We believe that costs can best be restrained by changing the incentives that determine how care is provided and used. For example, providers in organized delivery systems paid on a capitated basis will conserve health resources while keeping people healthy. We also believe that an independent national commission responsible for recommending a budget for publicly subsidized health care can help to maintain the correct balance between people's needs and the funds available to meet them. Universal access is meaningless if we can't pay the bills for care. That is why we are deeply concerned by another element of the President's proposal: restraining projected Medicare spending by $125 billion over five years. Funding universal access through Medicare cuts could threaten access to care by endangering hospitals with large Medicare populations. We support an adequately funded Medicare program, with incentives for Medicare beneficiaries to join capitated delivery systems. Illinois hospitals support the idea of purchasing cooperatives for small businesses and individuals, but we have serious reservations about the size and structure of the health alliances proposed by the President. We recommend that they be limited to an administrative rather than a regulatory role. We are also concerned that a sudden influx of new patients into the current system could lead to an explosion in costs that will trigger rigid budget caps. We advocate a six-year period for phasing in universal coverage as new incentives bring providers into integrated delivery systems and as new efficiencies are realized. In closing, let me summarize four basic principles that Illinois hospitals support. First is universal coverage — a guarantee that all citizens will have access to essential health care benefits. Two: Responsible health care financing, with requirements for employer and individual participation, government subsidies for low-income citizens, and a continuation of Medicare, but with some new incentives. Three: Insurance market reforms making coverage affordable and portable, with purchasing cooperatives for individuals and small businesses. And four: A restructured delivery system based on community care networks. Without this fourth goal, none of the other reforms will work. Illinois hospitals accept the challenge of comprehensive health care reform, because we believe the goal -- better health for all Americans - is worth it. We look forward to working with you to reach that goal. Chairman STARK. Dr. Champion. STATEMENT OF HOWARD R. CHAMPION, M.D., PRESIDENT, COALITION FOR AMERICAN TRAUMA CARE, AND DIRECTOR, TRAUMA POLICY AND RESEARCH, THE WASHINGTON HOSPITAL CENTER, WASHINGTON, D.C. Dr. CHAMPION. Mr. Chairman, I am a specialist in trauma surgery. Unlike other kinds of surgical specialists, as a trauma surgeon, I have been delivering extensive amounts of pro bono care to injured Americans. I have been in the Baltimore-Washington area doing the same for the last 20 years. I am the founding president of the Coalition for American Trauma Care and secretary of the American Trauma Society; and on behalf of those organizations, I want to thank for this opportunity to testify. I also want to thank you, Mr. Chairman, for your longstanding support for efforts to improve the delivery and financing of trauma care services for seriously injured Americans. The Coalition's specific comments on the Health Security Act are contained in our written statement and I will comment on the main issues. To do that appropriately, it is important to place serious injury in the public health context. Injury is the leading cause of death for Americans from birth through age 44. For every death there are at least three or four permanent disabilities. Injury is also the leading cause of years of lost productivity-more than cancer and heart disease combined. Since it affects the young in the workforce, injury is also our most costly disease-estimated at $180 billion in lifetime costs in 1988. The Coalition has worked to address this public health problem on many fronts. This includes community-based injury awareness and prevention efforts and university-based injury research programs. Unfortunately, even in the most effective public health models, injury can never be entirely prevented. Thus, we must focus on mitigating the consequences of injury to the greatest extent possible. Practice guidelines for trauma care are designed to provide costeffective secondary and tertiary prevention services so that when serious injury does occur, death and disability are prevented. When disability cannot be fully prevented, then every effort is made to restore as much function as possible. The Coalition believes strongly that organized, regional system of trauma care are a model for reform of costly, specialized tertiary care services. The components of a trauma system are described more fully in our written statement. Let me just mention that they include prevention, 911 access, prehospital care, triage or transfer decisionmaking, specialize acute hospital care in a trauma center, and rehabilitation. Despite the clear benefits of a regional or State trauma system, the Health Security Act does not provide any recognition of trauma care, trauma centers, or trauma systems. The Coalition believes that individuals with life-threatening injuries must not be denied access to qualified trauma care. This must be recognized in health care reform policy. There is a concern that too much emphasis on State-based purchasing alliances could have a detrimental effect on trauma and burn centers that have catchment areas across state boundaries, as is the case in every city along the Mississippi River, leading to Balkanization of existing and effective regional trauma systems. The Coalition is aware of instances in many areas of the country, even those with fully developed trauma care systems, where some third-party payers currently refuse appropriate transfer to a trauma center for patients subsequently determined by community hospital physicians to need the services of a qualified trauma center. Other payers have inappropriately placed financial pressures on family members for premature transfer out of a trauma center. These concerns can and should be corrected in health system reform by applying uniform treatment standards for reimbursement for qualified trauma care services. I hasten to add, for the record, that there are many payers that specifically contract with trauma centers throughout the Nation. We need to provide