Legislature(2009 - 2010)BELTZ 211

04/08/2009 01:30 PM Senate HEALTH & SOCIAL SERVICES

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                SB 168-TRAUMA CARE CENTERS/FUND                                                                             
2:42:09 PM                                                                                                                    
CHAIR DAVIS announced consideration of SB 168.                                                                                  
TOM OBERMEYER,  staff to  Senator Davis, sponsor  of SB  168, read                                                              
the  sponsor  statement.  It  is  about  state  certification  and                                                              
designation of  trauma centers, creating the  uncompensated trauma                                                              
care  fund  to  offset  uncompensated   trauma  care  provided  at                                                              
certified  and designated  trauma  centers  and providing  for  an                                                              
effective date.                                                                                                                 
SB 168  addresses the  urgent need  for a comprehensive  statewide                                                              
trauma center system  coordinating and integrating  the efforts of                                                              
emergency medical  services, public  safety agencies,  air medical                                                              
services  and  health  care facilities  to  insure  that  patients                                                              
receive  the  most  efficient  and effective  care  from  time  of                                                              
injury  through  rehabilitation.  Trauma  care systems  have  been                                                              
shown to  reduce death from  injury by as  much as 25  percent and                                                              
are  recognized  as  an  integral  part of  the  state's  EMS  and                                                              
disaster   response  system.   Only   eight   states  have   fully                                                              
functioning systems and 15 states have no system.                                                                               
Trauma is  any life  threatening occurrence  either accidental  or                                                              
intentional  that causes  injuries. The leading  causes of  trauma                                                              
are motor  vehicle accidents,  falls and  assaults; trauma  is the                                                              
leading cause of death among Americans under 44 years of age.                                                                   
A trauma  center is a hospital,  clinic or other  certified entity                                                              
equipped to  provide comprehensive  emergency medical  services to                                                              
patients suffering  traumatic injuries.  They were established  by                                                              
the medical establishment  in response to traumatic  injuries that                                                              
often require  complex and multi-disciplinary  treatment including                                                              
surgery in order  to give the victim the best  possible chance for                                                              
survival and recovery.                                                                                                          
2:43:57 PM                                                                                                                    
Section  1 in  SB 168  adds subsection  (c)  to emergency  medical                                                              
services  to address the  state certification  and designation  of                                                              
trauma  centers. It  creates the  uncompensated  trauma care  fund                                                              
under section  2 to offset  uncompensated trauma care  provided at                                                              
certified  and  designated  trauma  centers and  provides  for  an                                                              
immediate effective date.                                                                                                       
The   bill  requires   the  commissioner   to  establish   special                                                              
designations in  regulation of levels  of 1-4 of  certified trauma                                                              
centers that  shall be  used to  set compensation eligibility  and                                                              
the amounts  under the  uncompensated trauma  care fund.  Although                                                              
current Alaska statutes  revised in 1993 require  certification of                                                              
hospitals,  clinics or  other  entities representative  of  trauma                                                              
centers,   they  do  not   require  or   provide  incentives   for                                                              
participation.  The uncompensated  trauma care  fund will  provide                                                              
the  needed  incentives  for  hospitals   for  clinics  and  other                                                              
entities to seek certification as trauma centers.                                                                               
Since  the state's  statutes  and regulations  in  this area  were                                                              
enacted  over  15  years  ago,   only  3  of  24  eligible  Alaska                                                              
hospitals    reportedly    have   successfully    completed    the                                                              
verification  and  certification  process  as trauma  centers.  In                                                              
order  to  qualify  as  a trauma  center,  a  hospital  must  meet                                                              
certain   criteria  established   by  the   American  College   of                                                              
Surgeons.  Trauma centers  vary in their  specific capacities  and                                                              
are identified by  levels 1-4; 1 being the highest.  Higher levels                                                              
of trauma  centers will have  trauma surgeons available  including                                                              
those  trained in  such  specialties as  neurosurgery,  orthopedic                                                              
