Legislature(2009 - 2010)BUTROVICH 205
02/10/2010 01:30 PM Senate HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| SB168 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 168 | TELECONFERENCED | |
| *+ | SB 169 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 10, 2010
1:32 p.m.
MEMBERS PRESENT
Senator Bettye Davis, Chair
Senator Joe Paskvan, Vice Chair
Senator Johnny Ellis
Senator Joe Thomas
Senator Fred Dyson
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
SENATE BILL NO. 168
"An Act relating to 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."
- HEARD AND HELD
SENATE BILL NO. 169
"An Act appropriating $5,000,000 to the uncompensated trauma
care fund; and providing for an effective date."
- SCHEDULED BUT NOT HEARD
PREVIOUS COMMITTEE ACTION
BILL: SB 168
SHORT TITLE: TRAUMA CARE CENTERS/FUND
SPONSOR(s): HEALTH & SOCIAL SERVICES BY REQUEST
03/27/09 (S) READ THE FIRST TIME - REFERRALS
03/27/09 (S) HSS, FIN
04/08/09 (S) HSS AT 1:30 PM BELTZ 211
04/08/09 (S) Heard & Held
04/08/09 (S) MINUTE(HSS)
02/10/10 (S) HSS AT 1:30 PM BUTROVICH 205
BILL: SB 169
SHORT TITLE: APPROP: TRAUMA CARE FUND
SPONSOR(s): HEALTH & SOCIAL SERVICES BY REQUEST
03/27/09 (S) READ THE FIRST TIME - REFERRALS
03/27/09 (S) HSS, FIN
04/08/09 (S) HSS AT 1:30 PM BELTZ 211
04/08/09 (S) Heard & Held
04/08/09 (S) MINUTE(HSS)
02/10/10 (S) HSS AT 1:30 PM BUTROVICH 205
WITNESS REGISTER
SENATOR COGHILL
Alaska State Legislature
Juneau, AK
POSITION STATEMENT: Sponsor of SB 168.
WARD HURLBURT, Chief Medical Officer
Department of Health and Social Services
Director, Division of Public Health
Anchorage, AK
POSITION STATEMENT: Supported SB 168.
DR. FRANK SACCO, Trauma Director
Alaska Native Medical Center
Chair, State Trauma Systems Review Committee
Anchorage, AK
POSITION STATEMENT: Supported SB 168.
DR. REGINA CHENAULT, State Chair
American College of Surgeons Committee on Trauma
Anchorage, AK
POSITION STATEMENT: Supported SB 168.
DAVID HULL, Chair
Governor's Alaska Council on Emergency Medical Services (ACEMS)
Fire Chief, North Tongass Fire Department
Ketchikan, AK
POSITION STATEMENT: Supported SB 168.
ROD BETIT, President
Alaska State Hospital and Nursing Home Association
Juneau, AK
POSITION STATEMENT: Supported SB 168.
MARK JOHNSON, Chief
Emergency Medical Services (EMS)
Juneau, AK
POSITION STATEMENT: Supported SB 168.
MARTHA MOORE, representing herself
Juneau, AK
POSITION STATEMENT: Supported SB 168.
SOREN THREADGILL, retired Chief
Emergency Medical Services (EMS)
Anchorage Fire Department
Anchorage, AK
POSITION STATEMENT: Supported SB 168.
ACTION NARRATIVE
1:32:31 PM
CHAIR BETTYE DAVIS called the Senate Health and Social Services
Standing Committee meeting to order at 1:32 p.m. Present at the
call to order were Senators Ellis, Paskvan and Davis.
SB 168-TRAUMA CARE CENTERS/FUND
1:32:50 PM
CHAIR DAVIS announced consideration of SB 168.
1:34:37 PM
SENATOR DYSON and SENATOR THOMAS joined the meeting.
SENATOR COGHILL, sponsor of SB 168, said the bill is pretty
simple in its workings; it creates a fund much like a piggy
bank, the purpose of which is to get hospitals to try to
increase their trauma ratings. It came out of the College of
Surgeons report that he read almost two years ago, which
revealed that the trauma system in Alaska is not as well
coordinated as it could be.