an appropriate and positive environment for the growth and development of middle-aged trauma care which is extremely cost-effective, particularly when the total costs of care are assessed. As you know, Mr. Chairman, over 100 trauma centers across the country have closed their doors since 1985, a majority of them due to chronic underreimbursement. It has been stated to us that trauma will get relief from the burdens of uncompensated care with health care reform, but we must respond that it depends on two factors-that universal coverage proceed in concert with and not after implementation of further cuts in Medicaid and Medicare; and two, that health plans be required to contract with qualified trauma centers. Unless these things happen, we predict that further trauma center closures will occur causing further compromise to the public's access to the lifesaving services of qualified trauma centers. The Coalition strongly feels that Americans expect good care when they dial 911. Excluding critically injured Americans from qualified trauma would, in fact, violate the clinical standards of medical care and would likely result in much more completely unnecessary disability, costing State and Federal treasuries millions of dollars in lifelong support payments. Thank you for the opportunity to share our views with the subcommittee today. The Coalition for American Trauma Care looks forward to working with you in recognizing these principles in health care reform legislation. Chairman STARK. Thank you very much. [The prepared statement follows:] STATEMENT OF HOWARD R. CHAMPION, M.D. PRESIDENT THE COALITION FOR AMERICAN TRAUMA CARE Mr. Chairman, and Members of the Subcommittee, I am Dr. Howard Champion, Director of Trauma Policy and Research at the Washington Hospital Center here in the District of Columbia. I am also Secretary of the American Trauma Society and the Founding President of the Coalition for American Trauma Care. The Washington Hospital Center's MedSTAR trauma unit is a Level I trauma center which serves the residents of the District of Columbia and seriously injured residents in a six state area. On behalf of the membership of the Coalition for American Trauma Care, I want to thank you for providing our organization an opportunity to testify before the Subcommittee on the vitally important issue of health care reform and how trauma care relates to this reform. We especially appreciate, Mr. Chairman, the support you have shown over the years for efforts to improve the delivery and financing of trauma care services. The Coalition for American Trauma Care is a national, not-for-profit organization whose membership includes physician directors of trauma care, leading trauma center institutions, and national organizations with a commitment to improving the delivery of trauma care services to seriously injured individuals and a strong commitment to injury prevention. The mission and goals of the Coalition are to improve trauma care services to seriously injured individuals through universal implementation of organized regional systems of trauma care, through improved basic and clinical trauma related research, through improved reimbursement for trauma center institutions, and to improve injury prevention activities at all levels of government. The Coalition has worked closely with the Congress, including some members of this Subcommittee, on re-authorization of the Trauma Care Systems Planning and Development Act (P.L. 101-590), on enactment and efforts to fund the trauma center grant program to assist trauma centers fiscally stressed due to drug related violence (Title VI, P.L. 102-321), on enactment of the trauma provisions in legislation re-authorizing the National Institutes of Health which will develop a national plan for basic and clinical trauma care research (P.L. 103-43), and in support of the newly established Center for Injury Prevention and Control and the Centers for Disease Control and Prevention. The Coalition is now pleased to comment on The Health Security Act,, President Clinton's plan to reform the nation's health care system. I would first like to state, for the record, that the Coalition genuinely applauds President Clinton and First Lady Hillary Rodham Clinton for their leadership in bringing this very important, but very difficult and complex issue, before the American people and the Congress. There is much in the President's bill that the Coalition can, and will, strongly support. But before I discuss specific provisions in the bill, I want to place the issue of injury and the work of our Coalition and other factions of the trauma care community in an appropriate context. Injury is the leading cause of death for Americans from birth through age 44. For every death there are at least three to four permanent disabilities. Injury is also the leading cause of years of lost productivity -- more than cancer and heart disease combined. Since it affects the young and the workforce, it is our most costly disease -- estimated at $180 billion in lifetime costs in 1988. In my opinion, injury is the nation's most important public health and social issue. The Coalition has worked to address this public health problem on many fronts. This includes community-based injury awareness and prevention efforts and university-based injury research programs. Unfortunately, even in the most effective public health models of prevention, injury can never be entirely prevented. Thus we must focus on mitigating the consequences of injury to the greatest extent possible. The Coalition, and other members of the trauma community, have promoted organized, regional systems of trauma care which are designed to provide cost-effective secondary and tertiary prevention services so that when serious injury does occur, death and disability are prevented. When disability cannot be fully prevented, then every effort is made to restore as much function as possible. The Coalition believes strongly that organized, regional systems of trauma care are a model of reform. costly, specialized, tertiary care services. The regional and state programs that have been established i United States go through a rigid professional and quality assurance process. The first step in establishing a trauma system is to determine need. This is done in conjunction wit state officials, health policy experts, and public input. Basing the trauma system on need limits the number of specialized centers that will be established within a region. The next step is to enact enabling