The 2009 ACEP Report Card, What it Says, What it Means and What it Might Accomplish

Perception Versus Reality 

The purpose of the new report is not to shock or surprise emergency physicians. The point, rather, is to forcefully remind Americans–the general public, politicians and decisionmakers–that the country's emergency medicine system remains perilously close to collapse in a number of states, and in critical condition elsewhere.

“There's a great need for this because there's a real difference between the perception of medical care and what's really happening out there,” said Stephen Epstein, MD, chairman of the 2009 Report Card Task Force.

“For a lot of people, they assume that every emergency center looks like what they see on TV, in shows such as “ER.” Everyone gets admitted quickly. Everyone gets a bed. But that's just not reality. When patients get to an emergency department today they might board several hours, wait hours to see a physician, and there might be no beds available. What we're trying to do with this report is provide a dose of reality to the public about what's really going on in their emergency departments.”

The first report card was a “push effort” said its chair, Dr. Gardner, who is an assistant professor of emergency medicine at the University of Texas Medical Branch in Galveston. It was completed in just 13 months, created from scratch, and often relied upon simply determining the policy of a particular state, ie, does Pennsylvania have a helmet law? The new report moves beyond this philosophy of policy reporting to determine what the actual outcomes of state policies are.

“We think a much better question to ask is what percentage of your population wears a seatbelt,” said Dr. Epstein, an emergency physician at Beth Israel Deaconess Medical Center, Boston, MA, and an instructor in medicine at Harvard Medical School.

In the new report card the number of metrics to characterize the state of emergency medicine has roughly doubled, to 116. Yet because of the philosophical change only 14 of the metrics exactly match those of the first report.

A further significant difference is the addition of a fifth category–Disaster Preparedness–the necessity of which the authors say became readily apparent following Hurricane Katrina and other disasters in which emergency medicine played a primary role during recovery.

The change in metrics has upset the rankings of some states, the authors say. Notably, the state of California has seen its overall grade slip from a respectable B in 2006 to a D+ in the new report card. The new grade largely reflects the decline in Access to Emergency Care grade from a C to an F. According to the report, California has only 7.1 emergency departments (EDs) per 1 million people, compared to an average of 19.9 among US states.

“Access to Emergency Care in California suffers from a serious lack of specialists, registered nurses, primary care providers, and mental health providers,” the report says. “The state also fares poorly with regard to the number of medical facilities.”

Dr. Gardner said the new methodology also rendered clear some real contradictions, such as the fact that a number of states with large rural areas and very low access to trauma and neural centers, lack helmet laws. “Makes no sense at all,” she said.

She also wondered how states–7 of which allow fully one-quarter of their children to miss out on immunizations–can leave their youth unprotected from preventable diseases.

“I am shocked that as a nation our children and elderly populations are not immunized,” Dr. Gardner said. “It's practically free. It's available everywhere, and it just isn't done. That leads to illness and death that are completely preventable.”

This, needless to say, ultimately increases the patient load on EDs.

A Clear View 

As a result of the methodological changes the authors acknowledge it is not possible to directly compare the report findings from 2006 to now. But they say this fact is more than compensated for by the fact that the new report provides a much more comprehensive view of the state of emergency medicine.

“The greater detail is critically important for identifying where the many complex factors affecting the emergency health system and broader health care environment stand,” the new report states. “It is also important for better identifying gaps and needs as well as effective policies, areas of strength or promise, and innovative strategies.”

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Released in January 2006, the first ACEP report card generated widespread attention. More than 200 news reports were published, running the gamut from national newspapers to local TV stations reporting the grade for their individual state.

“The first report card made a significant imprint,” said Jon Mark Hirshon, MD, an associate professor at the University of Maryland School of Medicine's National Study Center for Trauma and EMS, and an author of the new report card.

The report delivered some policy results.

The 2006 report noted that Oklahoma was the most populous state without a residency program in allopathic emergency medicine, and in part for this reason gave the state an overall grade of D+. Largely because of the report card, University of Oklahoma Regents approved the establishment of a department of emergency medicine at the OU College of Medicine campus in Tulsa. Last July the $3 million residency program began at the Trauma Emergency Center of Saint Francis Hospital in Tulsa.

