4
Regionalization: Potential and Pitfalls

Jon Krohmer, principal deputy assistant secretary and deputy chief medical officer of the Office of Health Affairs at the Department of Homeland Security, served as session chair for the final panel of day 1. The session focused on the potential and pitfalls of regionalization. He noted the landmark National Academy of Sciences publication Accidental Death and Disability: The Neglected Disease of Modern Society, published in September 1966, and cited the following quote: “The patient must be transported to the emergency department best prepared for his particular problem. Hospital emergency departments should be surveyed to determine the number and types of emergency facilities necessary to provide optimal emergency treatment for the occupants of each region. Once the required numbers and types of facilities have been determined, it may be necessary to lessen the requirements at some institutions, increase them in others, and even redistribute resources to support space, equipment, and personnel in major emergency facilities.” Krohmer observed that we are still struggling with many of the same issues that were raised in that report over 40 years ago. “We have made some progress,” he said, but “we still have a little ways to go.”

FINANCING A REGIONAL HOSPITAL FROM A LOCAL TAX BASE

The first panelist was Ron Anderson, president and chief executive officer of Parkland Health & Hospital System in Dallas, a large regional hospital and a Level I trauma center that is funded by a local tax base. Anderson acknowledged that it’s tough to explain to ad valorem taxpayers how they’re funding an entire region. He indicated that there is a free rider



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4 Regionalization: Potential and Pitfalls Jon Krohmer, principal deputy assistant secretary and deputy chief medical officer of the Office of Health Affairs at the Department of Home- land Security, served as session chair for the final panel of day 1. The session focused on the potential and pitfalls of regionalization. He noted the land- mark National Academy of Sciences publication Accidental Death and Dis- ability: The Neglected Disease of Modern Society, published in September 1966, and cited the following quote: “The patient must be transported to the emergency department best prepared for his particular problem. Hospital emergency departments should be surveyed to determine the number and types of emergency facilities necessary to provide optimal emergency treat- ment for the occupants of each region. Once the required numbers and types of facilities have been determined, it may be necessary to lessen the require- ments at some institutions, increase them in others, and even redistribute resources to support space, equipment, and personnel in major emergency facilities.” Krohmer observed that we are still struggling with many of the same issues that were raised in that report over 40 years ago. “We have made some progress,” he said, but “we still have a little ways to go.” FINANCING A REGIONAL HOSPITAL FROM A LOCAL TAX BASE The first panelist was Ron Anderson, president and chief executive officer of Parkland Health & Hospital System in Dallas, a large regional hospital and a Level I trauma center that is funded by a local tax base. Anderson acknowledged that it’s tough to explain to ad valorem taxpayers how they’re funding an entire region. He indicated that there is a free rider 

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 REGIONALIZING EMERGENCY CARE problem with other local counties, where the prevailing sentiment seems to be: “Why buy a cow when you can get the milk for free?” He noted that “we are surrounded by counties that don’t have public hospitals any longer; they have sold them. The market really rules in Texas, and that’s a big problem at times.” His county commissioners often express interest in closing down the county’s borders. Parkland spends $125 million a year to fund a faculty, pay doctors, take on the high volume of low-income patients on a regional basis, as well as the low volume of high-cost patients (e.g., HIV and cancer), and absorb the cost of medical education and clinical research and development. Parkland’s expense budget exceeds $1 billion. Anderson said it has been able to stay afloat because of volume—it has about 4,000 Level I activations per year. He noted they were recently named the best hospital in a cohort of 24 academic hospitals for trauma, based on severity-adjusted mortality rates. “Planning” became a bad word in Texas years ago, he observed, when there was an effort to ration computerized axial tomography (CAT) scans and other health resources through a certificate of need process. Planning is now viewed as akin to socialism. But, Anderson argued, “We need to plan like we’ve never planned before to deal with border issues” (including county, state, and national borders). He said the local politicians don’t real- ize that H1N1 flu won’t read any stop signs or abide by any borders, nor will F5 tornadoes, or cases of major trauma. But, he said, the potential to work together and find better ways to organize is out there. “We could easily sew the state together in a quilt . . . and have regionalization fairly easily, if we had the desire to do so and the funding to do so, and if we weren’t so dependent upon local taxation.” But, Anderson said, a real funding strategy is lacking. The counties have talked about establishing regional taxation at tiered levels to be able to handle stand-ready costs. Anderson said these costs are “very, very burdensome for us to deal with,” because it means you have to be ready for whatever comes in the door, 24/7, whether you get patients or not.” However, Parkland has now reduced its excess capacity to the point that it cannot take care of heavy surges in demand. Anderson reported that there is also a lack of providers. Parkland is short on primary care doctors, trauma surgeons, orthopedic surgeons, and others. This is partly due to “huge holes” that exist in current Emergency Medical Treatment and Active Labor Act (EMTALA) rules, which allows providers not to take call in their subspecialty (although they can decide to come in for paying patients). Letting the market decide is a “big pitfall,” Anderson said. “If the market decides, folks, we are really in deep trouble.” You may not trust your govern- ment, he said, but if you trust the market, or insurance companies, or other self-interested parties, “you are in worse trouble than you even know.”

