BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 787
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|AUTHOR: |Bates |
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|VERSION: |January 5, 2016 |
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|HEARING DATE: |January 13, | | |
| |2016 | | |
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|CONSULTANT: |Vince Marchand |
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SUBJECT : Hospitals: closures
SUMMARY : Permits Saddleback Memorial Medical Center to operate an
emergency department at its San Clemente campus, subject to
approval by the California Department of Public Health (CDPH),
even if the San Clemente campus stopped providing acute care
services, thereby permitting a freestanding emergency
department, subject to specified conditions.
Existing law:
1)Licenses general acute care hospitals under CDPH. Defines
general acute care hospitals as hospitals that provide 24-hour
inpatient care, including the following basic services:
medical, nursing, surgical, anesthesia, laboratory, radiology,
pharmacy, and dietary services.
2)Permits general acute care hospitals, in addition to the basic
services all hospitals are required to offer, to be approved
by CDPH to offer special services, including, but not limited
to, a radiation therapy department, a burn center, an
emergency center, a hemodialysis center or unit, psychiatric
services, intensive care newborn nursery, cardiac surgery,
cardiac catheterization laboratory, and renal transplant.
3)Requires CDPH to issue a single consolidated license to a
general acute care hospital that includes more than one
physical plant maintained and operated on separate premises or
that has multiple licenses for a single health facility on the
same premises if the general acute care hospital meets certain
criteria and applicable requirements of licensure.
4)Requires any hospital that provides emergency medical services
SB 787 (Bates) Page 2 of ?
to provide notice no later than 90 days prior to a planned
reduction or elimination of the level of emergency medical
services of the intended change to CDPH, the local emergency
medical services agency, and all health care service plans or
other entities under contract with the hospital to provide
services to enrollees. Additionally requires the hospital to
provide notice of the intended change in a manner that is
likely to reach a significant number of residents of the
community served by the facility.
Existing regulations:
1.Requires an emergency medical service to be so located in the
hospital as to have ready access to all necessary services.
2.Requires a hospital that is approved to offer emergency
medical service to have the following service capabilities:
a) Intensive care service with adequate monitoring and
therapeutic equipment;
b) Laboratory service with the capability of performing
blood gas analysis and electrolyte determinations;
c) Radiological service to be capable of providing the
necessary support for the emergency service;
d) Surgical services immediately available for
life-threatening situations;
e) Post-anesthesia recovery service; and,
f) The services of a blood bank containing common types
of blood and blood derivatives readily available, with
blood storage facilities in or adjacent to the emergency
service.
This bill:
1)Permits Saddleback Memorial Medical Center, notwithstanding
any other law, to operate an emergency department (ED) at its
San Clemente campus, subject to the approval by CDPH and all
of the conditions specified in this bill.
2)Requires the San Clemente ED to operate under the consolidated
license of Saddleback Memorial Medical Center and to meet all
of the requirements imposed under that license, including
being within 15 miles of its parent hospital.
3)Requires the San Clemente ED to be a conversion from a
previously existing acute care campus and prohibits it from
being a newly developed freestanding ED.
SB 787 (Bates) Page 3 of ?
4)Requires the San Clemente ED to be open 24 hours a day, 365
days a year.
5)Requires the San Clemente ED to be staffed by at least one
board-certified emergency physician at all times.
6)Requires the San Clemente ED to be staffed with properly
trained emergency room nurses and meet the minimum staffing
requirements for EDs in this state.
7)Requires the San Clemente ED to have a complete range of
laboratory and diagnostic radiology services, including a
complete array of laboratory test, basic X-ray, computerized
tomography (CT) scan, and ultrasound capabilities.
8)Requires the San Clemente ED to meet the specialty call
requirements, as defined by the Orange County emergency
medical services agency, under its consolidated license.
9)Requires the San Clemente ED to have transfer agreements with
specialty centers, such as trauma, burn, and pediatric
centers, to meet the needs of the injury or patient population
served in the community.
10) Requires the San
Clemente ED to have the capabilities to stabilize patients
with emergency medical conditions and to transport them to its
parent hospital or other higher level of care facilities in a
safe and timely manner, consistent with the standards of care
in the local communities.
11) Requires the San
Clemente ED to have a fully functioning transport program with
a proven track record of safely transporting patients who
require admission to its parent hospital or other higher level
of care and specialty services facilities, such as trauma,
burn, and pediatric facilities.
12) Requires all applicable
federal and state regulatory requirements to be met under the
consolidated license of Saddleback Memorial Medical Center,
including all applicable regulations of the Centers for
Medicare and Medicaid Services and Title 22 of the California
Code of Regulations.
SB 787 (Bates) Page 4 of ?
13) Requires the San
Clemente ED to satisfy any other site-specific criteria that
CDPH deems necessary.
