The National Report Card on the State of Emergency Medicine

Earlier this year, the American College of Emergency Physicians (ACEP) released its first-ever National Report Card on the State of Emergency Medicine with the intention of bringing the critical issues confronting emergency care in the United States before the public eye.

The ACEP Report Card is an assessment of the support that each state provides for its emergency medicine system. The January 2006 report card is the first in a proposed series that the ACEP plans to issue, and it will serve as a baseline measure for comparison with future changes as data become available from state government offices.

It is hoped that the results of the ACEP Report Card will serve as a much-needed wake-up call to state legislators and the public that the system they depend on for life-saving emergency care is itself in critical condition.

For the first time, the public saw the support—or lack of support—provided by the states to their local emergency care systems. The ACEP Report Card analyzed 2500 data points, all directly related to the financial support provided by the individual states. This was the first definitive look at the entire range of issues confronting the provision of emergency care. Fifty objective and quantifiable criteria were used to measure the performance of each state and the District of Columbia. These measurements were weighted and aggregated, and grades were assigned based on comparison to the best state's performance (ie, a “sliding scale”).

Each state received an overall grade as well as individual grades in each of four specific categories. Recognizing that not all categories or criteria were of equal importance, the task force assigned weighted scores to reflect “real world” priorities:

• access to emergency care, 40%;

• quality and patient safety, 25%;

• public health and injury/crisis prevention, 10%; and

• medical liability environment, 25%.

It is important to note that these grades are not evaluations of the quality of care provided by emergency physicians, residency programs, or hospital emergency departments. Rather, the grades in the ACEP Report Card show the overall effort of states to support effective emergency medicine systems.

Local emergency departments are at the front line of a national healthcare crisis. They are increasingly crowded—often to the point that ambulances en route must be diverted to another hospital.^1,2 A key cause of emergency department crowding is the lack of staffed inpatient beds.^1,2 Another cause of crowding is the high cost of medical liability insurance, which has led some specialty physicians to leave the practice of medicine or to be less willing to be “on-call” for emergency situations, aggravating hospitals' difficulties in providing emergency care.³

The ACEP Report Card indicates that the national emergency healthcare system is in serious condition, with many states in critical condition. While no state received an overall failing grade, many have serious deficiencies, and almost all states have areas in which there is substantial room for improvement.

Currently, emergency care is this country's safety net for the entire healthcare system.² The growing number of uninsured citizens, the lack of participation in preventive health programs, and the relentless demographic shift that accompanies the baby-boom generation all contribute to the increasing burden on the emergency medicine system.^2,4,5

No state received an overall grade of A, and only California, Connecticut, Massachusetts, and Washington, DC, earned a solid B. A summary of the grades for the states with the highest number of hospitals accredited by the American Osteopathic Association (AOA) is provided in Table.

Clearly, in those states with the worst environment for medical liability reform, the effects of a low score for that portion of the formula (25%) would have a negative impact on the overall grade. Therefore, those states in which emergency departments have closed because medical specialists such as neurosurgeons, obstetricians, and orthopedists could not obtain medical liability insurance would be inclined toward lower overall scores than states with more reform-friendly environments. States with hospitals that do not have critical on-call specialists available because of a fear of lawsuits would be similarly affected.

The AOA, American Medical Association, and ACEP advocate several possible solutions to the crisis in emergency medicine, including:

• improving payments by health insurance payers,^6–8 including private insurance companies, Medicare and Medicaid, and

• federal medical liability reform,^6,9,10 including liability protections for physicians who provide patient care under the 1986 Emergency Medical Treatment and Active Labor Act.¹¹

It is important to remember that in each category of the ACEP Report Card, at least one state is doing an excellent job. These models can be analyzed and adapted to improve emergency care for all states.

Osteopathic physicians and their patients can use the ACEP Report Card's key results to help support existing advocacy efforts for legislative reform. In particular, I encourage emergency department physicians to invite their state legislators and members of Congress to visit their workplaces. A first-hand experience can be a powerful motivator for change. In addition, I encourage patients to contact their elected officials so that they may personally describe to them their poor experiences with the present state of the emergency medicine system in their communities.

This spring, the Institute of Medicine is planning to release a report on the future of the nation's emergency healthcare system (J.R. Hedges, MD, written communication, April 2006). I encourage readers to review information on this project, titled “The Future of Emergency Care in the United States Health System,” at: http://www.iom.edu/CMS/3809/16107.aspx. The upcoming report will provide another excellent opportunity for the medical community to advocate for policy changes to address the key issues confronting our emergency medicine system. All osteopathic emergency physicians and their patients should actively support legislative initiatives to improve the accessibility of emergency care, healthcare quality and patient safety, public health and injury prevention, and the medical liability environment.