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 REGIONALIZATION: POTENTIAL AND PITFALLS Anderson spoke of the “Friday-night syndrome,” in Texas, referring to weekly high school football games between neighboring towns that are extremely competitive. In those cases, he said, “you don’t work together, you’re not collaborating at all, but you’re competing a lot.” A big problem is the need “to take down some of those parochial walls and work together for the good of our communities, rather than thinking we have to be the best in everything. Somebody has to be a Level II,” he said, and “somebody has to be a Level III. That’s one of the biggest problems we have.” REGIONALIZING RURAL PREHOSPITAL CARE Nels Sanddal, president of the Critical Illness and Trauma Founda- tion in Montana and a member of the 2006 Institute of Medicine (IOM) Committee on the Future of Emergency Care, discussed the provision of rural prehospital care. Sanddal said that in rural America, much of the pre- hospital staffing is provided by volunteers. In Montana, for example, about 85 percent of the 5,000 responders are classified as volunteers. Some may receive a degree of compensation, but by and large this is an avocation, not a vocation, for these people. In rural America, Emergency Medical Services (EMS) is often subsidized through the tax base, but the largest subsidy, Sanddal noted, comes from volunteer labor. If you had to pay those people to ensure ambulance cover- age 24/7, it would be costly. The inability to transition to a paid model is based on a fundamental flaw in the payment reimbursement system of the federal Centers for Medicare & Medicaid Services, which is that payment is based solely on patient transport. Payments are not made based on treat- ment provided or for recognizing that a transport may not be necessary. The EMS Agenda for the Future, released in 1996, advanced the idea that prehospital providers could support public health and community health functions. That concept is taking hold in other countries, where prehospital providers are being asked to assist with services such as chronic disease management and public health services such as inoculations, rather than receiving a paycheck for sitting idle 90 percent of the time. However, Sanddal observed, these models wouldn’t work under the current payment structure in the United States. Also, Sanddal noted that as EMS systems evolved in this country, there was really no forethought or planning as to where EMS agencies would be located. In fact, these systems grew up organically—“they basically sprung up wherever somebody planted a seed,” Sanddal said. Now, many of them are fighting just to survive. For most rural EMS agencies, the metric used to measure success, is: “Can I get an ambulance out the door tomorrow between the hours of 9 to 5 with a full tank of gas and two people on the vehicle?” Some of these agencies do not always provide service that