“The establishment of this department will not only greatly upgrade the quality of emergency and trauma care in Tulsa and eastern Oklahoma, it will train emergency professionals who will serve the entire state,” OU President David Boren said after the creation of the residency program.

Other states also took action after the 2006 report card's release. After receiving an overall grade of C-, in part because of having just 0.79 trauma centers per million residents, the Hawaii legislature approved a bill to create a trauma system fund. This law reimbursed hospitals for uncompensated trauma care, and for ensuring on-call specialist coverage for trauma care. The legislation directed $5 per annual auto registration fee into the new trauma fund.

Elsewhere at least a dozen other state chapters used the report to further discussions over crowding, boarding and other ED issues in their states.

On the national level the report card achieved less success, even after the subsequent release of the Institute of Medicine's “Future of Emergency Care in the United States Health System” underscored its basic themes.

The “Access to Emergency Medical Services Act of 2005” was the centerpiece emergency medicine legislation of the 2005-2006 Congress. The US House legislation directly addressed issues raised in the report card, notably providing special liability protection for emergency medicine as well as reimbursement consideration for dealing with EMTALA-mandated services. Yet the bill never made it out of the Energy and Commerce Committee's Subcommittee on Health.

Both the House and Senate renewed similar legislation during the 2007-2008 Congress, styled the “Access to Emergency Medical Services Act of 2007,” but again, even with the support of the report card as well as the Institute of Medicine reports, the bills never advanced beyond their original committees.

Advocates of the new report card say its methodological rigor should give supporters of both federal and state emergency medicine laws additional ammunition during the coming season of political change.

“The success of the report card hinges on the reaction of both the public and the government to the recommendations,” Dr. Epstein said. “We're showing that the emergency care system is in serious condition. We're talking about system changes, and so the natural route is state-by-state analysis. Clearly it's easier to move some legislation at the state level rather than the federal level.”

To that end, the new report includes detailed recommendations both nationally, as well as for individual states. For example, on the federal level, the report calls for passage of the Access to Emergency Medical Services Act as well as increasing the proportion of federal disaster funds (currently 4%) dedicated to emergency health responses.

Locally, the recommendations are specific to states, giving legislators ideas about how to proceed. Alabama received a D- for Access to Emergency Care, and a D for its Medical Liability Environment. To address both areas, the report card suggests:

“One way to attract more physicians to the state would be to improve the Medical Liability Environment by instituting reforms, such as a $250,000 cap on non-economic damages, a requirement for case certification by an expert witness, and joint and several liability reform.”

A Call To Arms 

Emergency physicians and those working in hospitals should not view the report card ratings as specific to their own facility, nor take them personally as a reflection of their level of care. Rather the marks represent an overall grade, the authors say, for a state as a whole.

Moreover, practitioners should use the information as a call-to-arms to engender support among lawmakers to provide the policy tools that will allow their practice of emergency medicine to improve.

“Emergency physicians need to take this information to their state legislators and to their hospital administrators,” Dr. Epstein said. “Clearly every state has some strengths, but that overall the state of emergency care is serious. Individual physicians can work through state ACEP chapters to approach policymakers, to educate them, and help them craft appropriate legislation.

“The report card is designed to help decisionmakers understand what's going on. It's one thing, as an emergency physician, to live this day by day. But there is this huge disconnect between perception and what really happens in an emergency department.”

Another author, Dr. Hirshon, said the report's release in December is carefully timed to precede the inauguration of a new president, a good time for key decisionmakers to hear again about the plight of emergency medicine.

Yet all politics is local, and like the other report card authors he cited the primacy of emergency physicians getting involved at a local level, where individuals can make a difference simply by setting up a meeting with their state legislator.

“Emergency physicians need to be involved to help influence the health care conversation,” Dr. Hirshon said. “We need to be active in state halls, to talk about the many issues raised in the report card that can be addressed by state rather than federal regulation. I think many emergency physicians don't realize the impact they can have by talking to people and putting the effort in.

“Just be involved. If you're not involved in the process, you'll get run over by it.”