Hearing of the House Oversight and Government Reform Committee - The Lack of Hospital Emergency Surge Capacity

Hearing of the House Oversight and Government Reform Committee - The Lack of Hospital Emergency Surge Capacity

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REP. DIANE WATSON (D-CA): Thank you very much, Mr. Chairman.

The Los Angeles County Board of Supervisors visited Capitol Hill last week, and the number one theme that continued to surface in my conversations with many of the supervisors was the widening gap between the demand for Medicare-Medicaid assistance and the administration's new regulations that will limit the amount of Medicaid-Medicare reimbursement to the state.

The administration estimates that the total fiscal impact of the regulatory changes are $15 billion. But a committee report based on states that responded to the committee's request for information concludes that the change in regulations would reduce federal payments to states by $49.7 billion over the next five years. The cost to California alone is estimated to be $10.8 billion over five years.

Mr. Chairman, as you well know, in the case of California the reductions in federal funding would destabilize an already fragile medical care delivery service for low-income residents and the uninsured. The impact of these changes will be far-reaching and potentially catastrophic.

In the last year, we have witnessed the closing of many of King/Drew's Hospital medical facilities located in Watts, California. The emergency care facility has been closed now for some time. The impact of this closing is that residents from this underserved area of Los Angeles are transported to other areas of town, and the critical minutes that are needed to administer care to save lives are now lost.

The impact of King/Drew closing has had a cascading effect on all the other area hospitals, including those outside of the Los Angeles area that now must pick up the slack. I cannot imagine what would happen in these areas in the case of a mass catastrophic event such as a terrorist attack using conventional explosives or a natural disaster, since they are already suffering from a lack of adequate emergency care facilities.

So I look forward to the testimony of today's witnesses who are experts in medicine and medical delivery services and counterterrorism.

Again, thank you, Mr. Chairman, for holding this hearing.

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REP. WATSON: Mr. Chairman, I think some of the questions that are being asked of the witnesses are to be asked of the members sitting up here who make the policy.

Dr. Lewis, I am so glad you're here. I am intimately familiar with the situation down in Watts, California and Martin Luther King Hospital. And when that hospital's Medicare funds were pulled and Medicaid funds were reduced, many of the patients that would have gone to King had to come to surrounding hospitals. They're overcrowded. And I know on the day of the survey, 33 of your ER patients were being treated in chairs of hallways.

I have been in that situation myself in one of our most prominent hospitals, waiting two hours and 15 minutes, and people had been there for four days. We have a critical problem in our community, in our county hospital system, and we probably have one of the largest ones in the state in the Los Angeles area.

The day we took this survey, was that an unusual day for your hospital?

DR. LEWIS: In reviewing the numbers -- and I should clarify that I was not working that day -- but in reviewing the numbers that were submitted, my impression was that was a slightly less busy than usual day. It was done on a weekday.

REP. WATSON: Yeah. St. Francis Hospital -- you're aware of it --

DR. LEWIS: Yes.

REP. WATSON: -- is a (dish ?) hospital, and it too is complaining. Doctors' hospitals -- I can name all the hospitals in the area. I chaired the Health and Human Services Committee in Sacramento, in the Senate, for 17 years. I am intimately aware of our problems.

What is it that we need to have a functional emergency trauma and comprehensive care system for the indigent? And I know you're not in the business of doing the work of immigration officials. You treat people as needed. What would you want to see in this Los Angeles County area -- and maybe some of the rest of you in other states would want to respond too -- that would make our system viable to care for the needy, to care for the people who come through your doors, regardless of whether they're there legally or illegally?

DR. LEWIS: If I was limited to a single answer --

REP. WATSON: Yes.

DR. LEWIS: -- my answer would be an increase in the number of available inpatient beds in the hospital that are staffed by qualified nursing personnel who are available 24 hours, seven days a week.

REP. WATSON: When Dr. Leavitt -- thank you for your response. When Dr. Leavitt cut the Medicare dollars from King, or from LA County, that was 50 percent of the resources. So it impacted all of not only the county hospitals, but private hospitals as well.

Staffing of emergency personnel -- what would you like to see there? And you talked about other beds, but emergency and trauma.

DR. LEWIS: The most pressing shortage that we have right now in Los Angeles County is related to nurses in the emergency department. There's a nationwide nursing shortage. The working conditions and the stress level in the emergency department makes it not a popular long- term career choice for the best nurses, and that is the most pressing immediate personnel need that we have.

REP. WATSON: Okay, how do we solve that problem? And I will ask that of all of the witnesses. Dr. Welsh?

DR. CONWAY WELSH: I have several suggestions. The amount of federal dollars that are available for nurses to go back to school and to become either BSNs or master's-prepared nurses is very, very limited. The faculty scholarship program is very, very limited.

Let me take a little bit different cut, though, on your question about what could be done. The school of nursing at Vanderbilt has just received status as a clinic, a nurse-run faculty clinic, as an F2HC. That process took us almost 10 years to be designated as an F2HC.

