BILL ANALYSIS Ó
AB 1357
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Date of Hearing: April 30, 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 (SGV), 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 SGV 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 collects funds from property taxes to fund emergency
departments (EDs) and trauma centers. The author states that
in SGV, 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 SGV.
2)BACKGROUND . According to the County of LA, in November 2002,
the voters of LA County approved Measure B, which authorizes
LA County to levy a special tax on structural improvements
located within LA 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. LA County's DPH 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 LA County
through: a) LA County Fire Department, Helicopter Lease/Trauma
Air Transport and Paramedic Air Squad in the East SGV; 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)SGV MEASURE B DISTRIBUTION FOR TRAUMA CARE . According to a
September 16, 2004 report by the Executive Director of the
(San Gabriel Valley Council of Governments SGVCG) to the
Governing Board, the LA County Board of Supervisors determined
that the majority ($140 million) of Measure B funds would be
allocated to LA County's Hospitals as follows: Harbor/UCLA
Medical Center ($29.6 Million); Martin Luther King Jr./Charles
Drew Medical Center ($21.6 Million); USC Medical Center ($68.0
Million); Olive View Medical Center ($20.9 Million) ( Olive
View did not have a trauma center). The LA County Board of
Supervisors has determined that $18.6 million or 10.9% of the
Trauma Tax will be allocated to support the delivery of trauma
care at 10 private hospitals in LA County. These hospitals
include: Cedars Sinai Medical Center - West LA; Children's
Hospital of LA - Central LA; Henry Mayo Newhall Memorial
Hospital-Santa Clarita; Huntington Memorial Hospital-Pasadena;
Long Beach Memorial Medical Center- Long Beach; Northridge
Hospital Medical Center-Roscoe Campus-San Fernando Valley;
Providence Holy Cross Medical Center-San Fernando Valley; St.
Francis Medical Center-Lynwood; St. Mary Medical Center-Long
Beach; and, UCLA Medical Center-West LA.
According to the report, of the 20 private hospitals in SGV,
only Huntington Memorial Hospital in Pasadena is currently
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designated to receive Measure B funds. During this last year,
reports show that SGV residents and businesses contributed
19.8% ($33.7 million) of all Measure B funds countywide, which
is proportional to the Valley's share of LA County's
population. The report further states that the cities of La
Canada Flintridge, Pasadena, Sierra Madre, Arcadia, Monrovia,
San Gabriel, Alhambra, San Marino, and South Pasadena are
intended to be served by the trauma center at Huntington
Memorial Hospital. The cities of Temple City, Rosemead,
Montebello, and Monterey Park are intended to be served by the
trauma center at USC/LAC Medical Center. However, 18 of the
remaining cities and the unincorporated communities in SGV,
essentially those bordering and to the east of the 605
freeway, representing more than 1.2 million residents, have no
designated trauma center within easy access. Victims
requiring assistance are to be transported to other open
trauma centers in the County on a rotating and available
basis.
The report concludes that analysis of the allocation of Measure
B revenues raises several significant public policy issues
regarding LA County's trauma care including: funding, its
service delivery system, and SGV's residents' ability to
access and receive their "fair share" of resources for these
critical services. The report further states that the East LA
County area (SGV) is the largest urban portion (1.2 million
residents) of the County not served by any particular trauma
center. In the cases where trauma care is needed, EMS will
transport victims to an open trauma center within the County
along with the attendant delays that may jeopardize healthcare
and safety of the victim. The report concludes that over the
last several years, many private hospitals throughout LA
County, including several in SGV, have closed their trauma
centers due to the inadequate available funding. According to
the report, the issue of adequate resources to fund trauma
care in SGV and LA County appears to be more a function of
adopted County policies and priorities rather than actual cost
of service and financial limitations.
