Emergency care in Pennsylvania is "in a near-continuous state of crisis," said Charles Barbera, an emergency doctor in Reading and president of the state chapter of the American College of Emergency Physicians.
And Pennsylvania is among the best, ranking sixth in a report released Thursday by the national organization.
New Jersey, by contrast, ranked 30th - down by 17 from the 2009 report.
No place scored particularly high. Translated to letter grades, New Jersey got a D+ (down from a C+). Pennsylvania was C+ (unchanged, despite moving up two places in the rankings). The nation got a D+ (down from C-).
The grades don't reflect medical outcomes. They are based on 136 measures of what the report calls the "emergency care environment": regulations, practices, and pressures under which emergency medicine is given.
Many are invisible to the general public. Pennsylvania and New Jersey were among 21 states that got an F on medical liability, for example, the most failures in any of the five subcategories. Malpractice premiums in both states are around 50 percent above the national average; the Philadelphia region would be higher.
Besides raising the price of health insurance, costly malpractice coverage encourages doctors to leave.
"If your state has a terrible medical liability grade, you may not be able to get that neurosurgeon or hand surgeon when you need one," Jon Mark Hirshon, an associate professor in emergency medicine at the University of Maryland, said in a teleconference with reporters.
The amount that physicians are reimbursed for seeing Medicaid patients has a similar effect. Pennsylvania is below the national average, but New Jersey, at 40 percent, is second-lowest by one-tenth of 1 percentage point. Patients have a hard time finding both primary care physicians and specialists who accept it, and end up crowding the emergency department.
Reimbursement is higher for patients who gain insurance under Obamacare's Medicaid expansion. But that is unlikely to help with overcrowding.
Emergency department usage "will go up for a few years as people get insurance," said Brian J. Zink, author of Anyone, Anything, Anytime: A History of Emergency Medicine. When Massachusetts expanded in 2006, emergency visits rose more than 7 percent, he said, and there were similar increases when Medicaid and Medicare first began in the mid-'60s. The system adjusted after several years.
There is some evidence that long waits in the ED, known as boarding, can be harmful. Zink, who is chief of emergency medicine at Rhode Island Hospital in Providence, said that waiting more than four hours for a bed after doctors have decided to admit a patient, which is usually several hours after arrival, is considered excessive.
In the Philadelphia region, the average wait from ED arrival until admission - the measure used in the report - is 5 hours, 34 minutes. (Find your hospital's wait time at www.inquirer.com/vitalstats).
Nationally, emergency department visits increased 34 percent between 1995 and 2010, the new report found, while the number of EDs dropped 11 percent.
Although it calls on government and communities to address the ED environment through new policies, planning, and funding, many of the issues resulted from cultural shifts and improvements in general medical care.
"People who used to die 25 years ago now live with a variety [of complex conditions], and when they come into the ED they are very sick," said David Adinaro, chief of adult emergency medicine at St. Joseph's Regional Medical Center in Paterson, N.J.
Victims of car accidents increased dramatically over the decades as more people drove. ED visits due to misuse or abuse of prescription painkillers have skyrocketed. Meanwhile, the practice of medicine has changed.
"[P]rimary care physicians increasingly rely on emergency physicians to help manage care for patients whose illnesses are severe or complex, as emergency departments can efficiently perform complex diagnostic workups and handle after-hours demand for care," according to the report.
The 4.2 percent of doctors in the United States who are emergency physicians handle 11 percent of all outpatient care and 28 percent of acute-care visits, many of which used to take place in the doctor's office.
Family doctors once made most patient admissions, too. Now they go through the ED. Patients also get diagnostic tests in the ED that used to be done after admission, causing long waits for results.
In one of the biggest recent shifts in medical care, however, most aren't admitted at all: 83 percent are discharged home.
"It's not just about making a diagnosis and admitting patients any more, it is a more comprehensive sort of care," said Shelley Greenman, president-elect of the American College of Physicians' New Jersey chapter. "We have to take that next step to make sure they are safe to go home, to make sure they have antibiotics, that they have physician follow-up, that they have care at home."
When she arrived at Cooper University Hospital 23 years ago, Greenman said, there were 15 to 17 beds in the emergency department.
"It was an exception that we had patients in the hall," she said. "Now we have probably about 40 beds and probably another 15 hallway beds and chairs, and it is exceptional when we are not using hallway beds."
Doctors say that solutions are likely as complex as the problems.
"The entire system is under a huge amount of stress," said Adinaro, the Paterson physician and chapter president whom Greenman will succeed in June.