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 REGIONALIZING EMERGENCY CARE is in the best interest of the patient, he said. Sanddal observed, “Some of those agencies are clearly going to have to go away.” But part of the way we can cover the geographic holes that may develop, he said, is through regionalization. At a recent conference Sanddal attended, a person in the audience said she was from an agency that does just 12 EMS runs per year. She said that if they are able to get an ambulance out of the garage in 20 minutes, that would be a great response. But when asked whether they would allow that agency to shut down to allow for a regionalized response, she said they would prob- ably reply, “we can’t, we won’t, because they’re not going to care about our people the way we do, and it’s going to take longer to get there.” He said this is largely an issue of community identity. Sanddal said that typically the word “regionalization” is equated with things being taken away. If you have a regional airport, or a regional train station, or a regional grain elevator, it means that the local stuff is gone. So regionalization of EMS or emergency care should emphasize an inclusive model. Sanddal concluded that emergency care cannot be fixed until there is leadership at the top. Somebody has to say: we need EMS agencies at these locations, supported by regional advanced life support (ALS) and regional interfacility transfers. They will need to employ both carrots and sticks to make this type of system work. DILUTING PARAMEDIC EXPERIENCE Michael Sayre, associate professor of emergency medicine at Ohio State University and chair of the American Hospital Association Emergency Car- diovascular Care Committee, said that the various systems of critical care we have heard about today—percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), trauma centers, stroke centers—all rely on the fundamental premise that we can improve clinical outcomes by having experienced providers take care of patients. That is, if we concentrate patients in a relatively small number of centers, clinical outcomes will improve, because when you do the same thing over and over again, you get better at it. Contrast that with what has happened in EMS over the past 15-20 years, Sayre said. “We have dramatically ramped up the number of paramedics that we have taking care of patients.” In fact, many communities now have all ALS systems and paramedics on every fire truck. However, he said, “We have some evidence that that may not have been the optimal way to design the system. Even in rural areas this is somewhat of a problem. We have pro- viders who just aren’t getting the kind of experience that we need them to get in order to provide optimal care for patients.”

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 REGIONALIZATION: POTENTIAL AND PITFALLS What is the optimal balance? Sayre said he viewed this as a curve. “If you get somebody [to respond] right away, but they don’t have a clue about what they’re doing, well, that is not particularly a good thing. And if you have to wait until tomorrow to get somebody who does know what they’re doing, well, that’s not a good thing either. So somewhere in there is the optimum. The trick is figuring that out.” He said a paper soon to be released shows that in King County, Washington, cardiac arrest outcomes are better if the care team consists of more experi- enced paramedics. King County paramedics are already more experienced than paramedics in most other places, because they have less than one tenth the number of paramedics per 100,000 population than other cities. But the study will show that senior paramedics with 10-15 years of experience have better patient outcomes. By then, they have taken care of hundreds, perhaps thousands, of cardiac arrest patients and the effect is observable. Still, he said, we don’t know what the optimal point is. We need to pay attention to this as we redesign the systems. We should track whether the EMS system is delivering care by providers who have enough experience, making sure the paramedics are kept relatively few, and the tradeoff that may occur with slightly longer response times. ADDRESSING SUBURBAN ACCESS CHALLENGES Dennis Andrulis, associate dean for research and director of the Center for Health Equality at Drexel University in Philadelphia, discussed region- alization in the context of the demographic and sociological trends affecting suburban America. Andrulis noted that some of the greatest population growth is occurring in the suburban areas surrounding large cities and that these areas are also seeing some of the greatest increases in poverty. These trends conflict with where the centers of excellence have been placed for regional emergency and trauma care centers. Andrulis cited Houston as a good example. The city has 5 million people and two trauma centers, both located downtown. He asked, “What can be done to advance the care for those in the surrounding areas?” Some hospitals are expanding to more affluent suburbs, but access is much more limited in high-poverty suburbs. While 26 percent of the people live in the wealthiest suburbs, those wealthy suburbs have 60 percent of the Level I and II trauma centers, he said. He argued that the issues around access are becoming more significant and they are affecting both the city and the greater metropolitan area. They have implications for exurbs (small, usually prosperous communities situ- ated beyond the suburbs of a city) and rural areas as well, both in positive and negative ways—positive in that suburban capacity can be used to pro- vide a link to these outlying areas, but negative in that, whereas there are