surgery,  as  well  as  highly  sophisticated  medical  diagnostic                                                              
equipment  and  specialized  treatment   units.  Lower  levels  of                                                              
trauma  centers may  only  be able  to  provide  initial care  and                                                              
stabilization of  a traumatic injury  and arrange for  transfer of                                                              
the victim to a higher level trauma care.                                                                                       
2:45:52 PM                                                                                                                    
MR. OBERMEYER  said under the Alaska  trauma center system,  it is                                                              
anticipated  that tertiary  hospitals designated  as higher  level                                                              
trauma  centers  will insure  the  availability of  critical  care                                                              
specialists  24  hrs/day, 7  days/wk.  The Alaska  Native  Medical                                                              
Center  is a level  2 trauma  center; Yukon  Kuskokwim and  Norton                                                              
Sound Regional  Hospitals are level  4. It is believed  that there                                                              
are adequate  medical resources to  establish more level  2 trauma                                                              
centers in Anchorage,  and it is considered feasible  to establish                                                              
level  3 and  4  centers throughout  the  state.  Because of  long                                                              
transport  times trauma  centers at  all levels  are necessary  to                                                              
improve patient  outcomes.  Level 1 trauma  centers have  critical                                                              
care specialists in the hospital or on call at all times.                                                                       
The closest  level 1  trauma center  is Harborview Medical  Center                                                              
in  Seattle.  The  operation  of  a  trauma  center  is  extremely                                                              
expensive. Some  areas are underserved  by trauma  centers because                                                              
of this  expense. For  instance,  Harborview is  the only  level 1                                                              
trauma center  to serve  the entire  states of Washington,  Idaho,                                                              
Montana, and Alaska.                                                                                                            
He said  that patient  traffic at trauma  centers can  vary widely                                                              
as there  is no way to schedule  the need for  emergency services.                                                              
A variety  of different  methods have  been developed  for dealing                                                              
with this.  Halifax Health in  Daytona Beach, Florida,  reportedly                                                              
is employing  a pod  system to  be provided  by several  different                                                              
small  emergency departments  at different  hospitals rather  than                                                              
one large trauma center.                                                                                                        
It is  anticipated that Alaska,  likewise, will have to  develop a                                                              
trauma center  system which  is best  suited to  its needs.  It is                                                              
anticipated  that persons  critically injured  in remote  areas of                                                              
Alaska will  be transported  directly to  a distant trauma  center                                                              
by plane  and helicopter for faster  and better care than  if they                                                              
had  been  transported   to  a  closer  hospital,   which  is  not                                                              
designated a trauma center.                                                                                                     
The designation,  coordination and funding  of a trauma  center in                                                              
Alaska  as provided  under SB  168 will  save time  and lives.  It                                                              
will   also   provide   the   financial    incentives   for   more                                                              
participation  by hospitals,  clinics and  other certified  trauma                                                              
care entities which are not available under present law.                                                                        
He  drew  the   committee's  attention  to  the   attachments  and                                                              
documents  that  indicate that  in  Alaska  the leading  cause  of                                                              
death in  persons ages 1  to 44 is  trauma; the average  number of                                                              
fatalities  from trauma  is 400  each year, and  for every  injury                                                              
death,  11 people  are hospitalized  for trauma-related  injuries.                                                              
For every trauma  death that occurs in the hospital,  there are an                                                              
estimated  3  people  discharged  with  permanent  disability.  On                                                              
average,  more than 800  Alaskans are  hospitalized annually  with                                                              
central nervous  system injury  (spinal cord  or brain  injuries).                                                              
In 2004  motor vehicles  were the  leading cause  of injury  death                                                              
(117), followed by  firearm injuries (116). In  2004, the economic                                                              
cost  of  hospital  stays  for   trauma  patients  in  Alaska  was                                                              
estimated  at  over  $73  million;   1  in  4  of  those  hospital                                                              
admissions were uncompensated.                                                                                                  
CHAIR DAVIS set SB 168 aside.                                                                                                   
