Los Angeles County's trauma center network, established in 1983 after years of contentious planning, is facing an uncertain future because no provisions have been made to defray the costs of treating large numbers of uninsured patients.
This financial hardship, which reflects a national problem, has already caused one inner-city hospital to drop out of the network and a second to announce that it will do so later this month. A third hospital is experiencing similar problems. And a fourth has dropped out for other reasons.
Trauma care experts and county officials see no easy solutions, but proposals to reimburse the hospitals that treat a disproportionate number of uninsured trauma patients are pending in Washington and Sacramento. One idea is to raise money by putting a surcharge on traffic tickets, since motor vehicle accidents are a major cause of trauma injuries.
In a sense Los Angeles is lucky to have a trauma center program at all--most areas of the country do not have organized programs to save those who have been shot, stabbed or severely injured in motor vehicle accidents. Southern California, where San Diego and Orange counties also have trauma networks, is an exception.
The Los Angeles County network is designed to guarantee critically injured patients a 20-minute or less ambulance ride to a hospital, where a specially trained surgeon and other personnel are available around the clock to back up emergency room staffs.
Health officials are still hopeful that the 20-minute transport goal can be met even after Hollywood Presbyterian Medical Center, the county's fourth-busiest trauma hospital, withdraws from the program on Feb. 23 because of "financial hardship."
"We've patched the system, but we haven't solved the central (financial) issue," said Virginia Price Hastings, director of the county's trauma center program after a meeting last week with the Los Angeles city Fire Department paramedics and representatives of the nearest trauma centers: Cedars Sinai Medical Center, County-USC Medical Center and St. Joseph Medical Center in Burbank.
Cedars-Sinai and County-USC will receive the bulk of the patients that paramedics have been taking to Hollywood Presbyterian, although Hollywood Presbyterian will continue to receive some critical patients during heavy traffic periods and others who may not survive an ambulance ride to another hospital.
But there is concern that the increased strain on these hospitals as well as similar difficulties at Daniel Freeman Memorial Hospital in Inglewood may create a "domino effect" that would disrupt the entire system, according to Robert Gates, the director of the county's Department of Health Services. And there are other pressing concerns for the 20-hospital network as well, including establishing a system to monitor the quality of trauma care.
"We have our own financial problems to deal with, (including) a proposed reduction of $100 million in next year's budget," Gates said. "It is going to be very difficult for us to find money to deal with any new problem, no matter what that problem is."
Inadequate subsidies for trauma care in urban areas are "penny-wise and pound-foolish," said Dr. Philip Bosco, assistant director of Hollywood Presbyterian's trauma center. Not only do trauma systems "save lives" but "the cost of medical care to the community goes down because there are less (trauma-related) lawsuits and prolonged hospitalizations," he said.
After the county's trauma center program was established, it was anticipated that some of the hospitals that saw limited numbers of trauma patients would drop out of the system. Pomona Valley Community Hospital dropped out for this reason last October.
But it was not expected that the busier hospitals would also experience financial difficulties. Indeed, many private and nonprofit hospitals competed with each other to sign up for the program, thinking that trauma care would be prestigious and potentially lucrative.
Even if they didn't make money on trauma care, hospital administrators thought that the designation would attract additional patients and physicians, according to Dr. Albert Yelin, chairman of the Southern California Committee on Trauma of the American College of Surgeons.
But as the expenses mounted, some hospitals reconsidered. California Hospital Medical Center in downtown Los Angeles dropped out in February, 1985, eight months after it joined the program.
Hollywood Presbyterian said its withdrawal was based on a "dramatically" increasing number of uninsured trauma patients; of the 1,000 trauma patients it saw in 1986, 45% were indigent. Many could not be transferred to county hospitals after they were stabilized because these facilities were already full.
So far, Daniel Freeman, where 55% of the 1,283 trauma patients treated in 1986 were indigent, has taken a different approach to uncompensated care. Instead of withdrawing from the trauma system, it is asking the county to instruct paramedics to send more of these patients to neighboring trauma centers, such as County-Harbor-UCLA Medical Center in Torrance, UCLA Medical Center and County-Martin Luther King Jr.-Drew Medical Center.
"If Daniel Freeman were to go, there would be a certain amount of chaos in the system," Yelin said. "County-USC Medical Center and Martin Luther King (the two busiest trauma centers) are already working at over 100% capacity. They cannot continue to take added numbers of patients without a very significant impact on the quality of care."
Later this year, the financial burdens of uncompensated trauma care will be at issue in the Los Angeles County Board of Supervisors budget hearings and when bills to address the problem are debated in Washington and Sacramento.
In Washington, legislation sponsored by Sen. Alan Cranston (D-Calif.) would increase federal support for trauma care, including grants to reimburse trauma centers for the costs of treating uninsured patients.
In Sacramento, legislators will debate a proposal by Sen. Ken Maddy (R-Fresno) to create a fund to reimburse uncompensated emergency medical care by adding about a 10% surcharge to fines for moving violations, including speeding and drunk driving. This surcharge would raise about $25 million a year.