Legislature(2009 - 2010)HOUSE FINANCE 519
04/06/2010 09:00 AM House FINANCE
| Audio | Topic |
|---|---|
| Start | |
| HB168 | |
| HB413 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | HB 168 | TELECONFERENCED | |
| + | HB 413 | TELECONFERENCED | |
| + | TELECONFERENCED |
HOUSE 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."
9:09:38 AM
REPRESENTATIVE BOB HERRON, SPONSOR, explained that the
legislation would set up a trauma care fund that could
reimburse trauma centers for uncompensated or
undercompensated services and create incentives for forming
trauma centers. The measure could help Alaska establish
have more trauma centers and balance services to people in
need.
Vice-Chair Thomas MOVED to ADOPT Work Draft CSHB 168(FIN)
(26-LS0437\P, Mischel, 3/24/10, copy on file) as a working
document before the committee. Co-Chair Stoltze OBJECTED.
SENATOR JOHN COGHILL, SPONSOR, explained that the CS would
remove the alcohol tax as a funding source. The CS would
establish compensation standards to encourage hospitals to
incentivize doctors. Section 1 would remain the same.
Section 2 discusses how to manage the funding sources.
9:13:40 AM
Vice-Chair Thomas asked whether the Alaska Native Medical
Center (ANMC) was the only trauma center in Anchorage.
Senator Coghill replied there were 24 hospitals in Alaska,
one Level II hospital (ANMC in Anchorage) and four Level IV
trauma centers. The Alaska Native Medical Center is the
only major qualified trauma center in Anchorage; generally,
it did not serve the wider population. He pointed out that
there were two hospitals in Anchorage (Regional and
Providence Hospitals) and one in Fairbanks (Fairbanks
Memorial Hospital) that could reach higher levels; the fund
was intended to incentivize that process.
Senator Coghill reported that Providence Hospital wanted to
be certified under national standards. The doctors at ANMC
are on contract and work under the conditions required of
Level II centers (doctors have to be on call and able to
arrive within 15 minutes or present at the facility).
Doctors at Providence and Regional Hospitals work with
hospital privileges and are on a rotational call, but there
is no guarantee that doctors will arrive at the hospital at
a certain time. The protocols and the equipment are
different as well.
Senator Coghill stated that the legislation would
incentivize for uncompensated and undercompensated care.
The fund would incentivize organizations to organize and
make agreements about handling emergency responses at the
trauma center. He referred to backup materials ("Trauma
Care in Alaska 2010" copy on file) and pointed to the
American College of Surgeons report (November 2008), which
informs the bill. He noted the advantages and assets of
trauma care referenced in the report:
· Committed individuals who use their time and expertise
every day to serve Alaska citizens.
· Extensive networks for transport.
· 3 large medical centers with extensive subspecialty
expertise within the state.
· Large Level I trauma center in Seattle which freely
accepts adult and pediatric trauma patients.
· One center maintains ACS Level II verification
standards and others have obtained consultations and
are working toward verification.
· Alaska Trauma Registry - all 24 acute care hospitals
provide data.
· Injury prevention activities are well established.
· Initial efforts at legislative change.
Senator Coghill listed challenges and vulnerabilities:
· No trauma system plan.
· Geography/Weather/Remote and isolated communities.
· No standards or scene trauma triage or trauma inter-
facility transfers.
· Trauma system issues have limited visibility within
state government.
· Public not aware of trauma system issues.
· Limited human resources.
· Few incentives for hospitals to participate.
· No statewide evaluation of system performance.
9:18:29 AM
Senator Coghill noted that the legislation intended to
address the item on the list of challenges regarding few
incentives. He added that the College of Surgeons report
recommended that the bill mandate [that hospitals achieve
trauma care system standards] as some states do. He thought
having a fund with incentives was a better approach. The CS
included the requirements for getting into the fund and
incentives for using it properly. He commended ANMC and
urged the rest of Alaskan facilities to follow suit.
Vice-Chair Thomas asked whether the bill would allow non-
Native people to use ANMC for trauma situations. Senator
Coghill responded that the bill does not address the issue,
but there are protocols at the medical center to allow
trauma cases. He thought hospitals outside the Native care
system needed to step up.
Representative Austerman asked how many hospitals have the
ability to take advantage of the fund. Senator Coghill
replied that every hospital had the ability. Some hospitals
have already gone through the process and gotten a Level IV
designation. Of the 24 hospitals in the Alaska, only five
have actual designations and nine are under review, leaving
quite a few hospitals that could take advantage of the
measure.
