S.D. County’s Trauma Care Acclaimed but Troubled

Martin Buser has a trauma care program to be proud of.

As administrator of Scripps Memorial Hospital-La Jolla, he helps preside over one-sixth of a countywide program that in 1986-87 brought more than 5,000 people back from the brink of death.

Scripps managed to lose only $635,000 in the process, less than one-third of the amount lost by some other hospitals in the system.

This year the financial picture looks dimmer.

“We were going along great, and then over the last 90 days we had three cases--$300,000, $500,000 and $50,000--that had no (insurance) coverage,” Buser said last week.

$9 Million in Losses

So, while saving those three critically injured people is still something to be proud of, Scripps, in just the first quarter of the year, accumulated $850,000 worth of red ink.

Though hurt by more than $9 million in such losses last year, San Diego County’s trauma system has not gone down for the count. It may receive another blow this week, however, when doctors at Palomar Medical Center in Escondido vote on whether to recommend pulling out of the system.

Indeed, it is an undercurrent of dissatisfaction among doctors themselves that appears to be the latest threat to the survival of the county’s nationally acclaimed system.

Doctors Shun System

For almost four years, the system has routed victims of car accidents, shootings, stabbings and other traumatic injuries past the nearest hospital. Instead, they have gone to one of six designated centers that are required to have specially trained trauma specialists available 24 hours a day.

But, quietly and behind the scenes, uncompensated care has made it increasingly difficult to find surgeons, anesthesiologists and specialists such as plastic surgeons who are willing to take on the burden of being on call for a trauma center, officials say.

“The compensation is, of course, not the primary consideration to any of the surgeons that do trauma,” said Dr. F. Barry Knotts, director of the unit at Sharp Memorial Hospital. “But if they become disgruntled over it or unhappy, they can always look to the financial picture and say, ‘I can live better outside of trauma.’

“The hours are bad, case difficulty is bad and, in addition, we’re having to fight the financial battle,” Knotts said. “What each physician has to do is compare how he spends his time with how it’s compensated. Trauma is a difficult way to make a living, above and beyond the compensation.”

As of last week, Knotts still hadn’t determined his June and July rotation schedule for trauma surgeons, because two of eight have dropped out and a third wants to reduce the number of hours he spends at the center. Usually, the schedule is finished three months in advance, Knotts said.

Similar problems with keeping doctors in the system have been encountered at the other hospitals, with the exception of UC San Diego Medical Center in Hillcrest, said Dr. Steven Shackford, director of the unit there. UCSD trauma doctors do not maintain private practices, and they also have the help of medical residents, he noted.

“The ability to have residents--other doctors who are in training--to do a lot of the legwork and night care is a real advantage for an academic center,” Shackford said.

A study by Knotts found that because of undercompensated or uncompensated care, Sharp’s trauma surgeons received 15% less overall for their surgeries--for a $300,000 annual loss overall--than if they had performed them as part of their private practices.

Statewide, doctors lost about $30.8 million in 1986 on trauma care services, the Assembly Office of Research estimated last year. The study, released in October, suggests that the doctors’ losses may pose a threat to the survival of trauma systems.

“There was a general feeling that, left unattended, the (physician reimbursement) problem will eventually cause private trauma centers to drop out of the system because of a lack of physician staffing, even if the center itself is financially sound,” the report says.

Despite the problems, all six trauma centers here are negotiating with the county to renew their contracts, which expire June 30. That contrasts with Los Angeles County, where seven hospitals have withdrawn from the trauma system over the past three years because of financial losses.

Knotts found that the biggest portion of the Sharp surgeons’ losses came not from totally uninsured patients, but from the low reimbursement rates paid by federal, state and county programs for caring for the poor and medically indigent.

The doctors received 53 cents for each dollar billed to Medicare, 27 cents from the Medi-Cal program for people who qualify for public assistance payments, and 32 cents from the County Medical Services program for the working poor.

