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The money for this program is desperately needed by our Nation's trauma centers and programs. The magnitude of trauma as a national problem is documented by data which identifies injury as being the primary cause of death in those under the age of 45. Trauma deaths in the United States exceed 140,000 per year and an additional 70 million persons suffer nonfatal injuries which result in a staggering cost of disability and rehabilitation.

It cannot be overemphasized enough that this is a disease of the young that prevention and adequate trauma care could reduce. Študies have documented that trauma care systems can improve the outcomes of severe injury. Of those patients treated in trauma care systems, preventable death can be reduced by 50 percent and 80 percent of injured individuals return to preinjury activities within 4 years of their accident.

Despite this proven effectiveness, and as a result of mounting uncompensated costs over the past several years, many trauma centers in the country have closed their doors. There remains approximately 370 functioning trauma centers in this country which serves only 25 percent of the population.

There is substantial evidence that trauma care programs work. They save lives and reduce the numbers of deaths of disabilities; 244,000 patients each year will require trauma center care in the United States. Emergency departments and trauma centers are being overloaded, and the quality of care is being compromised.

PREPARED STATEMENT Funding for this bill will help to make a difference in emergency and trauma care throughout the country. The provisions of this bill will enable the Federal Government to once again take a leadership role with regard to trauma care systems assisting States to determine what services are essential, aiding in the dissemination of information, and most of all, helping to establish trauma centers and programs.

We again request $30 million for this new program.
I will

be glad to answer any questions. Senator BUMPERS. Thank you, Mr. Green.

STATEMENT OF PAUL GREEN Mr. Chairman, distinguished Members of the Subcommittee, my name is Paul Green. I am a registered nurse and I currently serve as the Chairperson of the National Government Affairs Committee of the Emergency Nurses Association (ENA). Additionally, I am Assistant Director of Ambulatory Care at the Medical College of Virginia, a level I Trauma Center. I have the privilege today of speaking for ENA which represents nearly 21,000 emergency and trauma nurses in the country.

The Emergency Nurses Association is a voluntary national membership association of professional nurses committed to excellence in emergency care, which includes trauma care. ENA exists to serve its members by achieving the following aims: -To be the definitive authority on emergency nursing.

-To define the standards of excellence for emergency nursing.
-To promote the specialty of emergency nursing.
-To promote quality emergency care through continuing education activities.

This includes the internationally recognized Trauma Nursing Core Course
(TNCC).
-To be the resource for emergency nursing practice, professionalism, education,

research, and consultation. -To identify and address emergency care issues. -To reaffirm the ENA Code of Ethics.

-To work collaboratively with other health related organizations toward the im.

provement of emergency care. This includes but is not limited to the American Trauma Society, the American College of Emergency Physicians, the National Federation for Specialty Nursing Organizations, the National Association of State Emergency Medical Services (EMS) Directors, the National Association of

Emergency Medical Technicians and the American College of Surgeons. I want to thank the Chair and members of the Committee for this opportunity to testify in support of funding for the implementation of the Trauma Care Systems Planning and Development Act of 1990. H.R. 1602 was enacted into law (Public Law 101-590) late last year. The authorization of this bill took several years and required many compromises to be made along the way.

It is our understanding that the Department of Health and Human Services has taken the position that nothing would be done to implement the Act until funding has been received for this program. The new law authorizes $60 million for fiscal year 1991 and such sums as may be necessary in fiscal years 1992 and 1993. It is our belief that the sum of $30 million would be sufficient to begin this program. I am here today to make our plea for funding of this important program.

BACKGROUND The money for this program is desperately needed by our nation's trauma centers and programs. The magnitude of trauma as a national problem is documented by data which identifies injury as being the primary cause of death in persons under the age of 45. Trauma is the fourth leading cause of death for all age groups surpassed only by heart disease, cancer, and strokes (1).

Trauma deaths in the United States exceed 140,000 per year and an additional 70 million persons suffer nonfatal injuries which results in the staggering cost of disability and rehabilitation (1). The direct and indirect cost of trauma to society was estimated at $180 billion in 1988 (2). It cannot be overemphasized enough, that this is a disease of the young that prevention and adequate trauma care could reduce.

Trauma care consists of access to the health care system, prehospital care, field triage, acute hospital care and rehabilitation. The primary objective in caring for the trauma victim is the return of this person to society at the highest level of function possible. The continuum of injuries sustained by patients includes immediate life threatening, urgent and nonurgent. For the initial phase of trauma, the trauma team consists of Emergency Medical Technicians, Paramedics, Registered Nurses, Physicians, Social Workers, Respiratory Therapists, and X-ray, Lab, and Emergency Department Technicians. Emergency nurses are an integral part of the resuscitation phase of trauma care. Activities of these individuals include: performance of a rapid, initial assessment of the trauma patient to identify injuries, institution of appropriate life-saving interventions, monitoring of patients' responses to resuscitative efforts, communication with other team members and documentation of the care of the trauma patient.

Studies have documented that trauma care systems can improve the outcomes of severe injury. Of those patients treated in a trauma care system, preventable death can be reduced by 50 percent and 80 percent of injured individuals return to preinjury activities within four years of their accident (2).