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6 REGIONALIZING EMERGENCY CARE growing populations in these areas, hospitals are making market decisions to move to the rich suburbs in order to make money, essentially abandoning the poor suburbs and inner cities. Andrulis suggested a number of steps to address the problem. Federal and state leadership is needed to support providers and communities in cre- ating regional systems that connect and traverse these urban, suburban, and rural areas. A viable health safety net should be developed and maintained in underserved areas, since the suburban poor often face the longest distances to trauma centers and emergency care. As part of a broader regional strat- egy, suburban facilities should be explicitly included in transfer protocols, referral networks, and a centralized inventory of emergency capabilities. With regard to emergency practitioner capacity, suburban specialists should be given financial or other incentives to participate in emergency care systems. In addition, the National Health Service Corps could encour- age medical professionals specializing in emergency care to practice in these areas. Greater efforts should also be made to link the expertise, staff, and resources of urban emergency departments (EDs) and trauma systems with the facilities in suburban areas. For example, interpreter services and pro- tocols, which are more established in central cities, are likely to be required in many of these outer areas, and so should be integrated into the greater regional network. That way, less experienced personnel can tap into and benefit from lessons learned and resources in central cities. Finally, there should be recognition that emergency and trauma sys- tems do not work in a vacuum. They should partner with public health, environmental health officers, and communities, to bring about change that is related to a range of issues, such as urban sprawl and transportation systems, that are likely to directly affect the patients who trauma systems and emergency care facilities will address. Andrulis recommended being proactive in addressing these issues. DISTRIBUTION OF SERVICES TO OUTLYING AREAS Stephen Epstein, a practicing emergency physician at Beth Israel Deaconess Medical Center in Boston, talked about geographic access and some of the distribution issues involved in regionalization. He said that in Boston there are now five Level I trauma centers—more than there are in many states—and the city is truly a medical Mecca. But there have been efforts to transfer some of that knowledge base and some of the procedural capabilities out to the surrounding communities and to the more rural areas of Massachusetts. Epstein provided two examples: interventional cardiac catheterization and stroke centers, but, he said, these have been regionalized in very differ- ent ways. He explained that interventional cardiac catheterization was very

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 REGIONALIZATION: POTENTIAL AND PITFALLS tightly controlled until about five years ago. To be authorized to do interven- tional cardiac catheterization, you also had to be able to do a coronary artery bypass graft (CABG)—but to do a CABG you had to be a major tertiary center. As a result, there was very little interventional cardiac catheterization being done in Massachusetts outside of the three major cities. What the Level I trauma centers did was develop partnerships with some of the local community hospitals that were farther out. These are tightly controlled partnerships and backup catheterization is often only a half-hour away. But they have now been able to move interventional car- diac catheterization out to the suburbs and into the communities, thereby increasing the availability of this relatively high-tech procedure to a much broader group of people. The approach taken for the stroke centers has been very different, since the diagnosis is not as procedurally based. In this case, all that is needed is a neurologist, a CT (computed tomography) scanner, and TPA (tissue plasminogen activator). Epstein said that of the 73 emergency departments in Massachusetts, 70 are designated as stroke centers. All of these have CT scanners and TPA, and, with telemedicine, essentially all of them have neurologists. This allows stroke patients to receive TPA in a more timely manner. However, Epstein cautioned that post-TPA care for these patients typi- cally takes place at tertiary centers, so that requires additional transport, more time, more money, and more care transitions. He said the care being provided now is probably better overall, but it is probably more expensive as well. Epstein also brought up emergency department crowding. While the outflow of patients from the emergency department is the major contributor to crowding, he said that one of the things that we have thought about doing with regionalization is working on the inflow of patients. Massachusetts eliminated diversion as of January 1, 2009, and there has not been an ambu- lance diverted in the state since then. That may have caused some crowding in some hospitals. He asked whether diversion is necessarily a bad thing or whether it might be considered an important safety valve that should be more effectively managed. Boston’s 9-1-1 system is centralized—there is one ambulance service for the entire city. But he asked whether the service could be improved if, instead of those ambulances circling around the community trying to find a place to land, there was a real-time, centralized dashboard providing information about centers that are open for the specific diagnosis. Finally, he argued that health care is a market failure. The people who demand services have no idea what the actual costs are. That is a good thing in terms of patient care, but it means that supply and demand do not work together, as they did in Economics 101. Attempts to regionalize hospital