9:22:42 AM
Representative Austerman asked what steps have to be taken
to achieve appropriate status and queried financial
barriers. Senator Coghill answered that there are
requirements. There are national standard for Levels I, II,
III, and IV with different requirements and various
reviews, including staff, equipment, and timeliness of
response. He stated that the fund was meant to encourage
hospitals to begin the process and to work with the
doctors.
Representative Austerman wanted to discern the practical
and financial steps necessary to meet the requirements,
especially outside major population centers that are able
to support expensive equipment. Senator Coghill responded
that in most outlying areas, personnel such as Village
Public Safety Officers, Emergency Medical Services (EMS)
personnel, public health officials, and medical transport
personnel would work to stabilize patients in order to get
them to the next level of care needed. A hospital will
perform at the level it can. The fund would provide
incentives to get hospitals to the highest level possible.
The reality is that there will not be a Level I hospital in
Alaska, as a facility at that level must be a teaching
hospital. Alaska can have level II facilities, like the
ANMC. He thought Fairbanks could rise to a Level III, which
would enable them to stabilize and prepare patients for
treatment.
9:26:37 AM
Representative Austerman queried the cost factors of the
fund. Senator Coghill responded that they had looked at the
trauma mandates and requirements throughout the U.S. and
calculated for Alaska's population base and geography. The
sponsors thought that having $5 million in a fund would
adequately provide the ability to give incentives. The
money could be divided several ways. Some of the Medicaid
money could be matched by state money. Hospitals get a
certain amount for Medicaid that they are able to use for
match money. Services with billing must be performed in
order to access the money. He thought there were other ways
to enhance Alaskan dollars. Research on funding sources
resulted in a preliminary list, including funding private
sources and grants, but he believed the state should put
some money in to get the fund in place.
Representative Austerman pointed to page 2, line 11,
regarding spending up to 25 percent of the fund for one
facility and queried how to replenish the fund. Senator
Coghill responded that he did not want any one hospital to
dominate the fund. He thought it would be unwise to deplete
the fund. He was open to discussion; the provision was just
a way to limit one entity from getting all the assets.
9:30:35 AM
Representative Austerman commented that up-front money
would be needed to get started, plus there would be annual
needs. He was not optimistic about pulling funds from the
sources referenced on the list.
Representative Foster queried the total need relative to
the $5 million. Senator Coghill responded that the number
was a judgment call. He reported that other states have
mandated meeting the standards and put the cost on the
facilities. He thought that factors unique to Alaska would
affect the situation. He viewed the fund as a way for the
state to contribute to the process. He agreed that the
total need was unknown. He pointed out that the hospital
association and the insurance people would have numbers.
Representative Foster referenced a fact sheet from the
Alaska Statewide Trauma Center saying that in 2004, the
economic cost of hospital stays alone for trauma patients
in Alaska was estimated at over $73 million; one in four
hospital admissions were uncompensated. He asked whether
there were updated numbers. Senator Coghill replied that
much of the uncompensated care would be picked up by the
state or Medicaid, requiring matching funds. He recommended
taking Medicaid (disproportionate share) money and matching
it to get more money. He thought the window in which to do
that from the federal government might be two or three
years.
Senator Coghill argued that people would not get served and
would die if the state did not incentivize trauma care. The
state was already spending money for trauma care.
9:34:35 AM
Vice-Chair Thomas queried using alcohol and tobacco tax as
other states do. Representative Herron responded that the
House Health, Education and Social Services Committee had
discussed the major causes of the kinds of trauma cases
coming to hospitals and determined that alcohol was
related. There was discussion as to why the alcohol money
would not work.
Senator Coghill explained that both the tobacco and alcohol
taxes were considered, but they are general funds. The
proposed fund would have the option of drawing other money
as well. Some states use vehicle registration funds, as the
vast majority of trauma cases result from using alcohol and
vehicles together. He emphasized that there are other ways
to collect the funds, including increasing alcohol taxes.
Vice-Chair Thomas referred to previous legislation related
to tobacco tax and questioned why the tobacco tax could not
be used.
9:38:15 AM
REGINA CHENNAULT, GENERAL SURGEON, ALASKA NATIVE MEDICAL
CENTER and MEMBER, VIOLENT CRIMES COMPENSATION BOARD (via
teleconference), spoke in support of the legislation. She
informed the committee that she also served on the Alaska
Trauma System Review Committee and was the American College
of Surgeon's chair for Alaska's Committee on Trauma. She
pointed out that trauma was a public safety threat for all
citizens. She had seen people die because of the lack of
standards. She emphasized that the state is paying through
Medicaid dollars for some of the care, but the quality of
care that the rest of the nation receives was not being
met.