He explained that Alaska put together a voluntary system of
trauma care about sixteen years ago, and it has done many things
well, but there are things that could be done better. There are
currently 24 hospitals in Alaska. There is one Level II trauma
center at the Alaska Native Medical Center in Anchorage. Of
those 24 hospitals, there are four Level IV trauma centers, none
of them in Fairbanks or Anchorage. This bill creates a fund to
incentivize hospitals to move up to a trauma Level II or III.
There are two hospitals in Anchorage within reach of a Level II
and one in Fairbanks that could easily reach a Level III if the
state can help them get their uncompensated care taken care of
and provide the right incentives.
1:37:46 PM
SENATOR COGHILL referred members to the November 2008 Trauma
System Consultation report by the American College of Surgeons
Committee on Trauma (ACSCOT), which is the report that moved him
to start looking more closely at this issue. Page 7 lists the
challenges and vulnerabilities of the Alaska trauma system. He
said the first hearings on this bill occurred on the House side
last year, and since that time he has had two meetings with
stakeholders including hospitals, Department of Health and
Social Services (DHSS), and others. Their discussions have
resulted in some very positive steps. DHSS has made it a
priority to improve trauma care in Alaska. They have created a
position in the department to oversee it and have hired a person
whose responsibilities will include development of a trauma
system strategic plan and creation of standards for trauma
triage.
However, he pointed out, as the College of Surgeons' report
states, "few incentives exist for hospitals to participate in
the trauma system." That is where SB 168 comes in. The hospitals
have been doing a yeoman's job, but they could do better. The
doctors do a yeoman's job, but they have private practices and
work in the hospitals on call. Both get credit for doing their
jobs very well, but the collaboration between them has not been
as good as it could be. He hopes this bill will help them
establish a better relationship that will allow them to work
together to improve the level of trauma care available.
1:41:19 PM
SENATOR COGHILL acknowledged that Alaska has a large volunteer
base and a lot of people who are unpaid first responders. These
volunteers should be commended and supported in any way
possible, he said; they invest their lives in helping people
from the time of any tragedy until they can reach a hospital,
but if their work goes unappreciated at the entrance to the
hospital because there is not a good working relationship
between the doctors and the hospitals, the system has failed
them and the people of Alaska.
SENATOR COGHILL related his own experience with the system when,
just over two years ago, his grandson fell and suffered a brain
trauma. The boy was stabilized in Fairbanks and medevaced to
Anchorage, but it was almost seven hours from the time he fell
until he saw a doctor. His grandson died. He does not blame
anyone; everyone was doing the best they could do, but it was
just not good enough. He is very motivated to push this issue
forward.
1:43:08 PM
He said the fund is just a piggy bank right now, with no money
in it, and asked that the committee forward a $5 million fiscal
note to Finance to fill the fund. That amount is commensurate
with the amounts similarly populated states have set aside for
uncompensated care. He admitted that he does not know how they
are going to come up with that money and said he is open to
suggestions. One option is to ask the Department of Health and
Social Services to re-identify a portion of the Medicaid
"Disproportionate Share" funds, which are intended for
uncompensated care. Another, suggested by the House, is to take
a portion of the tobacco tax or tobacco settlement money for
this purpose; that is general fund money anyway.
SENATOR COGHILL went on to provide a sectional analysis of the
bill.
Section 1 provides that the commissioner [of the Department of
Health and Social Services] shall establish special designations
based on nationally recognized standards and procedures for
varying levels of trauma care. In other words, in order to get
into the fund, a hospital has to have reached nationally
recognized standards for trauma care. He added that he is loath
to give the department any more authority to make regulations,
but knows of no other way to do it. The good news is that Levels
I through IV are very well defined in national standards and are
outlined in Alaska statutes.
Section 2(b) creates the fund and states that the fund "consists
of money appropriated to it by the legislature." Section 2(c)
designates it as uncompensated trauma care money and provides
for a review by those committees that already do trauma system
review.
1:46:39 PM
Section 2(d) creates stability in the fund by limiting to 25
percent per year the amount of total assets, including earnings
that the commissioner can give to one trauma center.