                SB 168-TRAUMA CARE CENTERS/FUND                                                                             
CHAIR  DAVIS  returned attention  to  SB  168 to  continue  taking                                                              
2:50:46 PM                                                                                                                    
DR. JAY  BUTLER, Chief Medical  Officer, Department of  Health and                                                              
Social  Services  (DHSS),  said  Alaska's trauma  death  rate  has                                                              
declined  over the  last 30  years thanks  to prevention  efforts,                                                              
but  it  is  still significant.  The  department  took  a  neutral                                                              
stance on SB 168.                                                                                                               
DR.  BUTLER said,  "A  better job  can be  done  with the  medical                                                              
management of trauma  victims." To begin a systematic  approach to                                                              
improving  trauma care  in Alaska,  the DHSS  hosted the  American                                                              
College of  Surgeons' Committee  on trauma  system evaluation  and                                                              
planning this past  November. The committee noted  that Alaska has                                                              
no trauma system  and the report included over  70 recommendations                                                              
for  improving  trauma  care  and   creating  a  statewide  trauma                                                              
system. Among  the priority  recommendations was a  recommendation                                                              
to  require  all  acute  care  hospitals  to  seek  trauma  center                                                              
designation  appropriate to  their  capacity within  the next  two                                                              
years to  improve the quality of  medical care for  trauma victims                                                              
and improve outcomes.                                                                                                           
DR. BUTLER  said SB  168 provides  an incentive  for hospitals  to                                                              
become certified  trauma centers  rather than creating  a mandate.                                                              
It creates a fund  for reimbursement of trauma care  that would be                                                              
provided  for care to  uninsured or  underinsured patients.  There                                                              
are a  number of potential  sources of  funds, and the  department                                                              
has  been working  to  develop the  sources  further. However,  he                                                              
said   because  of   the   uncertainty  involving   funding,   the                                                              
administration is taking a neutral stance on SB 168.                                                                            
2:53:07 PM                                                                                                                    
SENATOR DYSON asked if the administration requested this bill.                                                                  
CHAIR  DAVIS replied  no;  it was  requested  by  others than  the                                                              
2:54:10 PM                                                                                                                    
ROD BETIT, President/CEO,  Alaska State Hospital  and Nursing Home                                                              
Association  (ASHNHA), said they  support the  concept of  SB 168.                                                              
The  detailed report  from the  College of  Surgeons prescribes  a                                                              
mandatory approach,  which he didn't think would  be well received                                                              
for a  variety of  reasons. This  is a  priority that his  members                                                              
selected to work  on in 2009, and he understands it  is one of the                                                              
department's  priorities,  too.  The  trauma system  needs  to  be                                                              
improved;  the  reasons   why  it  hasn't  happened   need  to  be                                                              
understood why  it hasn't happened  before. Some of  those include                                                              
the  availability of  physicians  and their  willingness to  serve                                                              
because   there   are   very  significant   and   time   sensitive                                                              
requirements  around  each  classification  level  in  the  trauma                                                              
scheme,  and the  costs  to  do that.  And  since  there is  clear                                                              
evidence  that  if you  have  trauma  centers, they  attract  more                                                              
uncompensated  care that  has to  be dealt  with as  well as  what                                                              
levels are care should be in each community.                                                                                    
He understood  that Alaska  has five  designated facilities,  four                                                              
of those  are tribal. The one  with the highest  level designation                                                              
is Alaska Native  Medical Center. Those are staff  model hospitals                                                              
where  the  physicians  work  for  those  hospitals.  One  private                                                              
facility that  is certified at the  lowest level is  co-located in                                                              
a community  with one  of those tribal  facilities. The  rest have                                                              
struggled  with ways  to meet  the conditions  of certification  -                                                              
being private hospitals  with physicians who do not  work for them                                                              
and having  a shortage of some  of the types of  physicians needed                                                              
and the ability  to make sure the physicians will  be there within                                                              