“Half of all our losses come from Medi-Cal and CMS patients,” Knotts said. “And another 26% come from the unfunded patient, and in San Diego that’s primarily the illegal alien.”

Palomar, located near the agricultural areas of North County where undocumented workers are likely to be found, is the biggest money loser of the six hospitals in the network. Administrators there expect 31% of their trauma patients this year will not be covered by any insurance program and will be unable to pay for their care. Systemwide for the six hospitals, the figure was about 10% in 1986-87.

Last spring, as Palomar was losing more than $2 million for the fiscal year to the trauma program, disgruntled non-trauma doctors concerned about hospital resources agreed to hold off on forcing a vote on withdrawal until this year.

In the meantime, Palomar cut its deficit this year by raising trauma-care rates in September, effectively making paying patients subsidize the non-paying ones. Other hospitals in the system have not followed suit.

Dr. David Cloyd, chairman of the trauma unit at Palomar, said the move may have blunted critics’ concerns, but it did nothing to deal with the “second-level problem” of losses to the trauma doctors themselves.

“All of us are willing to see patients like this on an occasional basis,” Cloyd said. “But these patients aren’t minor problems. You can’t keep asking people to do that forever.”

The Palomar vote comes despite apparently unanimous agreement that the coordinated system does exactly what was intended when it began in 1984. In 1986-87, 85% of the patients who were whisked past neighborhood hospitals to trauma facilities eventually went on to lead full and productive lives.

Just 0.4% of 5,975 traumatic injuries resulted in deaths that might have been prevented, compared to 30% before the system existed.

Such statistics have drawn nationwide, even worldwide, acclaim for the San Diego system.

But the six hospitals lost big money in 1986-87 by taking on the burden of caring for the county’s most seriously injured patients:

- Children’s Hospital, $1.95 million.

- Mercy Hospital, $1.7 million.

- Palomar Medical Center, $2.05 million.

- Sharp Memorial Hospital, $900,000.

- Scripps Memorial Hospital-La Jolla, $635,000.

- UCSD Medical Center would not disclose its figures, but subtracting the other hospitals’ total losses from the countywide total yields a UCSD loss of $1.9 million.

Doctors involved in trauma care say that some form of public funding is the only answer to the system’s financial problems.

The state of Virginia imposed a surcharge on motor vehicle licenses, and Pennsylvania placed a surcharge on fines for moving violations. In San Diego, some doctors favor establishing a charge for using the 911 emergency telephone number. Another proposal would impose a tax on alcoholic beverages, mainly to pay for emergency medical care.

But so far help from Washington and Sacramento have not been forthcoming. Gov. George Deukmejian vetoed a bill last year that would have provided state funding for trauma centers, saying they are a county responsibility.

“We know how to take better care of the patients than so far anybody is willing to pay for,” said Cloyd, head of Palomar’s unit.

Dr. Donald Trunkey, widely recognized as a pioneer in convincing communities of the need for trauma systems, blamed a failure of political leadership for the money problems nationwide.

“What trauma is really now starting to bring out in a very public way is that so many of our people in the United States are uncovered by any insurance. Trauma is just a microcosm of the problem of unsponsored health care,” said Trunkey, chief of surgery and head of the trauma unit at Oregon Health Sciences University in Portland. He was formerly at San Francisco General Hospital.

“The U.S. and South Africa are the only two countries in the world that practice medical apartheid,” Trunkey said. “In South Africa they do it on the basis of color. In the United States, we do it on the basis of ability to pay.”

Such discrimination has not occurred in trauma care, doctors say, because the ambulances, helicopters and highly trained medical teams in the system rush to the aid of the critically injured regardless of their financial status.

“That’s what’s kind of exciting about trauma,” said Dr. Brent Eastman, director of the Scripps unit. “It’s one of the last frontiers in medicine where that is actually taking place. If you get injured in San Diego County, there is absolutely no double standard of care.”