SENATOR COGHILL said when his grandson fell, they didn't
question how much it would cost to get the care he needed, but
the care was not available. Alaska can do better. He would
rather accomplish that through incentives than directives; it is
a better business model, and Alaska's health care situation is
much more fragile than some people realize.
1:49:01 PM
SENATOR ELLIS asked if there will be any distinction between
for-profit and non-profit health care facilities.
SENATOR COGHILL said some of that is left to the Department of
Health and Social Services, but he does not anticipate that
there will be any distinction. He said Providence is most likely
to reach a Level II designation, and the regional hospital could
establish at least a Level III fairly easily. There are economic
considerations because they compete for the same customers,
which is another reason he thinks an incentive-based program is
best.
1:50:14 PM
SENATOR THOMAS said he is concerned that there is so much
lacking in Alaska's trauma care. He asked if it is due to a lack
of insurance coverage for trauma situations.
1:50:59 PM
SENATOR COGHILL answered that insurance will pay, and Medicaid
does pay, but a lot of the uncompensated care is more primary
care related, and he thinks the state should first look at
uncompensated trauma care. Another part of the issue has to do
with the different business models. For example, the Alaska
Native Tribal Health Consortium (ANTHC) is a Level II trauma
center; they keep paid doctors on staff. Doctors working at the
other hospitals have private practices to maintain and are on
call for emergency room (ER) work. Their interest is to keep
their private practices healthy, so there is a natural tension
in the working relationship. He hopes to relieve some of that
tension so trauma doctors can afford to be on call more often;
this fund will give hospitals a designated uncompensated care
package they can count on if they raise their trauma levels, but
insurance will still be a huge factor.
1:53:05 PM
SENATOR THOMAS restated that the problem is more one of having
doctors available continuously.
1:53:42 PM
SENATOR PASKVAN said he thinks the public has a natural
expectation that hospitals have the capacity to deal with
trauma. He also knows there is a contractual relationship
between hospitals and emergency rooms. He asked how this will
apply to the separate legal entity that is staffing the
emergency room.
SENATOR COGHILL said he does not know, but he thinks they should
draw that out in the course of discussion. Those contractual
relationships should not be barriers.
1:54:57 PM
SENATOR ELLIS asked if hospitals break out their uncompensated
trauma care from other types of uncompensated care. He said his
impression is that for-profit facilities "eat" less
uncompensated care; they tend to pass more of the cost on to
paying customers.
1:56:03 PM
SENATOR COGHILL responded that he is not an expert in that field
but believes the uncompensated care through disproportionate
share is streamed to hospitals when they bill Medicaid and flows
fairly equally whether an institution is non-profit or for-
profit. Probably the biggest difference is where the money ends
up in investment, whether in profit centers or additional care.
1:57:12 PM
SENATOR DYSON said the uncompensated costs for both for-profit
and non-profit hospitals often get shifted to third-party payers
and more lucrative portions of the business. Governor Murkowski
started an effort to fix that by saying, if government is going
to force hospitals to provide uncompensated care in the
emergency room, then government should come up with a mechanism
to pay for that so they don't have to cost-shift. Unfortunately,
he didn't get very far with it.
He said he is very proud of the hospitals in his area, including
Providence and Alaska Regional, but a lot of money that comes
into Providence does not stay in Alaska. He was surprised that
Alaska's hospitals are not equipped to provide a higher level of
treatment and, if this bill will provide the incentive for them
to do that, he is really in favor of it.
1:59:57 PM
SENATOR COGHILL said he thinks the profit that hospitals make is
due to them, whatever the business model. The fact is that
hospitals in Alaska cannot turn people away from the emergency
rooms, and the state has to find a way to pay for it.
2:00:54 PM
SENATOR COGHILL said the College of Surgeons recommended a
mandate, but he doesn't want to go there. This is an incentive
and, because of this bill, changes are already being made. Not
only has DHSS hired a coordinator, but hospitals have actually
begun discussions with each other and with the military, which
has trauma doctors who are familiar with trauma in war zones.
They are looking at how the military can work with the hospitals
and how they will deal with the hand-off. They already have out-
of-state doctors coming in to work at some hospitals, so he
knows it can be done.
2:02:38 PM
SENATOR ELLIS asked Senator Coghill where he came up with the $5
million figure and whether that will increase in future years.
