BILL ANALYSIS Ó
AB 1357
Page 1
Date of Hearing: April 23, 2013
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 1357 (Roger Hernández) - As Amended: April 8, 2013
SUBJECT : Emergency departments: diversion of patients.
SUMMARY : Requires funds, collected by the County of Los Angeles
(LA) through a voter approved initiative for emergency rooms
from properties within the San Gabriel Valley, to remain within
that geographic region of the county. Requires the funds to be
used for the purposes intended by the voter initiative, within
that geographic area, to reduce ambulance diversion.
Establishes a task force consisting of the Director of the
Emergency Medical Services Authority (EMSA), the Director of the
State Department of Public Health (DPH), the California State
Auditor, and a representative of a local hospital task force to
be selected by the other members. Requires the task force to
study and audit the funds collected from properties in the San
Gabriel Valley since the passage of the local voter initiative
to gain an understanding as to how the moneys have been
allocated and to gauge what improvements, if any, have been
made. Requires the task force to report its findings to the
Legislature by January 1, 2015.
EXISTING LAW :
1)Establishes EMSA, which is responsible for the coordination
and integration of all state activities concerning emergency
medical services (EMS), including the establishment of minimum
standards, policies, and procedures.
2)Authorizes counties to develop an EMS program and designate a
Local Emergency Medical Services Agency (LEMSA) responsible
for planning and implementing an EMS system, which includes
day-to-day EMS system operations.
3)Requires a LEMSA that elects to implement a trauma care system
to develop and submit a plan to the EMSA according to the
regulations established prior to the implementation.
4)Permits each county to establish an EMS Fund, known as the
Maddy Fund, and specifies how these funds are to be used,
including limiting administrative costs to no more than 10% of
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the amount in the fund, with 58% of the balance of the fund
distributed to physicians for emergency services in hospitals,
25% distributed only to hospitals providing disproportionate
trauma and emergency medical care services, and 17%
distributed for other emergency medical services as determined
by each county, including funding regional poison control
centers.
5)Assesses additional penalties on every fine and penalty
imposed and collected by the courts for all criminal offenses,
including all offenses involving a violation of the Vehicle
Code, and requires funds from these additional penalties to be
deposited into a county Maddy Fund, if the county has
established a Maddy Fund, to pay for emergency medical
services as specified
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, currently LA
County collets funds from property taxes to fund emergency
departments (EDs) and trauma centers. The author states that
in the San Gabriel Valley, the eastern most part of LA County,
there are not sufficient funds for EDs and trauma centers even
though this tax is being collected. According to the author,
the problem is that the taxes being collected are not being
allocated evenly throughout the county. The author states
that this bill is needed to mitigate ambulance diversion and
emergency room overcrowding in the San Gabriel Valley.
2)BACKGROUND . According to the County of LA, in November 2002,
the voters of LA County approved Measure B, which authorizes
the County to levy a special tax on structural improvements
located within the County to provide funding for the
Countywide System of Trauma Centers, Emergency Medical
Services and Bioterrorism Response. As approved by the
voters, Measure B established a tax rate of $0.03 per square
foot of structural improvements. The measure authorized the
Board of Supervisors to approve upward adjustments to the rate
limited to changes in the medical component of the Consumer
Price Index. The current rate of the tax levy is $0.0424 per
improved square foot.
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The County of LA further reports that on December 18, 2012, the
Auditor-Controller reported a total of $256.1 million in
Measure B revenues for the Fiscal Year ending on June 30,
2012. This revenue was allocated to the LA County Department
of Health Services (DHS) hospitals for trauma and emergency
care, 12 non-County trauma hospitals to provide for trauma and
emergency care services to eligible indigent patients, and to
provide reimbursement for the Physicians Services for Indigent
Program. The County's Department of Public Health uses
Measure B funds for bioterrorism preparedness and for response
activities, including disease and health event surveillance,
laboratory detection and investigation response related to
potential acts of biological, chemical and radiological
terrorism. Measure B revenues also provide resources to
expand access to trauma services for patients in underserved
areas of the County through: a) the County Fire Department,
Helicopter Lease/Trauma Air Transport and Paramedic Air Squad
in the East San Gabriel Valley; b) the Sheriff's Department
Air Search and Rescue in the Antelope Valley; and, c) the LA
City Fire Department Trauma Air Transport in the San Fernando
Valley.