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 REGIONALIZING EMERGENCY CARE services in Massachusetts are sometimes hindered by patients’ desires to be treated at an academic medical center, which may be more expensive for procedures that might be commonly done in a community hospital. To attract patients, community hospitals often invest in expensive equipment (e.g., MRI [magnetic resonance imaging] scanners) that see relatively little use. So the government may need to take steps to restructure the market or it may need to reexamine the Medicare payment system, which currently reimburses providers based on the number of resources used, not the value of those resources. A SURGICAL SPECIALIST’S PERSPECTIVE Alex Valadka, chief of adult neurosciences at Seton Brain and Spine Institute, represented the perspective of surgical specialists. He said that they are not on the front line to the degree that nurses, paramedics, emergency physicians, and trauma surgeons are, but “at the same time, you need us,” Valadka said. “The system is not going to function well without us.” He observed that “We don’t have to wade through 50 headache patients a day to find the one who has a ruptured aneurysm, but someone has to take care of that aneurysm when you do find that patient.” Also, he noted that surgi- cal specialists often cover multiple hospitals rather than just one, which can provide a different perspective. While many people have said that medical facilities are not able to reach their specialists—the neurosurgeon, the orthopedic surgeon, the plastic surgeon—he said, “by and large, I think the system is working.” Some have said that systems are being held together with spit and chew- ing gum, but most patients do receive care. He agreed with Anderson that it’s hard to get specialists to work together in some places. But it can also be hard to get hospitals to work together. There are multiple turf issues among hospitals within communities, and they often seem intent on serv- ing their own interests more than those of their patients. Valadka noted that an earlier speaker mentioned that we have focused on Level I and Level II trauma centers almost to the exclusion of the Level IIIs and Level IVs, and Valadka agreed with the comment. “We don’t need to fill up the Level I trauma center with every patient who’s awake and alert with a tiny little bit of acute blood in his or her head,” he said. “Yet that is what often happens.” He said that in a perfect world that patient would show up at an outside emergency department, a CT scan could be viewed through telemedicine, there would be a discussion with the physician, and the patient would stay in the original location. If the patient were one of the few whose condition does deteriorate, he or she would be immediately transferred to the larger tertiary care center. “That is probably not going to happen anytime soon, but I think that is one goal we can all certainly keep

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 REGIONALIZATION: POTENTIAL AND PITFALLS working towards,” Valadka said. “We have heard that regionalization does not equal centralization, and I agree that we cannot dump everything on the main tertiary care center.” Effective regional coordination often “does not exist,” Valadka added. He has seen the two trauma centers in Houston that Andrulis had mentioned when “one was just getting hammered with patients stacked up three deep in a hallway on stretchers.” Meanwhile, “the place right next door was half-empty and there was nothing going on in the OR [operating room], and ICU [intensive care unit] beds were not being utilized.” In Houston it is commonly said that we need another Level I trauma center. His response is always “Why don’t we get better use out of all the existing trauma centers we have before we try to build a third one?” Regarding the problem that sending hospitals are pushing too many patients to tertiary centers, Valadka said that EMTALA and other laws were created because receiving hospitals often refused patients for not very good reasons (such as having no insurance). Now the situation has completely reversed itself, and tertiary and quaternary hospitals automatically take everything they receive because they know they’re being policed. But, he said, “A lot of the stuff that is being sent is not really very appropriate.” AUDIENCE DISCUSSION Session chair Jon Krohmer began the discussion period by asking the panelists to assess why it seems that regionalization has worked in some cases but not in others. Anderson noted that at the time Parkland became the first Level I trauma center in the area, many other hospitals “did not want certification or verification, they did not want to be a number two or a number three, and they didn’t see a financial reason” for participating in a system. He said they were operating under proprietary business models and were not necessarily focused on the best interests of the community. Later, they began to see that it was in their interests to join a regional system but they were not going to be forced to do it. Their primary focus was on competition, not cooperation. Anderson agreed with the earlier comment that regionalization is asso- ciated with things being taken away. One local physician had remarked to him, “I send people to Parkland, because you’ll send them back. I don’t send them close to Abilene, because they’ll keep my patient.” Anderson reiterated that for many people regionalization is something of a bad word. Once the focus shifts to quality improvement and saving lives, Anderson said, then things can happen, and they happen quite naturally. But, frankly, he said, “it is not necessarily a very good business model.” Epstein observed that the United States has not adopted a model similar to single payer in Canada or the employer-based system in Germany. In fact,