14) Prohibits anything in
this bill from being construed to require Saddleback Memorial
Medical Center to provide for concomitant acute care service
at the San Clemente campus or to seek additional licensure for
operation of the San Clemente ED that is authorized pursuant
to this bill.
15) States legislative
findings and declarations that a special law is necessary and
that a general law cannot be made applicable within the
meaning of a specified provision of the California
Constitution because of the unique circumstances regarding the
provision of emergency medical services to the communities of
San Clemente, Dana Point, and San Juan Capistrano.
16) Contains an urgency
clause that will make this bill effective upon enactment.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, the operator of
Saddleback Memorial Medical Center's San Clemente campus ("San
Clemente Hospital") is considering plans to convert the
hospital into an ambulatory health care campus that would
provide outpatient surgery and urgent care services. This plan
would eliminate the hospital's 73-bed hospital and emergency
room. This bill authorizes San Clemente Hospital to continue
to provide emergency medical services to patients in the
region if it otherwise transforms its delivery of services.
San Clemente Hospital has served South Orange County for more
than 40 years, and operates the only emergency facility
between Mission Viejo and Oceanside. While the converted San
Clemente Hospital would have an urgent care center, state law
does not allow 911 patients to be transported to urgent care
centers. Ambulances transporting 911 patients to the closest
facilities that could take patients in need of emergency
services from the area that is presently served by San
SB 787 (Bates) Page 5 of ?
Clemente Hospital would face longer distances on roads and
highways that are frequently congested with traffic. The
longer ambulance rides could risk the lives of patients.
Additionally, the nearest emergency rooms are already strained
by the number of patients that come in, and could be forced to
turn away additional emergency patients.
2)Background on San Clemente hospital. San Clemente Hospital is
part of MemorialCare Health System, which is a nonprofit
health care delivery system with six hospitals, as well as a
number of surgical centers and outpatient clinics in Los
Angeles and Orange County. San Clemente Hospital is licensed
for 73 beds, and operates under a consolidated license with
Saddleback Memorial Medical Center - Laguna Hills, which has
252 licensed beds. The Laguna Hills campus is located about 14
miles north of San Clemente Hospital, with both hospitals
adjacent to the Interstate 5 highway. According to newspaper
articles, MemorialCare Health System announced in August of
2014 that they were planning to replace San Clemente Hospital
with a new facility that would offer a wide range of
outpatient services, including an advanced urgent care.
According to the Office of Statewide Health Planning and
Development's Annual Utilization Report for San Clemente
Hospital, the hospital's ED was placed on diversion (meaning
the ED was closed to ambulances because it was full) for a
total of 112 hours in 2014. The following table is San
Clemente Hospital's emergency utilization data for 2014:
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| ED Visit Type | (1) | (2) | (3) |
| | | | |
| | Visits not |Admitted from | Total ED |
| | Resulting in | ED | Traffic |
| | Admission | | (1) + (2) |
| | | | |
|-----------------+--------------+--------------+--------------|
|Minor | 548 | 0 | |
|-----------------+--------------+--------------+--------------|
|Low/Moderate | 4,626 | 4 | |
|-----------------+--------------+--------------+--------------|
|Moderate | 5,403 | 29 | |
|-----------------+--------------+--------------+--------------|
|Severe without | 1,798 | 1,006 | |
SB 787 (Bates) Page 6 of ?
|threat | | | |
|-----------------+--------------+--------------+--------------|
|Severe with | 423 | 591 | |
|threat | | | |
|-----------------+--------------+--------------+--------------|
|TOTAL | 12,798 | 1,630 |14,428 |
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| | | | |
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Other hospitals in the surrounding region include:
a) Mission Hospital Laguna Beach, with 123 acute care
beds with somewhat similar ED utilization rates and is
located seven miles north of San Clemente Hospital on
Highway 1;
b) Mission Hospital Regional Medical Center, with 345
acute care beds, a Level II trauma center, and an ED that
is about three times the size of San Clemente Hospital's
ED which went on diversion status for 683 hours in 2014.
Mission Hospital Regional Medical Center is located about
nine miles north of San Clemente Hospital along I-5, in
Mission Viejo; and,
c) Saddleback Memorial Medical Center - Laguna Hills,
the parent hospital of San Clemente Hospital, with 252
acute care beds and an ED that is roughly the size of
Mission Hospital Regional Medical Center, which went on
diversion for a total of 308 hours in 2014. This hospital
is located about 14 miles north of San Clemente Hospital
along I-5.
Under existing law, a hospital that offers emergency medical
services is required to provide CDPH, among others, with at
least 90 days notice of any planned reduction or closure of
the emergency medical service. According to CDPH, San Clemente
Hospital has not provided this notice, but that the
MemorialCare Health System is currently working on a
feasibility study to determine the future of the hospital.