legislation authorizing the state, or other entity, to establish the trauma system which includes designating trauma centers. The third step is to use professionally established guidelines of care in designing all components of the trauma system. Once these steps have been taken, the authorized entity -- usually the state emergency medical service agency -- typically then allows all hospitals to participate in the designation process, recognizing that o a few will be chosen based on need, including geographic considerations, and ability to meet professic guidelines. The applications are reviewed and verified on-site by a professional review team, ideally comprised of individuals from outside of the state. Hospitals that are chosen and verified to provide trauma care services are then formally designated by the authorized state entity. The final step is to institute ongoing needs assessment and quality assurance. This is extremely important since numerous studies document sharp reductions in preventable death rates immediately following implementation of a trauma system with even further reductions achieved in years thereafter One recent study of workman's compensation cases showed states with implemented trauma systems achieved significant direct and indirect cost savings when compared with states without trauma system Quality assurance studies show that the vast majority of even the most severely injured individuals, w provided with timely, qualified trauma care, return to work, household, or school activities full time w one year of injury. A state trauma system must address at least six critical components: 1) prevention -- short and long term strategies to identify root causes of behavioral and societal factors that result in unintentional and intentional injury must be identified and implemented; 2) access to the trauma system -- this mea 911 availability and public awareness and education to act quickly so that individuals with life-threaten injury get immediate access to expert care; 3) pre-hospital care -- trained personnel who provide th initial resuscitation and transport by ambulance, fixed-wing, or rotor-wing aircraft; 4) triage, trans, decision-making -- triage is a French word which means "to sort." Not all trauma patients need the expertise of a trauma center. The intent is to concentrate the critically injured in a few centers thus reducing costs while maintaining the skill level of the physician and nurses who provide care for critic: injured individuals; 5) acute hospital care -- specialized trauma care facilities where experienced surgeons and nurses and other health professionals provide 24 hour resuscitation and lifesaving surge every day of the year; 6) rehabilitation -- rehabilitation is started within hours of the lifesaving surg The goal is to return all injured patients to lives as productive members of society. Trauma centers are also uniquely organized to care for the seriously injured patient. The regional trauma center (Level I) has five main components: 1) pre-hospital medical control -- prehospital personnel at the injury scene consult hospital-based physicians with trauma expertise and receive triage and life support direction; 2) emergency department -- 24 hour, in-house availability of a specialized team of physicians, nurses, and other personnel that is mobilized to assess and treat seriously injured individuals upon arrival at the emergency room door; 3) operating room -- immediate operating room availability 24 hours per day and availability of multiple surgical specialists to manage multiple life-threatening injuries simultaneously; 4) intensive care unit -- availability of multidisciplinary state-of-the-art intensive care services coordinated by the trauma surgeon thus eliminating the need for multiple and fragmented specialty consultation; 5) rehabilitation -- early integration of rehabilitation assessment and services during the initial acute care admission with the goal of returning the patient to his or her pre-injury level of functioning. The trauma patient requires both an organized pre-hospital response and an organized acute care and rehabilitation response to achieve the most cost-effective outcome. This is because the trauma patient, especially the individual with multi-system involvement, requires immediate, coordinated, multidisciplinary care all available in one location. This may be best illustrated by describing a multiply-injured patient. A typical example might be an individual involved in a motor vehicle crash who sustains a severe head injury (intracranial hematoma), a torn major artery (torn thoracic aorta), massive liver injury, and unstable pelvic (hip) fracture. Clearly, this individual needs immediate and simultaneous attention by those trained in neurosurgery, general surgery with trauma expertise, and orthopedic surgery, as well as expert nursing care, rehabilitation assessment and services, and specialized x-ray, and other equipment. These specialized, and very expensive, services should be concentrated in just a few hospitals to ensure they are utilized in the most cost-effective fashion possible and to ensure that professional skills are maintained. The designation of qualified trauma centers, with these characteristics, form the backbone of the trauma system. Organized, regional systems of trauma care are a proven, cost-effective public health solution to a major public health problem. Americans expect and want safe water to drink and clean air to breathe. Americans also expect and want an environment safe from injury and a government prepared to implement primary prevention measures. But if primary prevention fails, Americans want a health care system that will save an injured loved one when death is truly preventable; a health care system that will prevent completely unnecessary disability; and a health care system that will provide the services that can make their family members productive again. It is in the context of this public health model that the Coalition for American Trauma Care assesses the provisions of the Health Security Act. 1 GENERAL COMMENTS Availability of Qualified Trauma Care While the various components of an organized, regional system of trauma care are covered under the benefit package there is no acknowledgement throughout the bill that serious injury, as a major public health problem, requires a system of care approach because of its time-sensitive nature and 1 For the pages that follow, the "Act" denotes the Clinton Health Security Act. |