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60 REGIONALIZING EMERGENCY CARE reaching a consensus on a system here may be an unrealistic goal. The real challenge, he said, may be to develop a system of regionalization flexible enough to allow for variation. This gets to be very complex, he said, and it is a very challenging problem. But the bottom line is you either have to move the system to the population or the population to the system. Regionalization is not black or white, Valadka said. It’s gray and it’s disease-specific. In the world of neurosurgery, patients are often de facto regionalized, because neurosurgery has become such a highly specialized area with a limited number of providers. Plus younger physicians nowadays have a focus on lifestyle issues that makes providing specialist coverage more difficult. Responding to an earlier point, Valadka said that in some communities the problem is not holding on to the patients inappropriately, it’s not being able to get rid of them. Often, there is no place for (non-resourced) patients to go. “On the other hand,” he said, “if that same patient has resources, they’re going to be in a rehab facility tomorrow, no question.” Sanddal said that he’s had the pleasure to serve with the Trauma System Evaluation and Planning Committee and has examined more than 20 state trauma care systems from a high-level perspective. He said the systems that are the most mature have two or three outstanding features. First, they have strong medical leadership that is willing to stand up, take on criticism, and help resolve issues among the various facilities and agencies. In addi- tion, they have legislative authorization, and this authorization is actually enforced. Many states have rules on the books, he said, but when it comes down to it, they are not applied. Turning to the issue of financial self-interest, David Boyd, former national director of the federal Office of Emergency Medical Services System asked the participants to consider a public utility model. He said such a model has benefits and it should not be viewed as socialized medicine. It is grouping hos- pitals organizationally in a way that gives them a kind of quasi-governmental status. This can be used to leverage real effectiveness. What we have now, Boyd said, is a situation where hospitals can opt out at various times of the day or seasons of the year, or for various other reasons. He said, “Nobody can manage that. I don’t care what kind of leadership you have, that is unmanageable.” He argued that a public utility model can be self-regulatory and self-determining. Anderson supported the public utility concept. Krohmer asked the panel whether the regional boundaries established by a state for its trauma system will necessarily be the same as the regional boundaries for cardiac, stroke, and pediatric care systems. He asked whether a state could potentially have six trauma regions, five cardiac regions (that cannot be superimposed), and four pediatric regions (that also cannot be superimposed). Epstein said that procedural specialties for the more cognitive diseases,

