Awards to be Offset NO
State provides for case certification YES YES
Expert witness required to be of the same specialty as the defendant NO NO
Expert witness must be licensed to practice medicine in the state NO NO

Public Health & Injury Prevention

Title 2009
Report Card
Report Card
Bicyclist fatalities per 100,000 cyclists 3.4
Pedestrian fatalities per 100,000 pedestrians 5.9
Percent of traffic fatalities alcohol-related 46 38
Percent of front occupants using restraints 77.2 79
Child safety seat/seat belt legislation - score out of a possible 10 points 5 5
Helmet use required for all motorcylce riders YES YES
Distracted driving legislation score - out of a possible 4 points 0
Graduated drivers' licenses legislation score -out of a possible 5 points 0
Percentage of children aged 19-35 months who are immunized 85 72.7
Percentage of adults aged 65+ who rec’d an influenza vaccine in the last 12 mos 72.2 63.1
Percentage of adults aged 65+ who ever rec’d pneumococcal vaccine 67.8 71.7
Fatal occupational injuries per 1M workers 61.8 39.2
Homicides and suicides (non-motor vehicle)(per 100,000) 19.7 21.5
Unintentional fall-related fatal injuries (per 100,000) 8.7 10
Fire/burn related fatal injuries (per 100,000) 1.6 1.5
Rate of unintentional firearm-related fatal injuries (per 100,000) 0.4 0.3
Rate of unintentional poisoning-related deaths (per 100,000) 14.8
Total injury prevention funds per 1,000 persons $224.78 $13.36
Dedicated child injury prevention funding YES
Dedicate elderly injury prevention funding NO
Dedicated occupational injury prevention funding YES
Anti-smoking legislation score - score out of a possible 3 points 0
Infant mortality rate per 1,000 live births 7.5 6.6
Percentage of adults who binge drink 16.5 19.2
Percentage of adults who currently smoke 23.2 25
Percentage of adult population who are obese (BMI > 30.0) 27.2 30.3
Percentage of children who are obese 13.5
Cardiovascular disease disparity ratio 2.1
HIV diagnosis disparity ratio 8.8
Infant mortality disparity ratio 3.6

Quality & Patient Safety

Title 2009
Report Card
Report Card
Funding for quality improvement within the EMS system NO YES
Funded state EMS medical director YES YES
Emergency medicine residents per 1M pop 13.3 17.4
Adverse event reporting required NO NO
% of counties with Enhanced 911 capability 80.2 84.5
State has a uniform system for providing pre-arrival instructions NO YES
State uses CDC guidelines for state field triage protocols NO
State has or is working on a stroke system of care YES YES
State has triage and destination policy in place for stroke patients YES
State has or is working on a PCI network or a STEMI system of care YES YES
State has triage and destination policy in place for STEMI patients YES
State maintains statewide trauma registry YES YES
State has triage and destination policy in place for trauma patients YES
Prescription drug monitoring program score (range 0-4) 0
% of hospitals with computerized practitioner order entry 26.3 80.3
% of hospitals with electronic medical records 35.3 92
% of patients with AMI given PCI within 90 minutes of arrival 60 96
Median time to transfer to another facility for acute coronary intervention 74
% of patients with AMI who received aspirin within 24 hours 99
% of hospitals collecting data on race/ethnicity and primary language 85.8
% of hospitals with or planning to develop a diversity strategy or plan 61.9

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