[House Hearing, 109 Congress]
[From the U.S. Government Printing Office]




                             EMERGENCY CARE

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                      COMMITTEE ON WAYS AND MEANS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED NINTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 27, 2006

                               __________

                           Serial No. 109-80

                               __________

         Printed for the use of the Committee on Ways and Means














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                      COMMITTEE ON WAYS AND MEANS

                   BILL THOMAS, California, Chairman

E. CLAY SHAW, JR., Florida           CHARLES B. RANGEL, New York
NANCY L. JOHNSON, Connecticut        FORTNEY PETE STARK, California
WALLY HERGER, California             SANDER M. LEVIN, Michigan
JIM MCCRERY, Louisiana               BENJAMIN L. CARDIN, Maryland
DAVE CAMP, Michigan                  JIM MCDERMOTT, Washington
JIM RAMSTAD, Minnesota               JOHN LEWIS, Georgia
JIM NUSSLE, Iowa                     RICHARD E. NEAL, Massachusetts
SAM JOHNSON, Texas                   MICHAEL R. MCNULTY, New York
PHIL ENGLISH, Pennsylvania           JOHN S. TANNER, Tennessee
J.D. HAYWORTH, Arizona               XAVIER BECERRA, California
JERRY WELLER, Illinois               LLOYD DOGGETT, Texas
KENNY C. HULSHOF, Missouri           EARL POMEROY, North Dakota
RON LEWIS, Kentucky                  STEPHANIE TUBBS JONES, Ohio
MARK FOLEY, Florida                  MIKE THOMPSON, California
KEVIN BRADY, Texas                   JOHN B. LARSON, Connecticut
THOMAS M. REYNOLDS, New York         RAHM EMANUEL, Illinois
PAUL RYAN, Wisconsin
ERIC CANTOR, Virginia
JOHN LINDER, Georgia
BOB BEAUPREZ, Colorado
MELISSA A. HART, Pennsylvania
CHRIS CHOCOLA, Indiana
DEVIN NUNES, California

                    Allison H. Giles, Chief of Staff

                  Janice Mays, Minority Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                NANCY L. JOHNSON, Connecticut, Chairman

JIM MCCRERY, Louisiana               FORTNEY PETE STARK, California
SAM JOHNSON, Texas                   JOHN LEWIS, Georgia
DAVE CAMP, Michigan                  LLOYD DOGGETT, Texas
JIM RAMSTAD, Minnesota               MIKE THOMPSON, California
PHIL ENGLISH, Pennsylvania           RAHM EMANUEL, Illinois
J.D. HAYWORTH, Arizona
KENNY C. HULSHOF, Missouri

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Ways and Means are also published 
in electronic form. The printed hearing record remains the official 
version. Because electronic submissions are used to prepare both 
printed and electronic versions of the hearing record, the process of 
converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


















                            C O N T E N T S

                               __________

                                                                   Page

Advisory of July 20, 2006 announcing the hearing.................     2

                               WITNESSES

Gail L. Warden, President Emeritus, Henry Ford Health System, 
  Detroit, Michigan..............................................     5
Alan Kelly, Vice President and General Council, Scottsdale 
  Healthcare, Scottsdale, Arizona................................    12
Alan Levine, President and Chief Executive Officer, North Broward 
  Hospital District, Fort Lauderdale, Florida....................    17
Frederick C. Blum, M.D., President, American College of Emergency 
  Physicians, Morgantown, West Virginia..........................    21
Larry Bedard, M.D., Senior Partner, California Emergency 
  Physicians, Emeryville, California.............................    29

                       SUBMISSIONS FOR THE RECORD

American Academy of Pediatrics, statement........................    61
Rios, Elena, National Hispanic Medical Association, letter.......    69
Sanger, William, Emergency Medical Services Corporation, 
  statement......................................................    69













 
                             EMERGENCY CARE

                              ----------                              


                        THURSDAY, JULY 27, 2006

             U.S. House of Representatives,
                       Committee on Ways and Means,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:10 a.m., in 
room 1100, Longworth House Office Building, Hon. Nancy L. 
Johnson (Chairman of the Subcommittee), presiding.
    [The advisory announcing the hearing follows:]

ADVISORY

FROM THE 
COMMITTEE
 ON WAYS 
AND 
MEANS

                         SUBCOMMITTEE ON HEALTH

                                                CONTACT: (202) 225-3943
FOR IMMEDIATE RELEASE
July 20, 2006
HL-18

              Johnson Announces Hearing on Emergency Care

    Congresswoman Nancy L. Johnson (R-CT), Chairman, Subcommittee on 
Health of the Committee on Ways and Means, today announced that the 
Subcommittee will hold a hearing on emergency care. The hearing will 
take place on July 27, 2006, in the main Committee hearing room, 1100 
Longworth House Office Building, beginning at 10:00 a.m.
      