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6 REGIONALIZATION: POTENTIAL AND PITFALLS such as stroke, can be greatly dispersed, but the procedural disease processes require a greater degree of centralization. He said there will naturally be some variation. According to Valadka, the shape of regions will definitely depend on how they are constructed. These boundaries should be based on existing referral patterns and where the tertiary/quaternary centers are, he said. If the boundaries are determined politically, they may not bear any relation- ship to reality. Which Services Should Be Regionalized? Joseph Waeckerle, editor emeritus of Annals of Emergency Medicine, asked, “When you are talking about regionalization, what are you going to regionalize?” He said he presumes that the list includes trauma, cardio- vascular disease, and pediatric disease, but what about neurosurgical disease, or ear, nose, and throat (ENT) emergencies, or behavioral health and psychiatric disease? “Are we going to have a center of excellence and a regionalization system for everything?” he asked? “If so, how are we going to justify that? Which should come first, the regionalization or the research? Then the question becomes, who will organize the regionalization? How is it going to be done and where is it going to be done?” Waeckerle said the centers of excellence in his area are divided into public and private, and the private facility is “pretty damn proprietary. They don’t want to be even talking to each other.” When you start talking about integrating them with the university, you start to get into town-and-gown issues. Then there are some people in Missouri, who will have to go to other parts of the state, and some will have to go into Kansas—where we still have a border war from the Civil War. Then, Waeckerle said, we have to deal with the physicians and the divisions that arise between the ivory tower university and the real world. There are the practical issues of how patients will be transported. Most rural communities are poor, and 60 percent of the EMS personnel are volunteers. They don’t get paid. They often can’t maintain their perishable skills. And it’s a long ride from Sikeston, Missouri, to any medical center. Waeckerle cautioned, “We ought to begin to consider these issues when we talk about regionalization.” Regionalization is not going to work for every one of the 23 specialties and every type of disease there is, he said. “People don’t want to go out of their communities. They don’t want to lose their doc. They don’t want to be away from their family. They don’t want to go hundreds of miles and then have to figure out how they are going to do follow-up in the future.” Handrigan replied, “I think the questions you raised are exactly the right questions.” If the framework is regionalization as centralization, he

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6 REGIONALIZING EMERGENCY CARE said, “Your comments are right on. I don’t think that [model] would work.” However, he said, if we frame regionalization as partnership development at the community level and make it about finding ways to make the best use of existing resources, then we won’t have patients traveling 50 or 60 or 200 miles for care. But “We do need to think about those things in advance,” he agreed. We need to find a way to regionalize emergency care services, Handrigan continued, without disturbing the existing safety net. In part, that means reaching out to the specialists and surgical subspecialists, but it also means reaching out to the primary care providers, because many people are utilizing emergency care services for primary care issues. We need to talk to primary care folks about what regionalization means to them and how we can all do this successfully together. Anderson said, “I don’t think you are going to find regionalization schemes that will work equally well everywhere. A lot of it depends upon relationships.” He added that Parkland is becoming an integrated health care system of its own—for example, by putting primary care clinics and subspecialty clinics in high poverty areas and providing chronic disease management. However, he noted, there is also interdependency among the facilities in the region. Parkland performs 70 percent of the major trauma, but if others, such as Baylor and Methodist and Children’s, didn’t also do trauma there would be much too much for Parkland to handle. “So we work together and we collaborate.” He said, “If something bad happens and we catch a cold, [then] they’re going to get at least a cold too, [perhaps] pneumonia. So we’ve got to work together.” Still, he said, regionalization is not easy and it cannot be applied to every disease. Sanddal said if we can reach a conceptual agreement that we all live under a large emergency care tent, then the referral patterns for the specific diseases can be overseen, and quality can be assured through a larger process. One of the strengths of Maryland’s system, he said, is that it manages every- thing out of this large tent model. He argued that trauma care systems made a critical error in their early years when they became exclusive systems. He said we now know that they need to be inclusive for many reasons, not least of which is the need to get buy-in from all the resisters, including other facili- ties and also EMS agencies that feed patients into those systems of care. EMS Liability for Hospital Bypass Andrew Roszak of the Emergency Care Coordination Center said that regulation of EMS is largely a state function and these regulations vary considerably across state. In cases where the nearest hospital is across the state line, EMS provider licenses differ in terms of what they allow. He observed that “a lot of the states have dealt with that issue but some have

