DM: The American College of Emergency Physicians did – the national organization for which we all have state chapters. I think they had several goals in mind. This really was the first comprehensive report to assess the state of emergency care in the United States in some sort of objective way using data that was publicly available and collected uniformly in every state. Part of their mission was to get an idea of how states compare with each other and how the nation did as a whole, using various data elements. In a broader sense, their mission was not only to define the problem, but to focus it and help states with legislative advocacy issues, and to help foster solutions.

DM: Change happens slowly, and many of the changes are legislative changes, so doing a huge, expensive project like this annually is of less value. The articulated plans right now are to do it periodically. I’m sure they’ll wait to see what kind of progress is made after this report.

DM: It began with the convening of a group of experts – largely emergency physicians but also some epidemiology consultants – that designed a report card process. Their mission was to collect 50 data points from public databases uniformly in every state – things like the number of emergency departments per capita, number of board certified emergency physicians per capita, number of emergency medicine residents per capita, alcohol-related fatalities as a percentage of all traffic fatalities, helmet use required for motorcycle riders, fatal occupational injuries per capita. On the medical liability side, things like the presence or absence of caps on non-economic damages, expert witness rules. They put together a report card that had four basic elements and decided what each data point within those four elements weighed, then calculated a score for each element and assigned grades based upon falling within a particular range. The first element of the report card is access to emergency care and is worth 40 percent. The second part is quality and patient safety, worth 25 percent. Public health and injury prevention is the third element in the report card and is worth 10 percent. Medical liability environment is the fourth element and is worth 25 percent. The panel started by benchmarking the grades, deciding what would constitute an A based upon what they thought would represent a high quality state of emergency care. The highest state in the country actually got an overall grade of B. Nobody got an A and nobody got an F. There were several D’s and D-pluses. States were fairly evenly distributed between the B, C, and D grades.

DM: Part of the role of emergency medicine is to serve as a vital functioning part of the medical system’s safety net and the biggest part of this report card has to do with access to emergency care and quality/patient safety. The mission primarily was to measure how well the emergency medical system functions as that safety net. Much of ACEP’s mission is also directed, not only at providing care for patients who are injured or sick, but also at public health and injury prevention. Many of our state’s advocacy agenda items are in this report card – things in Pennsylvania like the primary seat belt enforcement law and motorcycle helmet law, which are part of the public health and injury prevention category. The medical liability piece of this report card is not really so much about whether physicians can afford to pay their premiums, but rather how the medical liability environment interferes with access to emergency services.

DM: Pennsylvania got a B-minus, which had us ranked seventh in the nation and that overall is a good thing. Pennsylvania scored higher than all of the surrounding states. New Jersey and Delaware, numerically, were probably not very far behind us – they got C-pluses. So, we did fairly well in comparison to other states. With regard to the four data elements, we actually scored an A for access to emergency care, higher than every other state except for the Washington, D.C. area. We scored high because, compared to other states, we have a high number of board-certified emergency physicians, a high number of staffed hospital beds per capita – those sorts of things. We also scored high in quality and patient safety – we have an A-minus there. Part of that grade has to do with the number of emergency medicine residents in the state, but also issues like percent of population with access to advanced life support, number of pre-hospital folks that have access to online medical command, and our state’s training for natural disasters, biological disasters and chemical attacks. So, we scored pretty well there, but I think what is important about this part of the report card is that, even though it looks like our access is good and our quality is good, the descriptors have to do with the number of resources that we have in our state. It’s a little bit incongruous to look at how well we scored here and then walk over to your local emergency department and see a full waiting room, to see patients sometimes lay in the hallway waiting to go up to their bed, or watch emergency physicians try to find obstetricians or neurosurgeons to care for these patients – even though we have all of this access. So, there’s a bit of a disconnect between what is in our state, what is available for our patients and what our patients can actually access.

DM: Because they’re not measured by anybody uniformly, and they’re not collected from state to state. The Hospital & Healthsystem Association of Pennsylvania has convened a medical advisory board to look at ED crowding and EMS diversion – I serve on that advisory panel. Even within our own state there’s no uniform reporting system for the wait time to be seen by a physician, the amount of crowding that’s present in the emergency department, how long it takes you to be admitted and go upstairs after the doctors in the ER have decided. I think that you’d rather be from a state that has the resources, because you then have at least the potential capacity to solve the problem, rather than a state that doesn’t have those resources. So you’re right, I think you can look at these things and intuit that just because the resources are there doesn’t necessarily mean that they’re well-accessed. That’s been an important part of our message: even though we scored high here, there are still issues attached to access.