3)California's EMS system . California operates on a two-tiered
EMS system. EMSA is the lead agency and centralized resource
to oversee emergency and disaster medical services. EMSA is
charged with providing leadership in developing and
implementing local EMS systems throughout California, and in
setting standards for the training and scope of practice of
various levels of EMS personnel. California has 32 local EMS
systems that provide EMS for California's 58 counties. (Seven
regional EMS systems comprised of 33 counties and 25
single-county agencies provide the services.) Regional
systems are usually comprised of small, rural, less-populated
counties, and single-county systems generally exist in the
larger and more urban counties.
a) LEMSAs . LEMSAs are responsible for planning,
implementing, and managing local trauma care systems,
including assessing needs, developing the system design,
designating trauma care centers, collecting trauma care
data, and providing quality assurance.
b) Trauma planning . EMS provides statewide coordination
and leadership for the planning, development and
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implementation of local trauma care systems. EMSA
responsibilities include the development of statewide
standards for trauma care systems and trauma centers, the
provision of technical assistance to local agencies
developing, implementing, or evaluating components of a
trauma care system, and the review and approval of local
trauma care system plans to ensure compliance with the
minimum standards set by the Authority.
c) Trauma Center Designation . According EMSA, all trauma
centers are licensed hospitals, designated by the LEMSA in
accordance with state law and regulations. Designations
include levels I through IV and Level I and II Pediatric
(pediatric specific facilities). The American College of
Surgeons (ACS) has developed a verification process for
trauma hospitals. The criteria developed by the ACS are
similar but not identical to the California Code of
Regulations Trauma Center. Some LEMSAs utilize ACS
verification as part of the designation process; however,
ACS verification does not equate to LEMSA designation.
Trauma care systems and trauma center designations are part
of the local trauma system as detailed in the LEMSA trauma
plan approved by the EMSA. In LA County the trauma centers
are as follows:
i) Ronald Reagan UCLA Medical Center is designated as a
Level I Trauma Center and a Level I Pediatric Trauma
Center;
ii) Cedars-Sinai, Harbor UCLA, and LA County +
University of Southern California (LAC+USC) Medical
Centers are designated Level I and Level II Pediatric;
iii) Antelope Valley Hospital, California Hospital
Medical Center, Providence Holy Cross Medical Center
(Mission Hills), St. Francis Medical Center, St. Mary
Medical Center, Henry Mayo Newhall Memorial Hospital and
Huntington Memorial (in Pasadena) are Level II Trauma
Centers;
iv) Long Beach Memorial + Miller Children's and
Northridge Hospital Medical Centers are Level II Trauma
and Level II Pediatric; and,
v) Children's Hospital of LA is a Level I Pediatric.
d) LEMSA diversion policy . Each LEMSA, using state minimum
standards, establishes policies and procedures, approved by
the medical director to assure medical control of the EMS
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system and submits them to the EMSA. The policies and
procedures approved by the medical director may require
basic life support emergency medical transportation
services to meet any medical control requirements including
dispatch, patient destination policies, patient care
guidelines, and quality assurance requirements. Pursuant
to this authority, LA LEMSA has established an ambulance
diversion policy that generally requires the patient to be
transported to the most accessible receiving facility,
which may or may not be the closest facility
geographically. Transport personnel shall take into
consideration traffic, weather conditions or other similar
factors which may influence transport time when identifying
which hospital is most accessible. According to the
information supplied to the EMSA, final authority for
patient destinations rests with the base hospital handling
the call. Whether diversion request will be honored
depends on available system resources. Further guidance is
spelled out with regard to transport to trauma or other
specialty care centers.
4)ST-Elevation Myocardial Infarction (STEMI) Receiving Center
Program . In 2006, the LA County EMS Agency began the
implementation of a regionalized approach to providing cardiac
care to patients experiencing STEMI (an indication of a heart
attack). According to the County, the decision was based on
published literature that rapid provision of Percutaneous
Coronary Intervention (PCI) (balloon or stent angioplasty) is
the optimum level of care for patients experiencing STEMI.
According to the County of LA, the regionalized approach to
STEMI care was strongly supported by medical directors of the
various EMS constituents (provider agencies, paramedic base
hospitals) as well as the cardiologists. These standards were
developed to ensure that patients transported by the 9-1-1
system in LA County who exhibit STEMI on a paramedic unit's
12-lead electrocardiogram (ECG) are transported to a hospital
appropriate to their needs. With the initiation of 12-lead
ECG by paramedics and rapid transport to a STEMI Receiving
Center (SRC), patients now receive earlier definitive
diagnosis and treatment resulting in improved outcomes. The
SRC Program started in late 2006 with the designation of the
first three SRCs and has grown to 31 centers county-wide and
three out-of-county LA designated Centers. A system-wide
quality improvement program and data collection system has
been established and oversight is provided by the EMS Agency.
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Each center is required to review the care to its STEMI
patients and the SRC Advisory and Quality Improvement
Committees meets regularly to address prehospital, patient
care, system, and inter-facility transfer issues. System data
show that the LA County SRC Program exceeds the minimum
American Heart Association time standards. Participating
hospitals in or near the San Gabriel Valley region are
Methodist Hospital of Southern California, Huntington Memorial
Hospital and Garfield Medical Center, and Citrus Valley
Medical Center-Intercommunity Campus.
