Los Angeles County: Ailing Trauma Network on the Verge of Collapse

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Burdened with the nation's highest proportion of medically uninsured, Los Angeles County hospitals and trauma centers may have to shut down. In spite of good economic times, 60 percent of the hospitals statewide are in financial difficulty. As the record influx of uninsured legal and illegal immigrants pour into the state, "The infrastructureis crumbling," complains a hospital trade group spokesman. The nation's largest public health care facility, County USC Medical Center in East Los Angeles, is teetering on the brink of bankruptcy and is seeking federal money to stay afloat. But the ultimate cost may be in human lives. "The bottom line ispeople will die," says another California health care executive.

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Friday, September 8, 2000 Ailing Trauma Network on the Verge of Collapse Emergencies: Some of the 13 hospitals have told the county they may close facilities if funding doesn't improve.


The network of hospitals in Los Angeles County that provides emergency trauma care to 16,000 patients annually is once again in critical condition, with some of the 13 centers saying that their survival is threatened. The private hospitals that treat victims of freeway accidents and gunshots and handle other emergencies face a serious shortage of money at a time when neither private insurance companies nor governments are eager to pay for an expensive--although vital--level of medical care. "The county thinks the state should pay, the state thinks the county should pay, and both think the Feds should intercede," said Dr. Don Gaspard, medical director of trauma service at Huntington Memorial Hospital in Pasadena. "It's a three-ring circus." Five private hospitals have notified the county that they may close their trauma operations, according to county officials. Officials at two of those hospitals--Henry Mayo Newhall Memorial Hospital in Valencia and Providence Holy Cross Medical Center in Mission Hills--backed away from those threats Thursday, saying that they will not close. Another--Childrens Hospital Los Angeles--said it would consider closing only if others did first. Administrators at Huntington Memorial and Northridge Hospital Medical Center said they do not want to close but will consider it if the financial picture does not improve. The crisis here is the most visible symptom of nationwide traumas in health care: Hospitals and doctors are being battered as private insurers and government programs cut back their health care payments. Simultaneously, the number of patients without insurance has risen steadily. In California, trauma systems everywhere are severely strained. Hospitals in general are in a precarious state, with more than 60% operating in the red. Doctors balk at taking money-losing emergency calls at the expense of already ailing private practices. "The infrastructure, in my opinion, is crumbling," said Gary Stephany, president of a hospital trade group in San Diego and Imperial counties. "I think the whole health care system is in a meltdown--it's not just trauma." But trauma is the most dramatic example. This is especially true in Los Angeles County, which has one of the highest proportions of uninsured people in the nation, enormous market dominance by managed care companies and a sprawling territory to serve. Eleven trauma centers have closed in the last 15 years. Any further unraveling of the fragile system could mean dangerously long delays in treating patients. "The bottom line is . . . people will die," said Jim Lott, executive vice president of the Healthcare Assn. of Southern California. Trauma centers are hospitals that keep expert surgeons and specialists on hand around the clock to serve as the primary destinations for paramedics carrying patients with life-threatening or severe injuries.

