Hospital Economics, Medical Liability Put ER System at Risk

The nation's emergency medical care system is mediocre and likely to get worse without prompt action by state and federal legislators, according to a report issued by the American College of Emergency Physicians.

America's emergency system earned a C- overall, according to the Jan. 10 report, National Report Card on the State of Emergency Medicine, (PDF file: 129 pages / 5.5 MB. More about PDFs.) which includes state-by-state analyses. No state earned an overall A grade; no state earned an overall F.

"Americans assume they will receive lifesaving emergency care when and where they need it, but, increasingly, this isn't the case," said Frederick Blum, M.D., president of ACEP, in a news release about the report. "Our report found the nation's support for emergency medical care is mediocre or worse."

The report reflects several national trends that have weakened the capacity of the emergency medical system. In their efforts to remain financially stable, hospitals have slashed or eliminated their emergency capabilities and trimmed the number of intensive care and inpatient beds to which emergency patients could be admitted.

"Local emergency departments … are increasingly crowded, often to the point that ambulances must be diverted to another hospital," the report summary said. "A key cause is the lack of staff inpatient beds. Often, when emergency patients need to be moved into hospital beds, they must wait in emergency department hallways for hours and sometimes days."

Since 1993, the number of emergency departments in the United States has fallen by 14 percent. During the 1990s, hospitals lost 103,000 staffed inpatient medical-surgical beds and 7,800 intensive care unit beds nationwide, according to CDC data.

Meanwhile, community hospitals have been shuttering their doors, contributing to the decline in both emergency departments and available inpatient beds, according to "Hospital Care in the 100 Largest Cities and Their Suburbs, 1996-2002: Implications for the Future of the Hospital Safety Net in Metropolitan America," a study by the Robert Wood Johnson Foundation.

Between 1996 and 2002, the number of public hospitals fell by 16 percent in cities and by 27 percent in suburbs, the number of for-profit hospitals fell by 11 percent each in both cities and suburbs, and the number of nonprofit hospitals declined by 11 percent in cities and by2 percent in the suburbs, according to the report.

At the same time, the number of specialty hospitals -- those that focus on cardiac care, women's health, orthopedic conditions and surgical patients but that do not have emergency departments -- grew from 29 in 1990 to more than 100 that were either built or under construction by April 2003, according to the Government Accountability Office's 2003 report "Specialty Hospitals: Information on National Market Share, Physician Ownership and Patients Served," (PDF file: 20 pages / 157 KB. More about PDFs.).

Equally important in the equation is medical liability, according to the ACEP report. "In some areas of the country, emergency departments have closed because medical specialists, such as neurosurgeons, obstetricians and orthopedists, could not obtain medical liability insurance," the report said. "In almost all states, some areas do not have critical on-call specialists. Many of these specialists no longer provide services because they fear lawsuits. The problem could worsen as liability concerns drive medical students away from high-risk specialties, such as emergency medicine, surgery, neurosurgery, orthopedics and obstetrics."

"The results are sobering. The national emergency health care system is in serious condition, with many states in a critical situation," the ACEP report concludes. "While no state receives an overall failing grade, many have serious deficiencies, and almost all have areas in which there is substantial room for improvement. State and national policymakers should take the results to heart and support efforts to improve emergency care."