the time  response  required. This  is one issue  they don't  know                                                              
how to  solve at  this point,  but a  group within  the AHNSHA  is                                                              
working  on it.  This is  a great  approach  to try  to pull  more                                                              
facilities  in and  get  them designated.  Clearly,  uncompensated                                                              
care is one  way to do that,  but unless they can figure  out some                                                              
of the  logistical  problems around  physician availability,  they                                                              
won't get as  far as the committee  would like with this  piece of                                                              
2:57:49 PM                                                                                                                    
SENATOR  PASKVAN  asked, if  it  were  funded  at the  $5  million                                                              
level, what  range of hospitals  would want to participate  in the                                                              
MR. BETIT  answered that since  this deals  with "a half  a glass"                                                              
and  deals with  uncompensated care,  but not  with the  physician                                                              
cost or  availability,  none said  they would  be willing  to move                                                              
forward  to  get  the  designation.  It's  a  step  in  the  right                                                              
direction,  but maybe  the  $5 million  could  be matched  through                                                              
some  disproportionate   sharing   funding  that  Medicaid   makes                                                              
available that the  state hasn't fully capitalized  on. Maybe some                                                              
of  that could  also  go into  offsetting  some  of the  increased                                                              
costs for  the physician  on call and  recognizing that  they have                                                              
to have  the right physicians  available to  be on call.  He hoped                                                              
to work  with the  department on  these issues  over the  next few                                                              
2:59:09 PM                                                                                                                    
MARK JOHNSON,  former chief  of Emergency  Medical Services,  said                                                              
during that  time that he served,  he worked very hard  to develop                                                              
an EMS  system in Alaska  and made a lot  of progress. One  of the                                                              
issues they worked  on was to improve the trauma  system in Alaska                                                              
where they made  some limited progress. In the 1990s  with the use                                                              
of  some federal  grant funds,  his  office co-sponsored  American                                                              
College  of  Surgeon  reviews  of  eight  different  hospitals  in                                                              
Alaska that  created reports  on their  strengths and  weaknesses.                                                              
Some  hospitals  have been  reviewed  multiple times.  The  report                                                              
that the  college came  out with  addressed some issues  mentioned                                                              
by Mr.  Betit as well as  going into a  lot more detail on  how to                                                              
solve some of the problems.                                                                                                     
It's  been  said  for many  years,  that  trauma  systems  require                                                              
commitment,  and unless the  medical community  and the  hospitals                                                              
are  willing  to  provide  it, they  aren't  going  to  solve  the                                                              
problem,  Mr. Johnson  said, and  he's  been dealing  with it  for                                                              
decades. The  reality is that  Alaska's hospitals are  not meeting                                                              
national  standards in  trauma care,  and the  public is not  well                                                              
served  by that.  Harris polls  indicate  that nationwide,  people                                                              
actually  think they  live in a  community with  a trauma  system,                                                              
but in fact in many places it doesn't exist.                                                                                    
MR. JOHNSON  said reducing complications  and lengths of  stay can                                                              
produce better  outcomes and more  lives saved, and these  can all                                                              
result  in  downstream  long  term savings.  One  of  the  biggest                                                              
problems in this  state is on-call. Sometimes a  surgeon is needed                                                              
immediately, but  they must be called to find  somebody available.                                                              
Those  calls  take   time  and  that  sometimes   results  in  bad                                                              
outcomes.  That  should  be  pre-planned   and  pre-arranged;  and                                                              
that's what this is about.                                                                                                      
3:02:55 PM                                                                                                                    
SENATOR DYSON said "commitment" sounds like money.                                                                              
MR. JOHNSON said to some extent that is true, but other things                                                                  
can be done that don't cost much. You look at creative                                                                          
solutions, and some are in this report.                                                                                         
CHAIR DAVIS said this bill will come back next session. [SB 168                                                                 
was held in committee.]                                                                                                         

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