Representative Joule asked for elaboration regarding the
level of care in Alaska. Dr. Chennault described a recent
experience in an Anchorage hospital related to a violent
act. She had received a complaint because a person had been
picked up with life-threatening injuries; the emergency
personnel had tried to take her to one hospital (she would
not name the hospital) but the patient was turned back
because no surgeon was available. The patient was brought
to ANMC with good results, but she could have easily bled
to death without timely care. She was aware of other
similar cases during her tenure in Alaska.
Representative Joule asked how the legislation would change
the situation. Dr. Chennault referred to the review done by
the College of Surgeons (copy on file) listing 70 major
problems with Alaska's response system. She described care
that was automatically given in other parts of the country.
The important issue is timely care. Some hospitals do not
want to put up the money to train doctors and nurses. She
added that in the private sectors, doctors do not want to
be required to arrive at a hospital within 15 minutes,
which could mean the difference between life and death for
a trauma patient.
Representative Joule asked whether the goal of the
legislation was to change the behavior of service
providers. Dr. Chennault replied yes, to change the
behavior of both providers and hospitals, because sometimes
it comes down to training, equipment, or response
protocols. She pointed out that the same capabilities were
the backbone of preparedness response for natural disasters
like earthquakes.
9:43:21 AM
FRANK SACCO, TRAUMA DIRECTOR, ALASKA NATIVE MEDICAL CENTER,
ANCHORAGE (via teleconference), testified in support of the
legislation. He noted that the issue was a public safety
issue that applied to everyone, because a trauma system
decreases mortality by 15 to 25 percent.
Dr. Sacco informed the committee that he had been chair of
the Trauma System Review Committee and was the Trauma
Director at ANMC. He has been involved in developing a
trauma system in Alaska for 15 years. The original
legislation set up the framework for a trauma system but
did not provide incentives or disincentives for hospitals
to participate, and little progress was made. He pointed to
recommendations by the College of Surgeons' review.
Dr. Sacco explained that ANMC takes seriously injured
patients and would never turn a patient away. However, ANMC
has limited capacity and is often 100 percent full. It has
served as a safety net for the broader community, but at
times has been the only hospital available to take care of
critically injured children for several months at a time.
He wanted all the hospitals to be at Level II response
capability; the fund in HB 168 would allow hospitals to
help doctors be available on short notice. The costs to
smaller hospitals without surgeons would not be very large,
which is why there are four hospitals in rural areas at
Level IV capability, including Norton Sound Regional
Hospital (Nome), Yukon-Kuskokwim Delta Regional Hospital
(Bethel), Sitka Community Hospital (the only private
hospital), and Mt. Edgecumbe Hospital (Sitka).
Dr. Sacco emphasized that the most important part of the
system was continuous re-evaluation of care and outside
review of care, which results in steady improvement. He
believed HB 168 was a good start and that the incentives
were important. He thought if the incentives did not work,
then more would be needed. He pointed out that the size of
the $5 million fund amount was taken from states with
similar population.
9:48:20 AM
Representative Joule referred to the fact sheet stating
that more than 400 Alaskans die from trauma each year and
that more than 800 Alaskans are hospitalized because of
trauma. He asked whether the numbers would have been lower
if there had been trauma centers in place. Dr. Sacco
responded that other states have been able to decrease the
mortality rate related to trauma by 15 to 25 percent. He
believed that saving even 10 percent of the lives of trauma
victims, or one person each week, would have tremendous
impact. He reminded the committee that for every patient
that dies, three people are left with permanent
disabilities. Those people will never work at the level
they once had worked and the state would have to provide
additional resources. He underlined that the legislation
would save lives and emphasized that Alaska has the second
highest death rate from trauma in the country.
WARD HURLBURT, CHIEF MEDICAL OFFICER/DIRECTOR, DIVISION OF
PUBLIC HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES,
spoke in support of the bill. He remarked that his clinical
background was as a general surgeon, and that he had worked
many years in Alaska's Native healthcare system. He was
very involved with trauma systems and had served as
Director of ANMC. He emphasized that the administration
supported the concept of HB 168 and was neutral regarding
the fiscal note.
Dr. Hurlburt informed the committee that the U.S. had
adopted the kind of system that has been described as the
way to deal with trauma. He noted that studies conducted
nationally and reported in the New England Journal of
Medicine have documented that trauma victims who receive
care in certified and designated facilities have a better
survival rate.