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6 REGIONALIZATION: POTENTIAL AND PITFALLS not.” Similarly with treat-and-release programs—there are a number of states that have not given proper legal authority for paramedics in the field to do this. As we look at regionalization, Roszak said, there are liability issues associated with bypassing the closest hospital. If the closest hospital tells EMS to transport to the next town over, but then something happens to the patient en route, that could result in liability for both the ambulance provider and the hospital. Some states have addressed this in state law and have created some immunity provisions, but several states have not, so it is definitely an issue that needs to be examined. Roszak said there have also been troubling court cases dealing with EMTALA. If EMS personnel work- ing for a hospital-owned ambulance company call to consult medical control and are told to take the patient to a different hospital, [then] that could be considered an EMTALA violation. Finally, Roszak asked, if all of a sudden the standard operating pro- cedures of transport to the hospital in your town change and EMS are instructed to transport to a facility that is an hour away, what happens if that fire department or ambulance service gets another call during that time? If there are no mutual aid agreements in place and a bad outcome ensues, will there be liability because the town was left exposed? Sanddal responded, “I actually think that regionalization reduces liability.” He said one of the reasons it does so is that it is driven based on best practice. He pointed to the National Highway Traffic Safety Adminis- tration’s effort to develop best-practice strategies in the EMS environment and declared that if EMS are following those best-practice guidelines within a systemized regional approach to emergency care, “I think our immunity is much greater than it is if we’re just doing whatever the doctor on the phone tells us to do today or tomorrow or the next day. Bass agreed, saying that for inter-facility transports for patients with time-critical conditions, EMS personnel are exposed to liability unless they make transport decisions based on clear, published guidelines for the region-wide system. Otherwise, they face tremendous liability exposure for long-distance transfers. Workshop chair Arthur Kellermann closed the first day by saying he wanted to challenge the members of the audience to think about how we can narrow down the issues that had been discussed over the course of the day and figure out how to move the ball forward and make a difference. He asked: “What are the actionable, concrete strategies that we can develop to move this topic forward?” Noting that the problem is clearly very complex, he said, “We need to start pruning the tree back” and looking at things we can do to make a difference. Kellermann emphasized that the boundary surrounding this topic is the expeditious management of time-critical emergency conditions. These conditions may have taken decades to develop, but they can unfold over

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6 REGIONALIZING EMERGENCY CARE minutes. He asked, “Are there regional strategies that we can take to make a difference for that child, or trauma victim, or stroke case, or whatever it may be? How can we do that in the most efficient and effective way?” EMTALA Regulations Rick Wild of the Centers for Medicare & Medicaid Services (CMS) said that as a regulator, he is aware that EMTALA may have negative con- notations for some providers. However he noted that when hospitals offer services and advertise that they are, for example, a neurosurgical center of excellence, or that they have surgeons on staff, but nobody is taking call, that is a problem and it is something that CMS can help address. He said that while CMS does not designate specific physician call schedules, they require that hospitals demonstrate that they have a system in place. The hospital board needs to ensure that that hospital has coverage for those specialty systems. Wild said that CMS regularly reviews these issues. For example, to fol- low the point that Anderson raised, when CMS finds out that a surgeon is coming in to see their own patients in the emergency department but is not available for emergency call, that can present a problem. However he said they carefully examine each unique situation, because they understand that in some cases physicians may have to see their hospitalized patients but still do not take call. EMTALA aims to ensure that capacity and capability are utilized in a rational way, with the right levels of capacity being available at the right times. He said that CEOs would prefer not to report each other, but “if one facility is getting dumped on all the time, we need to hear about it, because we will not routinely learn about these patterns from individual patient complaints.” CMS’ response in these situations, he said, is to conduct an investigation, and if non-compliance is identified, request a plan of correc- tion. This generally does not involve monetary penalties, however CMS is required to propose termination of participation in the Medicare and Med- icaid program if an acceptable plan of correction is not provided. REFERENCE NAS and NRC (National Academy of Sciences and National Research Council). 1966. Acci- dental Death and Disability: The Neglected Disease of Modern Society. Washington, DC: National Academy of Sciences.