1)Background on freestanding EDs. There are currently no
freestanding EDs licensed in California, although they do
operate in other states. According to an article in Kaiser
Health News in July of 2013, the number of freestanding EDs
doubled to more than 400 between 2009 and 2013. According to a
2013 information paper published by the American College of
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Emergency Physicians, there are two distinct types of
freestanding EDs: those that are operated by, or licensed
through, medical centers or hospital systems but are
geographically separate from the hospital, and those that are
independent of a hospital. As an example of the latter, First
Choice ER is a for-profit chain of freestanding, 24-hour
emergency rooms that operate in Texas and Colorado. CHCF
published an issue brief in July of 2009, entitled
"Freestanding Emergency Departments: Do They Have a Role in
California" (CHCF report). According to the CHCF report, the
growth of freestanding EDs has prompted discussions regarding
their regulation and effect on the health care system. The
CHCF report states that these facilities differ from urgent
care centers in that they can accommodate additional
procedures such as defibrillation, intubation, and conscious
sedation. Additionally, most freestanding EDs are staffed by
trained emergency physicians and nurses, and some have been
permitted to receive ambulance patients. In California, in
order to offer emergency medical services, a facility must
provide certain services, such as intensive care, radiology,
and surgical services that are immediately available for
life-threatening situations, which essentially require an ED
to be part of a full-fledged hospital.
2)Pilot project at Centinela Airport Clinic. Using statutory
authority that authorizes a local EMSA to "approve or conduct
any scientific or trial study of the efficacy of the
pre-hospital emergency use of any drug, device, or treatment
procedure within the local EMS system," the Los Angeles County
EMSA approved a two-year pilot project beginning in 2004 to
allow the Centinela Airport Clinic at Los Angeles
International Airport to receive 911 transports of basic
life-support patients. This was apparently the first time that
an emergency medical services system in California was allowed
to transport patients from 911 dispatch to a facility that was
not part of a hospital. However, both CDPH and the statewide
California EMSA Medical disagreed that the local EMS agency
had the authority to permit the operation of such a facility.
Ultimately, this "freestanding ED" pilot project ended after
one year, partly as a result of low volume that resulted from
a restrictive county ambulance triage policy that limited the
severity of patients that could be transported to this
location.
3)Related legislation. AB 911 (Brough), is nearly identical to
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this bill. AB 911 is currently pending in Assembly Health
Committee.
AB 579 (Obernolte) permits a general acute care hospital to
operate an ED located more than 15 miles from its main
physical plant, if all applicable requirements of licensure
are satisfied. The bill would also permit a closing general
acute care hospitals' ED to continue to be operated at the
same location or locations by an acquiring general acute care
hospital, as specified. AB 579 creates an exception to permit
the acquiring general acute care hospital to operate the
closing general acute care hospitals' ED at that location or
locations, even if located more than 15 miles from the
acquiring general acute care hospital's main physical plant,
if all applicable requirements of licensure are satisfied. AB
579 is currently pending in Assembly Health Committee.
4)Prior legislation. AB 717 (Gordon of 2005) would have allowed
the Centinela Airport Clinic to receive private and government
reimbursement rates equivalent to that of a contiguous
emergency department of a general acute care hospital if
certain specified requirements were met. AB 717 failed
passage in the Senate Health Committee.
AB 1050 (Gordon of 2005) would have created a demonstration
project that required the Department of Health Services to
issue a special permit to up to four general acute care
hospital applicants in Los Angeles County to operate
freestanding emergency receiving centers. AB 1050 was never
heard in Committee.
5)Support. This bill is supported by Saddleback Memorial
Medical Center (Saddleback), which operates both the larger
hospital in Laguna Hills as well as San Clemente Hospital
under a consolidated license. According to Saddleback,
aggressive investments have been made in chronic disease
management infrastructure and care navigation personnel aimed
at finding new and innovate ways to care for patients in
non-acute care settings. A consequence of these efforts has
been that their inpatient volumes have contracted in
proportion to the growth of their ambulatory care services.
Saddleback states that the San Clemente campus doesn't perform
more sophisticated services such as interventional cardiology
or neonatal intensive care, and therefore has had a smaller
inpatient census than many hospitals. For the last decade, the
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average inpatient census has been around 25, but in recent
years, it has dropped below 14 on average, with many days
being below 10. Saddleback states that
as a result of their governing board, a study is being
conducted to evaluate transforming the San Clemente campus to
an array of coordinated, state of the art ambulatory care
services. Pursuant to this effort, Saddleback states that it
has had numerous discussions with various stakeholders, and it
became very clear that there was a strong desire to maintain
emergency services on the San Clemente campus. Saddleback
states that preserving emergency services is currently
dependent upon preserving the acute care service under current
law, but that maintaining acute care with a very small census
is becoming increasingly difficult given the market forces.
