On Jan. 16, 2014, ACEP released the latest version of its National Report Card on the State of Emergency Medicine. The report rates both the nation and individual states in five areas:
- Access to Emergency Care
- Quality & Patient Safety Environment
- Medical Liability Environment
- Public Health & Injury Prevention
- Disaster Preparedness
In its last report released in 2009, ACEP gave the nation an overall grade of C-. In 2014, we earned a D+.
Both reports identified Access to Emergency Care as the area of greatest need. (In fact, the nation earned a D- in this area in both 2009 and 2014.) The access grade evaluates:
- Availability of providers
- Availability of treatment centers
- Financial barriers
- Hospital capacity
Access is the highest-weighted of the five categories, accounting for 40 percent of the overall grade.
So is it true that we've made virtually no progress at improving the average person’s access to emergency care? As someone involved in healthcare advocacy, I'd have to agree that we haven't made a whole lot of progress. I do feel we've done a good job defining some real quantitative measures of access. But there's been relatively little political, regulatory or legislative movement to use these measures to guide policy.
Here's a close-to-home-example: in 2009, ACEP scored my state, California, 51st of 51 in the access category. The following year, CAL/ACEP sponsored a bill requiring emergency departments to assess crowding every four to six hours and implement certain interventions at each stage of overcrowding. The bill was introduced three times in a row, and each time it died in the state legislature. Hence the state missed an opportunity to reduce crowding and improve the virtual capacity of its emergency care system despite support from emergency providers.
This is especially unfortunate, because here in California, improving operational efficiency is one of the few ways emergency departments can realistically increase capacity. The cost of expanding our physical facilities is generally prohibitive.
Instead of pursuing meaningful solutions, politicians have instead focused on the idea that EDs are over-utilized — especially by Medicaid patients. (In fact, CMS released an informational bulletin on the subject refuting the politicians' statements on the same day ACEP released its report.)
This idea persists despite stark evidence to the contrary. Thomas J. Sugarman, president of CAL/ACEP, has written in depth about the "myth of the preventable emergency room visit." And a 2012 research brief by the Center for Studying Health System Change found that just 10 percent of emergency room visits by California Medicaid patients were for non-urgent symptoms. That's very low when you consider that Medi-Cal (California's Medicaid system) pays just $14 for an office visit, and that few primary care doctors can afford to see Medicaid patients at those rates.
So where do we go from here? Rather than focusing on keeping "non-emergent" patients out of the emergency room, I think we need to turn our attention to two crucial areas:
1. Increasing ED capacity. Rates of emergency room use are growing twice as fast as the population as a whole. But while having more EDs and more ED beds would be ideal, this simply isn’t possible in many parts of the country.
Instead, hospitals need to maximize their operational efficiency. About 80 percent of emergency room patients are discharged to home, so creating systems that decrease length of stay (LOS) and turnaround time to discharge is one way to create virtual capacity. If you can reduce your ED's LOS by 12 or 13 percent, it's the equivalent of increasing your bed capacity by 10 percent.
2. Improving access to specialists. People will always have access to emergency physicians. But while an EM physician in a trauma center can do a lot of stuff, he or she can't take a patient to the operating room and evacuate a subdural hematoma on the brain. We rely upon our backup specialist panel — a neurosurgeon in this case — to provide the full spectrum of life-saving care.
In order to have an adequate number of backup specialists available to America's EDs, we first need to train them. Unfortunately, there's been a move in the opposite direction, especially at the federal level. Funding for graduate medical education has been cut. There's also been a lot of talk about training more primary care providers, though we haven't yet seen funds shift in that direction.
Do we need more primary care physicians? Certainly. But I think the critical shortages in many specialties also need to be acknowledged. For example, right now in California, there are more hospitals with an ED that needs neurosurgical backup than there are neurosurgeons in the entire state. It's pretty frightening, and unfortunately, it's not unique to the specialty.
So what needs to happen? One option might be to regionalize our specialty care, so that in a closed healthcare ecosystem, one hospital would provide cardiac care, one hospital would specialize in orthopedic cases and so on. This would relieve some of the burden of having a complete call panel for every single hospital emergency department in the country.
In a lot of ways, I think ACEP's near-failing "access" grade represents a cry for help. Individual emergency departments can have some impact on access by making operational improvements. However, EM physicians have no direct control over graduate medical education funding. Nor do we enact tort reform laws that would attract high-risk specialties to our area and allow them to stay in practice. We need help. We need our lawmakers — and the public who elects them — to listen.