While California’s landmark Medical Injury Compensation Reform Act continues to provide a favorable liability environment, access to medical care in the state is seriously threatened by a number of troubling factors including a severe shortage of providers and facilities.
Strengths. California has created a favorable Medical Liability Environment. The state is one of only four that have a hard $250,000 medical liability cap on non-economic damages. In addition, California has abolished joint and several liability and provides for periodic payments of awards at the request of one or both parties. The state also deserves to be recognized for having the fifth lowest average malpractice award payment in the nation ($181,782), which is more than $100,000 less than the average across the states.
California also fares well with respect to Public Health and Injury Prevention. Fewer than 15 percent of adults in the state smoke cigarettes, compared to 20.1 percent nationwide. The state’s infant mortality rate is 5.3 per 1,000 live births, significantly lower than that of the nation as a whole. The state also experiences relatively low rates of fatal occupational injuries, as well as unintentional fatal injuries due to falls and fires or burns.
Challenges. Access to Emergency Care in California suffers from a serious lack of specialists, registered nurses, primary care providers, and mental health providers. The state also fares poorly with regard to the number of medical facilities. California has only 7.1 emergency departments per 1 million people, compared to an average of 19.9 among the states. The state also has a critical lack of staffed inpatient and psychiatric care beds (237.7 and 16.9 per 100,000, respectively). Contributing to the problems are high rates of uninsured adults and children and relatively low Medicaid reimbursement rates for office visits (66.7 percent of the national average).
The state’s poor grades in Disaster Preparedness and the Quality and Patient Safety Environment were significantly affected by the state’s inability to respond to ACEP’s survey questions regarding state-led efforts in each of these areas. This is due to California’s unique public health structure, in which counties have been charged with many of the responsibilities other states maintain at the state level. (Information provided for indicators related to the survey were gathered through phone calls with state officials and via the Internet.)
Recommendations. Access to Emergency Care throughout California is in crisis. As noted above, the state is desperately in need of specialists. Emergency physicians in the state report problems in finding specialists to provide critical on-call services to emergency patients. They also note problems with hospital crowding and boarding of patients in emergency departments. This problem may be further exacerbated by the relatively low number of staffed inpatient beds combined with the high daily hospital occupancy rate, which leaves little room for admissions from the emergency department.
The state should implement measures to draw more medical professionals to California. Increasing Medicaid fee levels would likely be an important step in attracting physicians, as well as ensuring that beneficiaries have access to and receive adequate primary medical care. Implementing additional liability protections for EMTALA-mandated emergency care, may also help to encourage specialists to provide on-call services for emergency patients.
While the lack of information with regard to the Quality and Patient Safety Environment and Disaster Preparedness clearly affected the state’s grades in these areas, it is not clear that California is doing all that it can to ensure that effective and appropriate systems are in place in each of its counties. Given California’s large size and population, the county-based system is not a detriment in itself, but without state level oversight, it is unclear that the state has an organized system for improving the state’s Quality and Patient Safety Environment or handling disaster events on a massive scale that cross county lines. The state should investigate ways to comprehensively evaluate and ensure the adequacy of county-level administration of EMS services and disaster preparedness programs.