Struggling to Preserve System In a sprawling area such as Los Angeles, each center in the trauma network is vital. Even a few minutes tacked onto an ambulance ride can mean the death of a critically injured patient. All summer, county officials have been struggling to keep the system intact. The county supervisors are scheduled to consider solutions in the next several weeks--and will hold a public hearing on the problem on Monday--but few believe the county, which is cursed with unreliable revenues, can fix the problem alone. "We need a cure, not a Band-Aid," said Supervisor Mike Antonovich. "It's a vital health program that needs to be strengthened, not weakened. Right now it's on life-support." The trauma system in Los Angeles County consists of 10 private, nonprofit hospitals and three county hospitals. The linchpin of the entire system is County-USC Medical Center in Boyle Heights. A decade ago, the county spent $9 million a year to help private hospitals pay for the care of the uninsured patients who make up 30% to 40% of those in the trauma system. But the amount of money has declined steadily, and this year is only $1.5 million. The cutbacks have put the private trauma centers under considerable strain. Even if only one closes, it could have devastating effects on the centers that stay open, because patients who would have gone to the closed hospital will be routed to the others, jacking up costs still further. "It's like a deck of cards or dominoes," said Carol Gunter, assistant director of the county's Emergency Medical Services Agency. "You line them up and they're all going to go." If Huntington Memorial were to shut down its trauma services, for example, as many as 800 trauma patients a year from the eastern part of the county would have to rely on County-USC, which is already overtaxed. "I'm not trying to be sensationalist here," said Dr. Demetrios Demetriades, trauma chief at County-USC. But should Huntington's patients be routed to County-USC, "a lot of severely injured patients from the east San Gabriel Valley will die on their way to the hospital." Closing trauma centers would complicate matters for hospitals that are not even in the trauma network, because they would be forced to treat patients without appropriate medical staff or equipment. The immediate reason for the funding emergency in Los Angeles County was a dramatic cut this year in money that the state passes along from its tobacco tax receipts. Private hospitals rely on those funds to pay for care of uninsured trauma patients. When faced with a 50% cut in that money this summer, the hospitals would only agree to month-to-month contracts with the county. The legislative session ended in Sacramento last week without any additional money for trauma care. Hospitals have proposed that the county add $17 million for trauma care. But budget planners estimate that the county's health department could have annual deficits as large as $500 million within five years. That makes county officials wary of any promises. Even some state officials acknowledged that the county can't solve this problem by itself. "It has always been my opinion that the state should step in . . . to help provide this vital lifesaving care," said Martin Gallegos (D-Baldwin Park), chairman of the Assembly Health Committee. He added, however, that private insurers--who cover about a quarter of the county's trauma patients--should pay their fair share as well. Other California counties are watching closely to see if Los Angeles can fix its troubled system, said Leonard Inch, regional executive director for the Sierra-Sacramento Valley Emergency Medical Services Agency, which oversees trauma care in five counties. "Where L.A. goes, the rest of the state will follow," he said. Inch, who will address Monday's hearing, is concerned that counties are forced to fund trauma care from uncertain, sometimes wildly fluctuating, sources. Tobacco tax dollars, for example, are destined to dwindle as fewer people smoke and as Gov. Gray Davis taps the fund for health care purposes other than trauma. Developing a more coordinated system, with more stability, would be better for taxpayers and patients, Inch said, noting that a few other states have done this. Trauma doctors said the government's reluctance to step forward is galling at a time when coffers are brimming with surplus revenues. Doctors are frustrated as well at the system's inability to compensate them adequately and on time for their highly specialized services. Hospitals have gone so far as to provide stipends to specialists just to entice them to take trauma calls. Doctors say that the stipends are not nearly enough and that the work interferes with their regular practices--and their lives. Dr. Daniel Higgins, medical director for emergency services at St. Francis Medical Center in Lynwood, recalled a recent situation in which an orthopedic surgeon was called in at 2 a.m. for a three-hour operation on a car accident victim, only to be paged again while in surgery to take care of a baby with a broken elbow. The doctor, who had had no sleep, "looked exhausted and said 'No problem,' " said Higgins. "But a month from now, when he's not paid by [the county] or the HMO, chances are he's not going to sign up." Health officials say they are being forced to balance dollars against lives. "There's no question that a trauma center does save lives," said Stephen Ralph, president and chief executive of Huntington Memorial. "The question is, what is that worth?"

* * * Times medical writer Julie Marquis contributed to this story. * * *

Trauma Network Health officials are worried about the future of the network of 13 trauma centers that are the primary destinations for anyone severely injured in Los Angeles County. Source: L.A. County Department of Health Services

* * * * PARAMEDIC SERVICES There are severe problems in L.A.'s paramedic operations, a Fire Department official said.

-- K (infosurf@yahoo.com), September 08, 2000

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