According to a 2007 article, supplied by the author, in the San
Gabriel Valley Tribune, a LA County DHS analysis of SGV
residents showed that only 0.5% of SGV residents used the
county's ED compared to 2.8% countywide. This lack of
utilization of LA County EMS is directly tied with the lack of
availability of a county hospital in close proximity. The
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article argues that the lack of a Level I trauma center east
of the San Gabriel Freeway necessitates that county
helicopters airlift patients to Huntington Hospital in
Pasadena or LA County-USC Medical Center. A 1988 article by
The Los Angeles Times identifies Huntington Hospital as the
only trauma center in SGV after seven of LA County's original
network of 23 trauma centers have closed during a period from
1985 to 1988. According to a 2006 op-ed by Carol Herrera,
former Mayor of Diamond Bar, California, in the Pasadena Star
News, SGV is home to almost two million residents living in 31
cities. According to Herrera, the limited access to trauma
and emergency room care for these communities can prove
critical for residents in the event of life threatening
injuries or serious medical incidents.
4)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 . EMSA provides statewide coordination
and leadership for the planning, development, and
implementation of local trauma care systems. EMSA's
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 EMSA.
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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 regulations.
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
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
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,
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which may or may not be the closest facility
geographically. Transport personnel 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 a 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.
5)ST-Elevation Myocardial Infarction (STEMI) Receiving Center
Program . In 2006, the LA LEMSA began the implementation of a
regionalized approach to providing cardiac care to patients
experiencing STEMI (an indication of a heart attack).
According to LA County, the decision was based on published
literature that rapid provision of Percutaneous Coronary
Intervention (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 LA LEMSA
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 SGV region are Methodist Hospital of
Southern California, Huntington Memorial Hospital and Garfield
Medical Center, and Citrus Valley Medical
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Center-Intercommunity Campus.
6)OPPOSITION . The County of LA, in opposition to this bill,
states that this bill could potentially fragment the County's
EMS system. LA 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 LA LEMSA. LA County further states that
Measure B funds are currently expended in SGV to maintain EMS
and trauma care. These expenditures include:
a) Funds allocated for LA County's Fire Department and for
the Sheriff's Department helicopter service to transport
critical trauma patients from SGV 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 SGV; and,
c) Support of Huntington Memorial's designation as a trauma
center and payment for trauma and emergency care to
residents within SGV.
LA County also opposes this bill because it poses legal
problems. LA County states, as noted by County Counsel, it
conflicts with the authority granted to charter counties and
would undermine the authority of the Board of Supervisors 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 SGV region be used "to reduce
ambulance diversion" and omits other uses expressly provided
for in Measure B, including bioterrorism response.
Finally, LA County points out that although this bill does not
define the area of the SGV 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 SGV region and
would result in a loss of approximately $47 million for
critical trauma care and emergency services.
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7)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.
8)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 (Diaz), 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.
9)POLICY QUESTIONS .
a) Local Control . Measure B funds are raised pursuant to a
Local County initiative and allocated by the County Board
of Supervisors. Is it appropriate for the state to
intervene in this local matter? The funds are raised and
distributed locally by the Board of Supervisors. The SGV,
depending on the definition, is represented by up to three
out of the five members of the Board of Supervisors.
Although the area has raised concerns about the funding
allocation, the only trauma center in the area is
Huntington Hospital in Pasadena. Seeking a trauma
designation is a major undertaking which none of the local
hospitals in the area have sought to date. In fact two
area hospitals closed their trauma centers in the
1980's-Methodist Hospital in Arcadia and Queen of the
Valley Hospital in West Covina. Merely diverting Measure B
funds would not address this.
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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 SGV 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 LEMSA plan. There are no resources for this
task force and the direction is vague.
c) Definition of SGV. There is no uniformly recognized
geographic area that could be definitively identified as
SGV. SGVCG is made up of 35-member public agencies,
comprised of 31 member cities, three LA County
Supervisorial Districts (1, 4, and 5), and the SGV 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 Los Angeles
Times has a mapping Website resource and according to this
map, neither Pasadena nor Altadena is included in SGV.
This Website describes the SGV as 284.13 square miles,
divided into 47 neighborhoods, whereas the SGVCG describes
the SGV 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
Citrus Valley Health Partners
City of Glendora
Opposition
County of Los Angeles
Analysis Prepared by : Marjorie Swartz / HEALTH / (916)
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