"We're Number One, but There's Room for Improvement" by Bruce Auerbach, M.D.

Add another “first in the nation” to the long list of accomplishments for health care in the Commonwealth.

The American College of Emergency Physicians (ACEP) last week issued its National Report Card on the State of Emergency Medicine, and listed Massachusetts as ‘first in the nation for its support of emergency patients.”

The report, a comprehensive analysis of the support that states provide for patients needing emergency care, which also includes recommendations to overcome weaknesses, was the second issued by ACEP. Massachusetts ranked second in the organization’s first analysis in 2006.

The move from second place to first is significant, because the 2008 report contained more than twice the measures of the previous report, analyzing 116 measures in five categories. Besides the overall number one ranking with a grade of B, the state also ranked first in the individual category of Public Health and Injury Prevention, with a grade of A.

Here’s a rundown of the five categories and our state’s 2008 overall rankings and grades in each: Access to Emergency Care (3rd in the nation, grade B); Quality & Patient Safety Environment (6th, A); Medical Liability Environment (33rd, D); Public Health & Injury Prevention (1st, A); Disaster Preparedness (19th, B).

ACEP cited many areas of strength in Massachusetts: the low rate of uninsured thanks to health care reform and efforts to end ambulance diversion; quality control and improvement systems in place or under development, such as a statewide trauma registry; a system of care for stroke; measures addressing childhood immunization, fatal unintentional injuries, and traffic fatalities; and low rates of obesity, infant mortality, and smoking among adults.

In Disaster Preparedness, a category analyzed for the first time in the 2008 Report Card, Massachusetts gained positive scores for planning, coordination and tracking systems, burn treatment capacity, and surveillance, as well as for its enrollment of providers in the Emergency System for Advanced Registration of Volunteer Health Professionals program.

It is gratifying to be cited for excellence in so many areas, and the state can and should be rightly proud of its achievement. As an emergency physician, I take some sense of pride in this as well.

But Massachusetts has its shortcomings, to be sure, and the ACEP report pinpointed “significant opportunities for improvement,” the most critical of which is medical liability, an area that has an enormous and pervasive influence on our health care system.

The effect of medical liability on the practice of medicine was recently highlighted in the findings of a Massachusetts Medical Society physician survey on defensive medicine. That survey of physicians across the state found that the practice of defensive medicine – ordering tests and procedures out of the fear of being sued - is widespread and adds a minimum of $1.4 billion to the cost of health care in the state.

But the specter of medical liability has other consequences, as ACEP noted. It affects the availability of on-call specialists to take what are generally high-risk cases in emergency departments. Emergency physicians have reported difficulties in getting on-call services from specialists, in part, because they’re reluctant to provide services that entail greater risks of liability. Such a situation can have serious consequences for patient care: If a patient is in an automobile accident or has a stroke, for example, and the emergency department has difficulty in finding a surgeon or neurologist on call, care may be delayed by precious minutes or hours.

Liability also affects the state’s ability to prepare for disasters. Should a pandemic or major natural disaster occur, the medical community would need to supplement the number of internists, pulmonologists, emergency physicians and others with physicians from other specialties. Asking them to work outside their specialty and under altered standards of care with inadequate staff and supplies – conditions that would exist in a major medical emergency — exposes them to liability.

Currently the state has no liability protection for physicians and health care providers who may be called to work under such conditions. A proposed bill, which would protect physicians and other health care professionals from civil suits when they volunteer or are called upon to assist during a health emergency, has yet to pass the legislature.

ACEP’s recognition of our many strengths in emergency care is rewarding. But they have also identified the challenges we face, most notably the need for medical liability reform.

Enacting such reform will improve our emergency care and disaster preparedness, yes, but it will also have benefits throughout our health care system — for cost control, quality of care, and access to care.

We must heed the warning: “Failure to take action in this area,” said ACEP, “may result in decreased quality and access to care for those presenting in the emergency department.” And elsewhere, I would add. And that, certainly, is not characteristic of a state leading the nation in health care.

Bruce Auerbach, M.D., is president of the Massachusetts Medical Society