2:03:25 PM
SENATOR COGHILL said the figure is based on data from other
comparable states and what they are doing in uncompensated
trauma care. He realizes that the department is going to come in
with a neutral position because they don't want to spend any
more money; he can appreciate that they are under huge downward
pressure, but if the state does less, it will get less.
2:04:32 PM
WARD HURLBURT, Chief Medical Officer, Department of Health and
Social Services; Director, Division of Public Health, said one
of the first things he learned when he started in his job last
summer was how appreciative people are of Senator Coghill's
interest and hard work in this area. One of the major
responsibilities of the division has to do with the prevention
of unintentional injuries and handling those after they occur.
He said he worked as a physician in Naknek, in Dillingham,
Alaska in 1961, where he saw a lot of trauma injuries. After he
completed his training as a general surgeon, he spent many years
at the Alaska Native Medical Center (ANMC), where a big part of
what he did was deal with trauma. Part of the reason for the
high incidence of trauma in this state is the lifestyle; the way
many Alaskan citizens make a living is hazardous; transportation
is hazardous; recreation in the state can also be hazardous.
DR. HURLBURT said when he was with the Alaska Native Health
Service after the 1964 earthquake, he was very involved in
planning for the new facility; as part of that planning, they
recognized the problem that unintentional injury and trauma play
in the lives of Alaska Natives and built a facility that met the
standards needed to provide that kind of care.
He stressed that trauma is the biggest killer of Alaskans from
birth to age 44; it is third behind cancer and cardiovascular
disease as the cause of death of all Alaskans, regardless of age
and is the number one killer of Alaska Natives of all ages. The
administration has learned about the trauma systems and the
categorization of trauma systems through the Alaska Trauma
System Review Committee and the Alaska Council on Emergency
Medical Services (ACEMS). The American College of Surgeons has
taken the lead; they are usually the first specialty to see
serious trauma victims, so their professional organization was
instrumental in developing Alaska's system.
2:09:19 PM
He said this is the kind of system that the rest of the country
has adopted and accepted, and it has generated improved results.
The New England Journal of Medicine, a respected medical
journal, compared the mortality outcomes for trauma victims who
got to certified trauma facilities and those who did not, and
found about a 25 percent difference. There was a lower mortality
rate for those trauma victims who were treated in certified
trauma facilities.
Alaska is the only state in the country, he said, that does not
have a Level I or a Level II trauma center for most of the
population. He admitted that Alaska may not have a justifiable
need for a Level I trauma center in the near future; the Level I
trauma center for Alaska is Harborview Hospital in Seattle at
this time. But this is the only state that does not have at
least a Level II trauma center for most of its citizens;
Anchorage is the largest city in the United States without at
least a Level II trauma center.
DR. HURLBURT confirmed that, consistent with the recommendation
in the American College of Surgeons 2008 report, they hired a
trauma system coordinator named Julie Rabeau last week. She
previously worked with Alaska Native Tribal Health Consortium
(ANTHC) and as a trauma nurse in Las Vegas. Her mother was a
nurse in Kotzebue, and her father was a doctor in Alaska, so she
has strong Alaskan roots and a passion for the job. He said they
recognize that hospital participation in meeting the criteria is
voluntary; they also recognize that the standards must be met by
both the physicians and the hospitals. For a Level II trauma
certification, general surgeons must be available in the
emergency room within 20 minutes of the call; for Level III, 30
minutes is the standard. Level II also has a higher level of
neurosurgical capability. He asserted that it would not make
sense for Fairbanks Memorial to go for Level II, but it would
make sense and would serve the citizens of that region for them
to go for a Level III.
2:13:50 PM
DR. HURLBURT agreed with Senator Coghill that it would be
reasonable for Alaska Regional to go for a Level II, but said it
probably would not meet the needs of Anchorage because Regional
does not have sufficient capacity. Providence, because of its
size and current capabilities, would be better placed as a Level
II facility. The administration encourages health care
facilities and the physician community to embrace this and seek
certification.