Dr. Hurlburt described the process of setting up a trauma
system. The American College of Surgeons Committee on
Trauma comes to a hospital, uses criteria to develop a
report, and certifies whether a hospital meets the
criteria. The state then designates the hospital as far as
levels. He did not believe there would be a Level I trauma
center in Alaska; Harborview Hospital serves as the Level I
trauma center for Alaska, Washington, and Idaho, and much
of Montana. However, ANMC is a Level II trauma center that
meets the necessary criteria; it does care for non-Native
people, but does not have the capacity to take care of the
other 85 percent of the population of Alaska on a regular
basis. As a result, Alaska is the only state where most of
the population does not have access to a Level I or II
trauma facility. Anchorage is the largest city in the U.S.
without a Level II trauma center. He declared that Alaska
is not participating in a system documented to save lives.
Dr. Hurlburt stated that the department would like to see
every hospital reach its appropriate designation. He noted
Sitka Community Hospital, a small hospital that took the
issue seriously and was able to meet the criteria. He
thought Level III would make the most sense for Fairbanks
Memorial Hospital. To achieve Level II, surgeons must be
available within 15 minutes. The surgeons at ANMC generally
stay in the hospital at night when they are on call; part
of the reason is that the facility has become increasingly
busy. The 15-minute availability is a major issue in other
Anchorage hospitals.
Dr. Hurlburt reported talking with the administrator of the
hospital in Soldotna, which would look at a Level III.
Ketchikan had recently looked at becoming a Level III
hospital, but did not meet the criteria because of
equipment.
9:56:28 AM
Representative Austerman asked whether the amount available
in the $5 million fund could get Anchorage hospitals to a
Level II designation. Dr. Hurlburt replied that as a
surgeon, he had expected to be on call. Younger doctors
expect to be paid more to be on call. The Alaska Health
Commission (which he chairs) calculates that approximately
$6 billion is spent in Alaska per year on health care, a
huge part of the state's economy. Physicians expect to be
compensated. He estimated that the $5 million was a good
amount, although only time would tell if it was enough. He
provided the example of two hospitals in Tacoma and Pierce
County in the state of Washington that had developed joint
compensation for an on-call system. Other states have
simply mandated that hospitals meet the standards.
Representative Joule noted that ANMC was designated as a
Level II facility, but that its certification had been due
in 2009. He asked whether the facility had been
recertified. Dr. Hurlburt responded that they were
recertified and have maintained the three-year
certification.
10:00:31 AM
MARK JOHNSON, MEMBER, ALASKA TRAUMA SYSTEM REVIEW
COMMITTEE, JUNEAU, spoke in support of the measure. He
described his experience as the chief of emergency medical
services for the state. He had been involved in the 1993
legislation and the subsequent development of regulations.
The American College of Surgeons standards had been
adopted; the same standards were part of HB 168. He had
taken part in reviews of eight hospitals in Alaska. They
had had a federal grant but it expired and momentum was
lost. Many studies have been done showing the difference in
outcome when standards are being met. He noted that trauma
was the number one cause of death for ages 1 to 44 and a
major cause of death and disability for all ages.
Mr. Johnson believed that HB 168 would move the state in
the direction of getting hospitals to meet national trauma
system standards. He described the process used in Alaska
and noted lesser expense for small rural hospitals. He
pointed out that the American College of Surgeons had 16
major recommendations. He commended work done to implement
some of the recommendations.
Mr. Johnson stated that undocumented care has cost $20
million; he was hopeful the $5 million fund was enough to
move forward.
Mr. Johnson emphasized that a certain percentage of people
who get definitive care within the first six to ten hours
would result in a better outcome and that the rural
hospitals could make the difference. He thought there could
be more prevention as well.
10:06:07 AM
Representative Austerman referenced the six-to-eight-hour
time period and asked about level designations. Mr. Johnson
answered that Level IV is the most basic level identified.
He pointed out that rural health clinics in Alaska have to
be considered. They would not be covered by the bill, but
their personnel also need the right kind of training.
Representative Austerman queried the number of hospitals in
the state with the potential to get to Level IV. Mr.
Johnson replied that every hospital in the state besides
Fairbanks, Mat-Su, Anchorage, Kenai Peninsula, Juneau, or
Ketchikan could be at Level IV. He listed hospitals that
could be various other levels. He emphasized that it could
be done.
Co-Chair Stoltze closed public testimony.
HB 168 was HEARD and HELD in Committee for further
consideration.