The American College of Emergency Physician’s has released the National Report Card on the State of Emergency Medicine . Overall this report ranked California as the best in the nation, earning an overall B grade for the laws and policies that support emergency medicine.
However, those of us who work in Emergency Departments throughout the state know that the report is misleading and may give legislators and the public a false sense of security. Although California ’s overall grade was buoyed by the A+ it earned in the Public Health and Injury Prevention category and for its relatively positive Medical Liability Environment; in the most important category, Access to Emergency Care, this report card revealed serious problems in California ’s health care safety net.
The true test of the State of Emergency Medicine for the citizens of California is:
“Can they obtain access, quality care and physician specialty assistance during a medical emergency?”
In regard to these critical indicators California did very poorly and is headed in the wrong direction:
· Our state ranked last in the nation (51st after all states and the District of Columbia ) for the number of emergency rooms per million people. The closing of 70 emergency departments in California in the last 10 years has markedly exacerbated this problem. This has lead to longer waits, increased crowding and ambulances being diverted to more distant hospitals when the closest ones can no longer accept more patients.
· California ’s nursing shortage is so severe that we were ranked 50 out of the 51 states and Districts that were surveyed. Without enough nurses our system is crippled. It delays emergency care and also delays admissions into the hospital. Many inpatient wards are closed throughout California because there are not enough nurses to care for admitted patients.
· California ranked 46th out of 51 in staffed hospital beds. This has lead to what we call ‘boarding’. This term means that admitted patients are kept in the ED for hours and even days, leaving fewer functioning ED treatment areas to care for emergencies. This leads to GRIDLOCK in our Emergency Departments.
· Waiting times and ambulance diversions have skyrocketed in recent years. The report card was unable to measure these symptoms of our overcrowded and overwhelmed emergency systems.
· The system is woefully under-funded. A 2001 Kaiser Foundation study determined that California ranked last in the country on spending per MediCal beneficiary. California spends less than $2500 per beneficiary per year as compared to the national average of over $4,000. This year, MediCal reimbursement rates fell another 5% and Medicare instituted a 4.5% rate reduction as well.
· California has more than 7 million uninsured patients. Fewer employers are offering health insurance and not all poor patients qualify for the MediCal program. The net result is that 20% of Californians are without health care benefits and these patients have little option but to seek their healthcare through Emergency Departments. This undermines the financial viability of the emergency care safety net.
· On call panels are deteriorating. Many physician specialists that we rely on to provide comprehensive care are no longer willing to be on-call for our emergency departments because they are are not fairly reimbursed for these services by either the health plans or by Medi-Cal. This year in Los Angeles County the Maddy EMS Fund (which on average pays about 17% of the provider’s fee for some uninsured patients) ran out of money after 9 months and for the rest of the year no emergency care providers were compensated from this Fund. Without adequate reimbursement these specialists will not be willing to perform this service on a moment’s notice 24 hours a day, 365 days a year.
· Emergency Care providers are leaving California . Because of the poor reimbursement rates, there is a net exodus of qualified emergency physicians and new Emergency Medicine resident graduates leaving the State for better pay and a lower cost of living.
The untold story behind the ACEP national report card is that California ’s emergency care safety net is a system in peril and in danger of a total collapse.
Had ACEP’s report card been issued fifteen years ago, California would likely have scored in the top of the country in all four categories, but in the area of access to care and patient safety we have slipped considerably. Particularly at risk are our inner city and rural communities where the unraveling of the emergency care safety net threatens all of us. We have a serious challenge ahead, and we must:
· address the shortage of nurses and hospital beds
· reverse the trend in closures of California ’s emergency departments
· diminish waiting times and ambulance diversion hours by increasing the capacity of our overwhelmed emergency system.
· ensure that MediCal reimbursement covers the costs of providing emergency care
· provide additional State support for the Maddy EMS Fund which provides at least some reimbursement for emergency care for the uninsured
· promote and stabilize our deteriorating call panel for specialists that complete the comprehensive care which commences in emergency departments.
On January 5, 2006 in his ‘State of the State Address’, Governor Schwarzenegger predicted that California ’s population will increase by 30% over the next 20 years.
California ’s healthcare infrastructure, like our roads and schools, is aged and overwhelmed. We cannot keep up with the current needs within our emergency healthcare system, never mind taking care of 30% more patients. Just as the Governor provided the wisdom, insight, and vision to begin the process of augmenting California ’s infrastructure, so must we begin the process to plan for an enhanced and more comprehensive emergency care delivery system to ensure prompt access and quality emergency care services for all of its citizens.
We urge the residents of California to visit www.acep.org and tell our state policymakers to protect their access to lifesaving emergency care.