There is an interesting example in Tacoma, Washington, where two
large competing hospitals, St Joseph and Tacoma General, agreed
to work together to create one trauma call system; patients are
taken to one or the other depending on a schedule. He said he
was very skeptical about it when it started, but it has lasted a
number of years now and seems to work. Madigan military hospital
at Fort Lewis is also part of that collaboration, although they
don't take civilian victims there very often. Anchorage has two
large civilian hospitals and a military hospital; if they can do
it in Tacoma, he said, they ought to be able to do it in
Anchorage.
The position of the administration is neutral. The Governor
clearly recognizes and agrees with the need, but there is a
preference to do this on a voluntary basis and, in a tight
budget year, the $5 million associated with it in SB 169 is
difficult.
2:17:13 PM
SENATOR THOMAS asked if there are additional costs anticipated
in human capital, beyond the $5 million fund.
DR. HURLBURT said there is some concern among hospitals that if
they are designated as trauma centers, they will attract more
uncompensated care. There may be some other additional costs,
but the major concern he has heard articulated is that of
attracting more patients who do not have coverage.
SENATOR THOMAS said if that is case, it is not only a personnel
issue, but an insurance issue, which brings up questions such as
whether the state should mandate insurance or move toward
greater affordability of insurance for individuals in order to
remove some of the problem with uncompensated care.
2:19:08 PM
DR. HURLBURT agreed that is a major concern. He said he sees a
report each quarter on the level of profitability of the 15 or
20 largest hospitals in the Northwest. The number two hospital
in terms of profitability is generally Sacred Heart, which is a
Providence hospital in Spokane, Washington; number one is
usually Children's Hospital. Alaska's Providence is not large
enough to make it into the report, but he understands that it is
the most profitable hospital in the Providence system. He also
understands that Alaska Regional is part of the Hospital
Corporation of America and is profitable for them, so both are
solid financially. They need to be profitable in order to
reinvest and return profit to their owners; part of managing a
business is making the bottom line. The sisters are quoted as
saying "No money, no mission," and they will naturally tend to
protect any challenges to their level of profitability.
2:20:51 PM
SENATOR DYSON asked if the Alaska Native Medical Center will
treat non-native patients who need Level I or II trauma care.
DR. HURLBURT said they will take some non-native patients but
have only 150 beds, so their ability is limited.
SENATOR DYSON asked if he is correct, that nothing in federal
regulation prevents them from doing that.
DR. HURLBURT confirmed that is correct.
SENATOR DYSON asked if the same is true of the military
hospitals.
DR. HURLBURT said he does not know that system as well, but
thinks that any hospital can take a trauma victim.
2:23:00 PM
SENATOR PASKVAN said the discussion of how soon surgeons must be
available at Level I and Level II facilities assumes a
contractual agreement between the hospital and the physicians,
and that infers there is a transfer of care out of the emergency
room and into the hospital. He asked if that is true.
DR. HURLBURT replied that is basically correct. Level I trauma
centers have physicians in-house at all times; Level II centers
have anesthesiologists in-house, but not general surgeons or
orthopedists. In any hospital, the trauma victim goes first to
the emergency room to be seen by the emergency room physician
who performs triage, makes an assessment, and then calls for a
surgeon as necessary. Generally, the on-call physician sees the
patient while still in the emergency room and assumes
responsibility at that time.
Regarding the point that ANMC physicians are salaried, yes they
are, he said, but when he was a surgeon there he had a full day
operating schedule and clinics to do and did trauma care at
night. It was somewhat easier there, in that he had colleagues
who could pick up the ball from him if he got tied up with a
trauma victim, but he did have a day job.
2:25:28 PM
SENATOR PASKVAN clarified that what he is focusing upon is that
it may be troubling to members of the public if they don't
understand their emergency room is qualified to handle trauma;
he wants to be careful how they use language in this regard. He
restated that what they are really talking about is that the
emergency room physician performs triage and, while the
paperwork may take some time to catch up, there is a transfer of
care from the emergency room doctor to the surgeon who is called
to address specific issues. It is the timeliness of that
transfer of care that reduces the mortality rate that is seen in
the difference between designated and non-designated hospitals.
DR. HURLBURT agreed it is very important to recognize that the
quality of care is very good in this state, but it has been
proven that when hospitals meet the specific criteria for trauma
centers, the survival rate is significantly better.