There are schools of nursing all over this country that close their clinics once their education dollars run out from (HERSA ?) because they can't maintain it, because all of our patients are indigent and poor. An increase in the amount of F2HC support would be extremely helpful.

And then the last point I might make is that we have many, many nurse practitioners who are not able to practice in the full scope of their practice because of state problems with the Medical Practice Act and the Nurse Practice Act. We need a federal preemption that would allow the current nurse practitioners to practice in the full scope of practice.

The other thing that we need to do is nurses are hunters and gatherers in hospitals. There's 30 to 40 percent of what they do that they shouldn't be doing, but the system doesn't allow them to give that up. There's not enough support of the non-nurse personnel for nurses to stop being hunters and gatherers.

We would significantly address the nursing shortage in this country if we could just allow nurses to nurse and if we could fully utilize our nurse practitioners.

REP. WAXMAN: Thank you, Ms. Watson.

Mr. Issa, you're now recognized for your five minutes.

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REP. WATSON: And I just want to say I don't think it's really clear to some members that if you are an illegal immigrant, you are not eligible -- you are not eligible for Medicare and Medicaid.

As Dr. Lewis astutely notes, there are some federal policymakers who still do not see the relationship between maintaining a robust emergency and trauma care capacity and a successful homeland defense strategy. Hello?

I'd like to ask Dr. Hoffman and Dr. Kaplowitz, both of whom know a great deal about emergency preparedness and response, to help us connect the dots.

While there is much dispute about whether the Medicaid regulations are justified, there is no dispute that they will reduce the amount of federal Medicaid revenues to level one trauma centers and other hospitals throughout the country.,

There is also no dispute that the loss of federal funds will vary from hospital to hospital, and that for some level one trauma centers, these losses will be substantial, potentially forcing reductions in services and degrading their emergency response capacity.

So Mr. Hoffman, does it advance the goal of homeland security for the federal government to be withdrawing funding from level one trauma centers, whether through the Medicaid program or some other funding source? And it is (sic) reasonable for the federal government to assume that states or localities will make up these losses to the hospitals, or that market forces will make up for the shortfall?

Mr. Hoffman. Dr. Hoffman, excuse me.

MR. HOFFMAN: Well, I think certainly not in those cities, for instance, that the Department of Homeland Security have identified as the least most likely threat of a terrorist attack.

REP. WATSON: Excuse me. When you say most likely those areas, how do you define the areas that are most likely the target of terrorist attack?

MR. HOFFMAN: Well, the Department of Homeland Security and also private risk management firms have assessed, on a variety of indicators in terms of terrorist interest, in terms of the vulnerability of facilities in those cities, which cities in the United States would be more likely than others to --

REP. WATSON: Would you consider the West Coast, the Los Angeles area?

MR. HOFFMAN: Certainly Los Angeles and Southern California.

REP. WATSON: Yeah. We've got all kinds of --

MR. HOFFMAN: (Inaudible) -- one of them. San Francisco probably falls into that category as well.

REP. WATSON: Okay. Okay.

MR. HOFFMAN: I mean, given the pattern of terrorism certainly since 9/11, there's a very high concentration of these activities -- fortunately not yet in the United States, but overseas in major cities that are at least if not the capital of their nations, then at least are business centers or transportation hubs.

REP. WATSON: I just wanted to hear your response.

Thank you.

MR. HOFFMAN: But if I could just finish, for a second? If that's all right?

REP. WATSON: Yes.

MR. HOFFMAN: I would go back to what Dr. Kaplowitz said about Israel, which I think is absolutely correct, is that their energy services are not as overstressed in terms of their personnel as it appears in the United States.

London, by contrast, though, I think is very similar to the United States in that respect, with emergency rooms that have -- that already are burdened by a health system with lots of people in urban areas coming into them. And you can see the difference in the response of the London hospitals to the 7/7/05 attacks.

There, I think, the coordination was not as good, even though that they had extensive drills and extensive training. The planning -- the system broke down, in essence, because there weren't sufficient personnel and that, because the systems themselves were stressed.

REP. WATSON: Dr. Kaplowitz, as a state official, you've been involved in a great deal of planning for emergency preparedness and response throughout Virginia. Does it help your planning efforts when the federal government withdraws funding from level one trauma centers, whether through the Medicaid program or some other funding sources?

DR. KAPLOWITZ: Not at all. I need those facilities to survive, and I know what kind of stress they're under on a daily basis. You remove Medicaid funding, it could be disastrous.

We've seen any number of hospitals need to close their doors. The last thing I need is for any more hospitals to not be able to survive financially. And the stressors for trauma centers are enormous. The additional cost it takes to keep your trauma center open is significant. And these facilities are functioning with very small margins.

So I need them to be able to function and stay open, and I need them to maintain their expertise in order to appropriately respond to emergencies.

I've been at the health department almost six years. In my prior life, I was at the VCU health system for 20 years, including working in hospital administration. And I know what kind of stress that facility is under on a day-to-day basis. You take away significant Medicaid funding, it's going to be disastrous. And the same's true of all the trauma centers in the commonwealth.

REP. WATSON: Thank you.

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