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cases, paramedics are employed by ambulance transport
companies. In rural areas, fire personnel are more likely to
be BLS certified volunteers with paramedical training at
an intermediate level known as Emergency Medical Tech-
nician.
California’s statewide EMS authority is responsible for
maintaining standards for emergency facilities and
personnel. Standards are categorized under state law
because of the wide range in training, equipment, and
capabilities between rural and urban areas of the state.
There are six multi-county EMS agencies that are respon-
sible for 30 rural counties. Metropolitan counties admin-
ister local EMS agencies that coordinate pre-hospital
care, ED services available at each hospital, and some
specialized services, such as trauma and stroke care.
Hospitals can define which medical and surgical special-
ties are available through the ED, provided they meet
standards defined under state law.
Emergency Care Coordination in Urban Areas
EMS agencies in metropolitan counties with the largest
number of acute care hospitals feature the most
advanced care coordination between pre-hospital and
ED personnel. In 2015, Los Angeles County had 9818605
residents, 73 hospitals receiving EMS patients, 2002 ED
treatment stations serving slightly more than 3 million
ED patients. Because Los Angeles also has large numbers
of medical and surgical specialists, interventions for time
sensitive conditions are available at many paramedic
receiving hospitals. In 2015, the Los Angeles EMS Agency
reported 3946 pre-hospital STEMI cases based on para-
medic interpretation of initial ECG. At receiving ED’s with
interventional cardiologists on call, 1364 patients under-
went cardiac catheterization, including 1088 undergoing
percutaneous coronary intervention (PCI). Intervention
was deemed unnecessary in 2585 patients with STEMI
designations by paramedics because of discordant ECG
interpretation in the receiving ED or other medical
contra-indications. For PCI patients, median time from
EMS medical contact to balloon was 76 minutes and
median time from ED arrival to balloon was 58 minutes
(10). The agency reported similar benefits from the
multi-level country trauma system.
Rural Emergency Departments
At the beginning of 2015 OSHPD reported that there
were 58 ED’s in hospitals with 75-beds or less in rural
areas of California. Most operate with low patient volumes
and narrow scope of specialty services backing up emer-
gency physicians. Forty-two hospitals (68%) operated as
Basic ED’s with physicians on duty in the department at
all times. Eighteen (28%) operated as Standby facilities,
where the emergency physician may not be present but is
available for rapid response. In many remote regions, the
physician or advanced practice providers on duty in the
ED is the only one available for primary care as well. Nurse
practitioners and physician assistants with experience in
emergency medicine are increasingly important in rural
facilities in California and other states.
OPPORTUNITIES FOR IMPROVEMENT
Universal Access Without Universal coverage
In 1966, the US enacted Medicare, public insurance for
the elderly, and Medicaid, public insurance for the poor.
Medicare is administered by the federal government,
though a growing percentage of beneficiaries receive
services through Medicare Advantage (MA), private insur-
ance companies contracting with the federal govern-
ment. Because it is partially funded and operated by state
governments, Medicaid (MediCal in California), has evolved
in a much less uniform manner, leaving tens of millions of
US residents in many states living below the poverty level
without health insurance coverage (11).
Widely-publicized failures of some hospitals to provide
adequate screening and stabilization for emergency
conditions resulted in the next step toward to universal
US care. In 1986, President Reagan (previously Califor-
nia’s Governor), established emergency care as the first
health service protected under federal law for all US
residents. The Emergency Treatment and Active Labor
Act (EMTALA)was structured as a mandate on hospi-
tals participating in Medicare rather than a program
directly funded by the US government (12). Hospi-
tals were required to uniformly screen and treat all
patients for emergency conditions without respect to
their ability to pay, including hospitalization if medically
necessary. Because 16-18% of US residents lacked any
health insurance coverage, this created a large burden
of uncompensated care for providers involved in emer-
gency services (13).
Because Medicaid (and to a lesser extent Medicare) do not
cover the full cost of emergency care for their own patients,
most hospitals attempted to shift the cost of uncompen-
sated emergency care to ED patients with private health
insurance (Figure1)(14). As ED visits and emergency hospi-
talizations by uninsured US residents continued to rise,
cost-shifting by hospitals and physicians providing emer-
gency services became an important political rationale
for the ACA, enacted along partisan lines by Congress and
President Obama in 2010.
[REV. MED. CLIN. CONDES - 2017; 28(2) 178-185]