The City of San Clemente states in support that without this
bill, their residents and the residents of the surrounding
area will be forced to travel 15 miles north on I-5 to the
nearest emergency room, a road whose access and travel time is
uncertain due to traffic congestions and road construction.
The City of San Clemente notes that this bill does not propose
changing the hospital and emergency structure throughout the
state, but proposes a standalone emergency department solely
for this unique geographic region in South Orange County. The
City of San Clemente states that it will leave a 40-mile void
in emergency care access between Oceanside and Mission Viejo
if it closes.
This bill is also supported by a group of several physicians who
have formed "Save Saddleback San Clemente Hospital" (SSSCH).
According to SSSCH, San Clemente Hospital's ED serves 15,000
people yearly and is the second busiest ER in the region.
SSSCH states that their community is effectively a peninsula,
with Camp Pendleton south, protected forest to the east, the
ocean to the west, and only one road north, I-5, to access
emergency services. According to SSSCH, an I-5 widening
project has just started closing shoulders and ramps
intermittently, and that this project will last three years.
SSSCH states that in 2013 and 2014, the average transport
times from a typical San Clemente residence was 17 minutes to
the next closest hospital, Mission Hospital Regional Medical
Center in Mission Viejo, and now that construction has begun,
transport times to this facility can exceed 30 minutes.
According to SSSCH, Mission Hospital, which will get their
15,000 patients, leads all 26 hospitals in Orange County in
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wall time (when emergency personnel must wait in the ED with
their patients while waiting for a bed to open up) and
diversion time (when the ED is closed to paramedic traffic
because the ED is full). SSSCH states that with San Clemente
Hospital closing, their community will be left with 75 ED beds
to cover more than 400,000 people. SSSCH states that this bill
is critical to keep access to emergency care in their
community.
6)Opposition. The California Nurses Association (CNA) opposes
this bill, and points to arguments by the owner of the
hospital that local 911 calls for patients who may have a
heart attack, stroke, or trauma currently bypass San Clemente
hospital to go to cardiac receiving centers, stroke receiving
centers, and trauma centers. According to CNA, in other words,
San Clemente hospital's ED is being bypassed by Orange County
emergency medical services because its ED is insufficiently
supported by certain necessary and specialized urgent support
services, and that this bill would exacerbate such
insufficiency by diminishing even further those support
services while simultaneously holding itself out to the public
as an ED. The California State Council of the Service
Employees International Union (SEIU California) states in
opposition that under existing law, in order to provide
emergency services in California, emergency services must be
located within a hospital so as to have access to all
necessary services. SEIU California states that the reason for
these requirements is that it is difficult to predict the
severity of the medical needs of patients presenting at an ED.
Should an individual require immediate surgery to save his or
her life, for example, SEIU California states that those
services should be as close and readily available to the
patient as possible. The California Labor Federation states in
opposition that health care consumers have a reasonable
expectation that when they visit an emergency department, they
will have access to more services than when they visit an
urgency care center. This expectation extends to billing
procedures as well, and the California Labor Federation notes
that patient cost-sharing for emergency departments are often
much higher than for urgent care. Patients may end up with
much higher bills because they assumed the freestanding
emergency department was an urgent care center, or conversely,
may end up at the freestanding emergency department expecting
a full range of services, only to be transported to a
hospital.
SB 787 (Bates) Page 11 of ?
7)Oppose unless amended. The California Chapter of the American
College of Emergency Physicians (CalACEP) opposes this bill
unless amended to include important, more specific patient
safety protections. According to CalACEP, their concerns
center around allowing facilities to contain the word
"emergency" in their title without ensuring that the facility
will treat all patients regardless of their ability to pay, as
well as their ability to provide patients with full-scope
emergency department care. CalACEP is also concerned about
placing freestanding emergency departments in areas with
little community need where the highest paying patients can be
siphoned away from the payer mix of a nearby emergency
department, which has a critical effect on the community
safety net. As a result, CalACEP states that they are opposed
to legislation which would allow for a freestanding emergency
department unless it contained important protections to ensure
that the freestanding emergency department complied with the
Emergency Medical Treatment and Active Labor Act, it is open
24/7, the ownership is open to all, there are reasonable
transfer agreements in place, there are minimum standards to
ensure quality care, there is an established community need,
and there are minimum education and training requirements for
providers. CalACEP states that while there are provisions in
this bill which seek to address these concerns, it believes
more specificity is needed.
SUPPORT AND OPPOSITION :
Support: City of Dana Point
City of San Clemente
Saddleback Memorial Medical Center
Several individuals
Oppose: California Chapter of the American College of
Emergency Physicians (Unless Amended)
California Labor Federation
California Nurses Association
California State Council of Service Employees
International Union
-- END --
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