5)OPPOSITION . The County of LA, in opposition to this bill,
states that this bill could potentially fragment the County's
EMS system. The County states that by statute, it is
responsible for the coordination and oversight of the EMS
system, including prehospital care and hospital ED
designations. Reallocating a portion of the Measure B funds
to be controlled and distributed by an entity other than the
LA County Board of Supervisors would undermine and fragment
the oversight, system design, planning and legal
responsibility of the EMS Agency. The County further states
that Measure B funds are currently expended in the San Gabriel
Valley to maintain EMS and trauma care. These expenditures
include:
a) Funds allocated for the County's Fire Department and for
the Sheriff's Department helicopter service to transport
critical trauma patients from the San Gabriel Valley to the
LAC+USC Medical Center;
b) Funds allocated to LAC+USC Medical Center which provides
a significant percentage of trauma and emergency care to
residents of the San Gabriel Valley; and,
c) Support of Huntington Memorial's designation as a trauma
center and payment for trauma and emergency care to
residents within the San Gabriel Valley.
The county also opposes this bill because it poses legal
problems. The County states, as noted by County Counsel, it
conflicts with the authority granted to charter counties and
would undermine the authority of the Board to allocate Measure
B revenues to best meet the needs of LA County's residents.
In addition this bill states that Measure B funds retained in
the San Gabriel Valley region be used "to reduce ambulance
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diversion" and omits other uses expressly provided for in
Measure B, including bioterrorism response.
Finally, the County points out that although this bill does
not define the area of the San Gabriel Valley region from
which Measure B funds must be retained, the County's DHS based
on a speculative assumption of what is intended, estimates
that approximately 17% of Measure B revenue is collected from
the San Gabriel Valley region and would result in a loss of
approximately $47 million for critical trauma care and
emergency services.
6)RELATED LEGISLATION . SB 191 (Padilla) deletes the January 1,
2014, sunset date on provisions of existing law authorizing
counties to assess an additional $2 on every $10 of certain
fines and penalties, including vehicle code violations, to
supplement revenues for county Maddy Funds, and that require
15% of these additional funds to be used for pediatric trauma
care.
7)PREVIOUS LEGISLATION .
a) SB 1236 (Padilla), Chapter 60, Statutes of 2008, extends
the sunset dates, from January 1, 2009, to January 1, 2014,
on provisions of law authorizing counties to assess an
additional $2 on every $10 in fines to supplement Maddy
Funds, with 15% of these additional funds allocated to
pediatric trauma care. These are the sunset dates that this
bill is proposing to delete.
b) AB 1988, Chapter 333, Statutes of 2002, requires EMSA to
convene a task force to study the delivery and provision of
EMS. Requires the task force, among other things, to
develop a plan to ensure that all Californians are served
by appropriate coverage areas for emergency and trauma
services and that sufficient numbers of EDs and trauma
centers exist to serve each area's population.
8)POLICY COMMENTS .
a) Local Control . Measure B funds are raised pursuant to a
Local County initiative and allocated by the County Board
of Supervisors. It is unclear why it is appropriate for
the state to intervene. The funds are raised and
distributed locally by the Board of Supervisors. The San
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Gabriel Valley, depending on the definition, is represented
by up to three members of the Board of Supervisors. There
is no evidence that the community has brought this issue to
the attention of the members of the Board, the local EMSA,
or requested a different allocation due to ambulance
diversion or lack of trauma access.
b) Task Force . This bill requires a task force consisting
of the Director of EMSA, the Director of DPH, the
California State Auditor, and a representative of a local
hospital task force to be selected by the other members.
It requires the task force to study and audit the funds
collected from properties in the San Gabriel Valley since
the passage of the local voter initiative to gain an
understanding as to how the moneys have been allocated and
to gauge what improvements, if any, have been made. This
charge seems overly broad and it is not clear what could be
determined beyond what the EMSA already does in reviewing
and approving the local EMS plan. There are no resources
for this task force and the direction is vague.
c) Definition of San Gabriel Valley . There is no uniformly
recognized geographic area that could be definitively
identified as the San Gabriel Valley. The San Gabriel
Valley Council of Governments (SGVCOG) is made up of
35-member public agencies, comprised of 31 member cities, 3
LA County Supervisorial Districts (1, 4, and 5), and the
San Gabriel Valley Water Districts. The area is described
as having 31 incorporated cities including Altadena and the
City of Pasadena (one of only three cities in California to
operate a Public Health Department independent from the
county). The LA Times has a mapping website resource and
according to this map, neither Pasadena nor Altadena are
included in the San Gabriel Valley. This website describes
the Valley as 284.13 square miles, divided into 47
neighborhoods, whereas the SGVCOG describes the Valley as a
400 square mile area. It is nearly impossible to fulfill
the requirements of this bill without an accepted
definition of the area affected or an agreed upon map of
the geographic region.
REGISTERED SUPPORT / OPPOSITION :
Support
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None on file.
Opposition
County of Los Angeles
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
319-2097