2:27:17 PM
SENATOR PASKVAN asked what Dr. Hurlburt believes is the best way
to get the money where it is needed so that surgeons can be
there within 20 or 30 minutes.
DR. HURLBURT said he doesn't know. The study in Tacoma looked at
the different specialties and how often they get called in, and
then tried to come up with fair compensation based on those call
projections. For example, a urologist might not be called in
very often, so he would be paid less than would an orthopedist
who is called in frequently. There is an expectation in the
country today that doctors should be compensated if they are on
call; some hospitals hire physicians especially for that. He
said that raises the concern that they could be placing those
doctors in competition with the doctors on staff.
2:29:14 PM
SENATOR THOMAS mentioned information in Representative Coghill's
booklet about prevention, and asked if there are statistics to
support the success of public education programs.
DR. HURLBURT said yes, they have seen prevention efforts pay
off; the trauma mortality rates are lower than they were when he
came to Alaska, despite the advent of snow machines and other
more dangerous methods of locomotion. But, he said, prevention
can mean a lot of different things, like the program "kids don't
float," which has reduced the number of drowning fatalities. It
also means getting other disciplines involved; he cited the
improvements highway engineers have made in the safety of the
highway between Anchorage and Girdwood.
2:31:20 PM
DR. FRANK SACCO, Trauma Director, Alaska Native Medical Center;
Chair, State Trauma Systems Review Committee, Anchorage, Alaska,
said the committee is made up of doctors, nurses, pre-hospital
care workers, and hospital administrators. They meet twice a
year to review how Alaska is doing as a trauma system and find
ways to improve. Trauma systems arose from the military
experience. In that model, there is a pre-planned response.
Victims go through several levels of care from the time they are
injured; they receive initial care from pre-hospital emergency
personnel; they get stabilized; they get moved, and finally they
are admitted to the facility where they will receive definitive
care. Every person who touches those patients has the right
training; each place they go is prepared to give them the
optimal care every step of the way. That is the basis for
civilian trauma systems; both federal and state governments
recognize that. Alaska was one of many states that started down
the road toward developing a state trauma system in the early
1990s, when Loren Leman introduced the first bill and decided to
make this completely voluntary. In the 15 years since that
legislation, only five hospitals out of the 24 acute care
facilities have been designated, and four of those are in the
native health system.
2:35:10 PM
DR. SACCO said this is not a red or a blue-state issue; it is a
non-partisan issue like fire departments and ambulances. He
admitted that there are a lot of questions about how this can be
done, but there are 270 Level II trauma centers around the
country and almost all of them are community hospitals, both
for-profit and non-profit. Because a lot of states are further
along in this process, Alaska has the opportunity to take
advantage of what they have already done. This is the level of
care people want for themselves and their family members, the
kind of care most people think they already have. Some states
have waited to do anything until a high-profile incident forced
them to react, but he emphasized that this is a huge public
health problem that affects almost everybody. He thinks it is a
good idea to provide incentives for hospitals to participate,
but if that doesn't work, then the State needs to take steps to
ensure that Alaska has a trauma system.
2:38:27 PM
DR. REGINA CHENAULT, State Chair, American College of Surgeons
Committee on Trauma, Anchorage, Alaska, said she is a general
surgeon, the physician member of the Alaska Department of
Administration, Violent Crimes Compensation Board, and a member
of the Alaska Trauma Systems Review Committee. She is in the ER
a lot, and the fact that Alaska is the only state without a
designated trauma hospital for the general public is a great
concern for her. It is a public safety threat for everyone in
Alaska and, she believes, an ethical issue. She said she works
at the Alaska Native hospital, which is a Level II trauma
center; their mission is to provide care to the Alaska Natives,
and their beds are usually full. She has had the opportunity to
provide surgical care in several different places since she came
to Alaska in 2003, including Soldotna, Kodiak, Ketchikan, and
Anchorage, both in a private setting and at the native hospital,
and she stressed that there are people dying who should not be,
because the systems are not in place. There is a lot of trauma
in the state of Alaska; there are high levels of domestic
violence; law enforcement officers are being shot; Alaska has to
get this trauma designation program in place so Alaskans can get
the same standard of care that the people in the other 49 states
are already receiving. An organized approach to trauma care
gives everyone a 25 percent better chance of surviving an
injury, she said, this is the reason we must pass this bill as
soon as possible.