DM: Probably it’s not easy to measure because of the various ways that people have decided to configure their practice. We have ob/gyns, but simply measuring that number doesn’t help if not all of them are actually delivering babies anymore. There are neurosurgeons that may have a robust practice but they won’t take call in the emergency department anymore. Just the aggregate numbers are difficult enough to measure. The report card didn’t actually measure that, but that’s a really important part of what makes access to emergency services difficult. The Emergency Treatment and Labor Act compels emergency physicians in a hospital to provide a medical screening examination and to determine whether there’s an emergency medical condition present. That law requires us to provide the patient whatever resources are necessary to conduct that medical screening exam. Whether or not we have specialists is critical to providing good care. If I can’t find a neurosurgeon, I can only go so far with the patient. If the patient needs to have surgery and there’s no surgeon in my county, I can’t get that care for the patient. That’s why the medical liability environment is important to emergency medicine, because when it is poor in the state, the specialists won’t take call, we can’t get residents to stay and continue to practice in our state and it ultimately impedes access to emergency care, since emergency care is really a coordinated effort between the folks in the ER and all the rest of specialists that are on call to support that care.

DM: The next section of the report card was public health and injury prevention, and we scored C-minus in that area. Some parts of that grade are a little more reassuring. We scored fairly well with the number of children age 19 to 35 months who are immunized, and the fraction of adults aged 65 or older that got flu vaccines is pretty good as well. But we have some automobile safety issues. Pennsylvania still does not have a law that allows the police to pull you over because you’re not wearing your seatbelt when that’s the only violation. The motorcycle helmet law, which was in place for many years in Pa., was repealed about 18 months ago. If you look at the National Highway Transportation Safety Administration data, the motorcycle crash fatality number actually was higher the year after the law was repealed. This part of the report card also has to do with things such as injury prevention, intimate partner violence, high-risk youth violence. It’s important to note that Pa. Health Secretary Calvin Johnson has placed these sorts of issues as an important part of the agenda in our state.

In the medical liability environment we got an F, which made us sixth from the bottom among states. Grade elements included lack of non-economic damage caps, medical liability insurance rate increases, and not scoring quite what we needed to for expert witness rules and pretrial screening panels. The elements together make up an environment, and when that practice environment is not good, then people won’t want to practice in Pennsylvania and we can’t provide good emergency care. There are certain issues here that are difficult for us to overcome. The medical liability environment of other specialists ultimately impacts on our capacity to provide good emergency care. When the medical liability environment has reduced the number of specialists that are available and I say to the patient, "Please call this number, make an appointment for a neurologist to follow-up about your headache," they may very well not get that appointment for six weeks or two months. So, the medical liability environment casts a long shadow over all of what we do in the emergency department, while having nothing necessarily to do with medical liability issues for emergency physicians in particular.

DM: We actually did get credit for some of those changes – they did make it into the report card. But we continue to have issues in our state related to the liability environment which need to be addressed. Some of the data in the report card is a year old and one of the things we want the governor to do is take a look at data that we can collect in our own state that might be more applicable than national databases.

DM: As I mentioned earlier, access is not really as available as you might like to think. If you look at the access piece, it’s all infrastructure measures – what we have in the state. A hospital has to have an emergency department that has to be available to take any patient regardless of their ability to pay. So in some very basic way, any patient, any citizen in the state can access the emergency department. It’s what happens when you get there: whether you can get in, whether you can get up if you’ve been admitted, whether we can recruit a specialist to see you – either in the emergency department or when you’re discharged from the department. That, combined with decreasing reimbursement rates for physicians, has done a lot to curtail the hours that primary care physicians are open to see their patients to address some of the chronic custodial issues that help keep people out of the ER, and to interfere with the coordinated care that we try to provide for the patient after we discharge them. Our particular role in the health care system is unique because all of the problems that can’t get solved in these other venues ultimately bring the patient to the ER because they know they can access the ER and walk in when they need care.

DM: The data we talked about already has limitations. It’s uniformly collected throughout the country and may not be reflective of what’s actually gone on in our state since it was collected. The state may have some additional data points which might better help us understand where our state really has strengths and weaknesses. We’d like to ask the governor to help us collect the data in a coordinated way and make our own report card for Pa. The second thing we’d like is for the governor to have a task force to help coordinate the approach to these problems. The Hospital Association of Pennsylvania is working on one piece of it, the Department of Health is working on another piece of it, the governor convened a task force to look at medical liability issues – but they’re not wrapped together to look at all those disparate issues and how they impact on emergency care. Emergency care in many ways has become an essential public service, meaning that it’s absolutely critical that the community has effective emergency services. This is a broader issue that transcends each one of those departmental or regulatory agency issues. They require effort on the regulatory side with The Department of Health. They require some legislative activity and we need the state legislature to pass primary seatbelt enforcement laws and reinstitute the motorcycle helmet law. We need to continue to focus liability issues to improve the practice environment for physicians in Pennsylvania.

The problem is complex – that’s one of the barriers. That sounds like an easy answer to give, but it really is part of the problem. Provision of emergency services in the commonwealth involves almost all aspects of the health care system, so addressing the problem isn’t something that’s easy to do because there’s no single solution to the problem. The second barrier is that it requires money to solve some of these problems. As reimbursement for physician and hospital services continues to decline, that further stretches the resources that we have even more thinly and makes it even more difficult for us to provide the emergency care that we can. And certainly, the medical liability environment is difficult for us to address because of the strong constituency that doesn’t necessarily agree with the physician’s perspective on medical liability issues.