Ranking second in the nation in Disaster Preparedness and the Quality and Patient Safety Environment, Maryland’s overall score is marred only by inadequate medical liability reforms and key access-related issues, including a low rate of emergency departments and a high hospital occupancy rate.
Strengths. Maryland’s grade in the Quality and Patient Safety Environment is a reflection of the many reporting requirements and systems the state has put into place. The state has adverse event, hospital-based infections, and mandatory quality reporting requirements, as well as funding for quality improvement within the EMS system and a funded state EMS medical director position. Maryland ranks third for the high percentage of hospitals that use electronic medical records (81.3 percent).
Maryland has taken significant strides to incorporate important Disaster Preparedness planning into state operations and to implement policies that enhance the state’s ability to respond to a disaster. Maryland has an all-hazards medical response or ESF-8 plan that is shared with all EMS and essential hospital personnel. Likewise, the state has written plans specifically for special needs patients and for supplying dialysis to patients, as well as for the coordination of the State Emergency Operations Center or local emergency management agencies to provide security to hospitals in case of a disaster event. Maryland also has a real-time notification system in place to notify identified health care providers of an event, as well as statewide “just-in-time” training systems.
Challenges. In Access to Emergency Care, Maryland ranks 44th for both its relatively low number of emergency departments (8.4 per 1 million people) and its high daily hospital occupancy rate (75.1 per 100 staffed beds). These indicators substantiate current concerns reported by emergency physicians in the state regarding hospital crowding. Physicians also report problems in finding specialists to provide on-call services for emergency patients, despite the state’s relatively high rates of neurosurgeons; plastic surgeons; and ear, nose and throat specialists.
Maryland’s poor grade with respect to the Medical Liability Environment is largely due to the state’s failure to enact meaningful and effective tort reforms. The state does not provide additional liability protection for EMTALA-mandated emergency care and has not abolished joint and several liability. Furthermore, Maryland does not require expert witnesses to be of the same specialty as the defendant or to be licensed to practice medicine in the state. Reflective of the overall liability environment, Maryland’s average malpractice award payment is $319,977, nearly $35,000 more than the average state. The state also has a high average medical liability premium for specialists ($100,625), compared to the average across the states ($65,489).
Recommendations. Maryland should act immediately to improve Access to Emergency Care. Addressing hospital crowding has been declared a top priority among emergency physicians in Maryland. The state must work with the health care community to increase the number and availability of staffed inpatient beds. Hospital crowding may be worsening due to a workforce shortage identified in a recent local study by the Maryland Medical Society and Maryland Hospital Association. A shortage could also affect access to on-call specialty services. The state should consider additional steps to recruit and retain on-call specialists and emergency physicians to cope with this overburdened system. The state could encourage current and future specialists to take call by passing critical medical liability reforms, such as additional liability protections for EMTALA-mandated emergency care or a lower medical liability cap on non-economic damages. These reforms may also help decrease the relatively high medical liability insurance premiums that may discourage specialists from working in Maryland.
Despite faring better than most states with regard to Medicaid reimbursement levels for office visits, the state has seen only a 2.9 percent increase in reimbursement rates since 2004. This, combined with the provision of services to uninsured and underinsured patients, has resulted in reports of poor third-party reimbursement throughout the state. As Maryland addresses the workforce issue noted above, ensuring that physicians and specialists are adequately compensated for their services may be an important step in maintaining a broader workforce.