2:41:29 PM
DAVID HULL, Chair, Governor's Alaska Council on Emergency
Medical Services (ACEMS); Fire Chief, North Tongass Fire
Department, Ketchikan, Alaska, said he is a practicing paramedic
with 35 years of responding to all kinds of emergency calls for
help, and it is from this arena that he approaches the issue.
Trauma is any bodily injury from an external force; it can be
accidental or intentional. Trauma puts a tremendous burden on
families and communities all across Alaska. An average of 400
Alaskans die each year from trauma, and for every death, 11
people are hospitalized. Insurance does not cover all of the
costs. A study done in 2004 showed that for trauma patients in
Alaska, the economic cost of the hospital stay alone was
estimated at over $73 million; one in four hospital admissions
was uncompensated, which puts an additional burden on the
state's hospitals and health care system. The trauma system is a
predetermined, organized, multi-disciplinary response to
managing the care and treatment of severely injured people. The
statewide trauma system also provides a framework for disaster
preparedness and response. For a severely injured person, the
time between an injury and receiving definitive care is the most
important predictor of survival. It is commonly known as "the
golden hour," but in some places in Alaska, that can be a day
or, depending on the weather, a week. The local Emergency
management System (EMS) responders across the state have gotten
pretty good at getting viable trauma patients to the hospitals;
then it becomes the hospitals' and the doctors' responsibility
to keep up that good work. Increased hospital participation is
necessary for the statewide trauma system to function optimally.
The goal of a statewide trauma system is to see every hospital
in Alaska become designated as a trauma center at an appropriate
level; the ultimate goal of everyone involved however, is to
save lives. The Alaska Council on EMS seeks the legislature's
support for a fully functioning trauma system, including funding
for the development of trauma centers and legislation addressing
the issue of incentives for trauma care designation and
uncompensated care trauma patients.
2:44:53 PM
MR. HULL closed by asking the legislators to consider his
request to help build a coordinated approach to trauma
management.
2:45:02 PM
ROD BETIT, President, Alaska State Hospital and Nursing Home
Association, Juneau, Alaska, stated that hospitals support this
legislation. He said Senator Coghill attended their annual
meeting in Soldotna this year, and they talked about some of the
challenges preventing hospitals from moving forward without
legislation like this to help closed the gap on the
uncompensated care burden and the availability of physicians. To
do this, they have to be assured that physicians with specific
specialties are in the hospital within certain time frames. That
is a pretty tall order; these physicians are independent
practitioners. He thinks they can get there, but suggested that
they amend the language in this bill to give the commissioner
the discretion to use the fund to address other economic
barriers in addition to uncompensated care.
2:48:08 PM
SENATOR PASKVAN asked what the position of hospitals would be to
increasing the cost of compensated care to help cover the trauma
system.
MR. BETIT said that is the typical way of doing things. When
costs have to be recovered, either an arrangement is made with a
government entity to help offset those costs, or an increase
does appear on the payer's bill. Senator Dyson spoke to that
earlier in terms of cost shifting. He said he hopes the amount
that is not otherwise recoverable will be minimized, but trauma
tends to carry with it a larger percentage of patients who don't
have full coverage than regular health care does. These costs
would not show up in uncompensated care however, because they
are to ensure the availability of specially trained physicians
within the required 20 or 30 minute window, regardless of
whether or not there is a patient.
SENATOR PASKVAN clarified that he was asking if hospitals have
considered increasing costs for compensated payers across the
board, in order to diffuse the cost of obtaining trauma
certification.
MR. BETIT could not speak to that.
2:51:09 PM
SENATOR COGHILL asked Mr. Betit if he knows what is going on in
Congress with regard to trauma payment issues.
MR. BETIT said everything is pretty much up in the air, with all
that has been going on with federal health reform lately. He
said he will let the committee know if he gets any clarification
on that.
2:52:53 PM
MARK JOHNSON, Chief, Emergency Medical Services (EMS), Juneau,
Alaska, said he was involved with Representative Lehman when he
got the initial legislation passed in 1992-1993. It provides for
state certification of trauma centers using the American College
of Surgeons standards. He added that a comprehensive trauma
system plan as defined by the American College of Surgeons and
others includes everything from injury prevention through pre-
hospital and hospital care, to rehabilitation.