Despite this proven effectiveness and as a result of mounting uncompensated costs over the past several years, many trauma centers in the country have closed their doors or eased participation in the trauma care system. Such examples of centers closing include California 13 centers, Illinois (Chicago) 4 centers, Florida 25 centers, Texas and Washington, D.C. 1 center each. This mirrors a nationwide trend of 40 percent withdrawal from trauma care (3). There remains approximately 370 functioning trauma centers within the U.S. serving only 25 percent of the population (2).

The problem of uncompensated costs surrounds three main issues: the high cost of trauma care, the high percentage of underinsured/uninsured trauma patients and declining levels of reimbursement under Medicaid, Medicare and other third party

There is substantial evidence that trauma care programs work—they save lives and reduce the number of deaths and disabilities. 244,000 severely injured patients each year will require trauma center care in the U.S. Emergency departments and trauma centers are being overloaded and the quality of care is being compromised by the lack of funding, the number of uncompensated care cases that are seen, the increase in the number of individuals with AIDS, and the increase in violence (gun shot wounds, stabbings etc.)

payers (2).

Funding for this bill will help to make a difference in emergency and trauma care throughout the country. Funding for this program will enable the following to occur. Establishment of an advisory council on trauma care systems; establishment and operation of a national clearinghouse on trauma care and emergency medical services; development of programs for improving trauma care in rural areas; and establishment of a matching grant program to states to improve the quality and availability of emergency services.

These activities will enable the federal government to once again take a leadership role with regards to trauma care systems, assisting States to determine what services are essential, aiding in the dissemination of information and most of all helping to establish trauma centers and programs.

On behalf of our patients, and all of us who may need trauma care at some time, we urge your favorable consideration for this funding. Thank you again for this opportunity to present our views, concerns and requests. I would be happy to answer any questions you may have on this subject.

REFERENCES (1) Emergency Nurses Association, “Trauma Nursing Core Course”, Second Edition, 1986.

[2] Champion, H.R. & Mabee, M.S., "An American Crisis in Trauma Care Reimbursement”, Surgical Critical Services, 1990.

(3) Keener, D., Trauma Care: When seconds Count, “Chicago Healthcare”, April, 1991, 7–10. STATEMENT OF PARVEZ SHAH, M.D., INTERNATIONAL ASSOCIATION

OF AMERICAN PHYSICIANS Senator BUMPERS. Mr. Shah.

Mr. SHAH. Thank you, Mr. Chairman. We appreciate this opportunity for us to be here for this testimony. I am Parvez Shah, a practicing urologist in the Washington, DC, area and Maryland since 1975.

The IAAP is a coalition representing more than 40,000 physicians from many countries practicing in the United States. There are currently an estimated 569,000 physicians in the United States, and out of those 130,000 are international medical graduates (IMG's). These physicians—23 percent of the Nation's medical doctors—are more likely to serve the disadvantaged and indigent in inner cities, State hospitals, and VA hospitals than domestic medical graduates. In the State of Illinois, 33 percent of the practicing physicians are international medical graduates.

Mr. Chairman, it has been our contention for several years that the differences in medical licensure requirements between domestic medical graduates and the international medical graduates have been used as a discriminatory vehicle to create additional obstacles in licensure by endorsement for international medical graduates. Licensure by endorsement is the process whereby a licensed physician seeks medical licensure in a second State.

Consistent with the recommendations of the 1990 GAO report entitled “Medical Licensing by Endorsement: Requirements Differ for Graduates of Foreign and U.S. Medical Schools,” the Educational Commission for Foreign Medical Graduates has worked with the Federation of State Medical Boards and the American Medical Association in developing a national repository for physician credentialling. The purpose of this repository will be to have information relevant to medical licensure for applicants in order to prevent the interminable delays experienced by the international medical graduates who apply for licensure by endorsement. Often a licensed physician must provide information to a second State licensing board that has already been provided to one State in the past. It frequently takes much longer for a practicing IMG to process applications for licensure by endorsement than it does for domestic medical graduates because of the difficulty involved with providing the requisite information to State licensing boards from the international medical schools. Document retrieval is often near impossible in certain situations for IMG's and extensive delays or minimal notice of opportunity for a hearing by a State board are not uncommon.

A clearinghouse for applicants' records will streamline the process for State-to-State licensing and will limit duplicative State efforts as well as avoid delays for practicing IMG's who seek licensure in a second State.

The function of a national repository is to promote fairness in medical licensure by expediting the process of licensure by endorsement for international medical graduates, as well as for the domestic medical graduates.

IAAP strongly believes that since international medical graduates will be the principal users and payors of a national clearinghouse for medical education documentation, appropriate representatives from the international medical graduate community should be actively involved in the oversight of the operation and implementation of such a repository.

It is absolutely imperative that a coalition of IMG groups be involved in the process of oversight of the operation and implementation of a national repository. Proper oversight would be assured by the creation of HHS advisory council whose function would be to issue recommendations to the Secretary on how to oversee the repository.

Legislation has been introduced to create this advisory council. Should the authorizing committees authorize the HHS advisory council, it will be necessary for Congress to appropriate the necessary staff salaries and funds for the advisory council. Funding for the actual operation of a national repository for medical credentials is self-sufficient based on fees assessed to the physicians who are using the service.

PREPARED STATEMENT

We are therefore recommending to the HHS Secretary for this new project. All expenses for these members should be paid for by the Federal Government.

Thank you, sir.
Senator BUMPERS. Thank you, Dr. Shah.
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