He stated that Alaska has made significant progress on
prevention and throughout the EMS and trauma systems. Alaska has
one of the most comprehensive trauma registries in the United
States; the trauma training courses required for trauma
certification, such as trauma nurse training and advanced trauma
life support have been readily available to Alaska hospital
staff for many years. Certification requires a certain amount of
equipment, which is already available in all of the state's
facilities; it requires a process for continuing quality
improvement, and that is also happening in many of Alaska's
hospitals. One obstacle to getting Alaska's trauma system to the
desired standard is that emergency departments are trained to
provide a certain level of care, but if there is internal
bleeding or another situation that requires surgical
intervention, they need to have a surgeon on call and readily
available. That is where Alaska's system is falling down right
now; it is inconsistent.
2:57:30 PM
MR. JOHNSON said this bill is a good step because it creates an
incentive, which was lacking in the previous legislation. The
American College of Surgeons recommends that every hospital in
Alaska should be designated at the appropriate level. Small
rural hospitals should be a Level IV, and four of them have
already achieved that status; mid-sized hospitals should be a
Level III. In the 1990s, his office co-sponsored American
College of Surgeons reviews at eight different hospitals in the
state, and some came close to passing Level II; the biggest
hang-up was the on-call schedule. He pointed out that some of
the surgeons who have private practices know the insurance
status of patients before they do surgery; if the surgeons are
on call for emergencies and get called in the middle of the
night, they have no way of knowing if the patient is or is not
insured, and roughly a quarter of them turn out not to be.
Hopefully, this incentive will be enough encouragement for
hospitals, in cooperation with their on-call staff, to provide
that care. He pointed out that there could also be some peer
pressure brought to bear as hospitals begin to step up, that
will encourage other hospitals to do it. He believes that once
they achieve certification, they will find it makes their
operation as a whole much smoother and more efficient.
3:00:03 PM
MARTHA MOORE, representing herself, Juneau, Alaska, said she
supports this bill and would like Bartlett to become a Level II
trauma center. She used to work in Mark Johnson's office and had
many discussions with hospital staff about this issue. She has
heard nurses say they have no idea what to expect when a trauma
victim comes into the ER; they should know and be prepared. She
has heard paramedics say that taking victims to a trauma center
has a whole different feel to them, because a trauma team is
there and ready to take over. The hospitals that have achieved
certification say that their staff's stress levels are down
because they have all trained and practiced the protocols and
procedures they will use to deal with trauma victims; they feel
confident and prepared. She thinks that if every hospital in the
state puts forth the effort to become certified, it will improve
care for all Alaskans, and she hopes this bill will be enough
incentive for them to do that.
3:03:11 PM
SOREN THREADGILL, retired Chief of EMS, Anchorage Fire
Department, Anchorage, Alaska, said he is the Chair of the Red
Cross Disaster Consortium and a member of ACEMS, and he supports
this bill. He thinks it will improve Alaska's trauma care,
thereby improving patients' outcomes. It is one of the
responsibilities of government to take care of its people,
especially in this case, when people are not really cognizant of
the difference between levels of care; they just expect their
hospitals to be able to take care of them.
He said EMS started in the 1960s due to the large number highway
traumas. There is fair amount EMS can do at the scene, but
definitive care is provided at the hospitals. The ACS review
emphasizes the importance of collaboration between EMS, the
hospitals, law enforcement, first responders, dispatchers, and
the public. If this kind of collaborative system is followed as
recommended by ACS, it really will do wonders toward improving
Alaska's trauma care.
3:05:26 PM
CHAIR DAVIS closed public testimony for today. She pointed out
that the fiscal notes attached to SB 168 from both the
Department of Revenue (DOR) and the Department of Health and
Social Services are zero, but SB 169, the $5 million
appropriation bill, is still alive if they wish to consider it
at some point.
[SB 168 was held in committee.]
3:07:12 PM
There being no further business to come before the committee,
Chair Davis adjourned the meeting at 3:07 p.m.
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