    In view of the limited time available to hear witnesses, oral 
testimony at this hearing will be from the invited witnesses only. 
Witnesses will include representatives from the Institute of Medicine 
and the hospital and health care provider community. However, any 
individual or organization not scheduled for an oral appearance may 
submit a written statement for consideration by the Subcommittee and 
for inclusion in the printed record of the hearing.
      

BACKGROUND:

      
    A recent report issued by the Institute of Medicine suggests that 
demand for emergency room services has increased in recent years, 
capacity has been reduced, patients are often ``boarded'' until 
inpatient beds become available, and diversions to other hospitals 
frequently occur. Also, there are concerns regarding the availability 
of medical specialists to provide emergency and trauma care.
      
    Hospitals are an important component of the nation's health care 
system, particularly with respect to emergency care, and they operate 
under various federal requirements. For instance, hospitals with 
emergency departments are required to screen and stabilize all 
individuals who enter hospital emergency rooms, regardless of their 
income level, citizenship, or insurance status.
      
    In announcing the hearing, Chairman Johnson said, ``Recent 
information appears to indicate that emergency health care providers, 
including the Nation's hospital systems, are experiencing increasing 
demands for their services. We need to better understand the demands 
placed on the health care provider community, and the reasons for these 
demands in order to fully assess any problems and explore potential 
solutions.''
      

FOCUS OF THE HEARING:

      
    This hearing will focus on the status of emergency health care and 
administration of health care services within the jurisdiction of the 
Subcommittee.
      

DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:

      
    Please Note: Any person(s) and/or organization(s) wishing to submit 
for the hearing record must follow the appropriate link on the hearing 
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August 10, 2006. Finally, please note that due to the change in House 
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encounter technical problems, please call (202) 225-1721.
      

FORMATTING REQUIREMENTS:

      
    The Committee relies on electronic submissions for printing the 
official hearing record. As always, submissions will be included in the 
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not alter the content of your submission, but we reserve the right to 
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    1. All submissions and supplementary materials must be provided in 
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hearing record.
      
    2. Copies of whole documents submitted as exhibit material will not 
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materials in alternative formats) may be directed to the Committee as 
noted above.

                                 

    Chairman JOHNSON OF CONNECTICUT. Good morning. Mr. Stark 
will be here momentarily, and I'm going to start with my 
opening statement and hope that by the time I finish it, he'll 
be here. He has been unavoidably delayed, but we're going to 
start. I'm very pleased to chair a hearing to consider the 
recent Institute of Medicine (IOM) report, ``Hospital-Based 
Emergency Care at the Breaking Point.'' We've all known this 
was coming. We've all known it as we've visited hospitals and 
circulated in our districts, so I welcome this report. I think 
it will be very helpful to this Committee and to the 
Administration, and I do consider addressing the issues it 
raises as very high on our agenda and indeed, an emergency.
    Emergency departments play a critical role in our health 
care system. They're responsible for urgent care, lifesaving 
care, they act as a safety net for those with limited access to 
the health care system, and they're the first line of defense 
in a public health emergency and in a disaster. Yet today, 
emergency departments face unprecedented challenges, and 
without attention, I believe they will not be able to fulfill 
their responsibilities, and the institutions on which they rely 
and which they serve will be at risk. Each year, there are 
approximately 114 million visits to emergency departments.
    According to the Institute of Medicine's recent report in 
2002, almost half of all hospital admissions occurred through 
the emergency department. In addition to the critical role 
emergency departments play in the health care system, they are 
also required to comply with unique legal requirements. In 
1986, Congress enacted Emergency Medical Treatment and Active 
Labor Act (EMTALA) (P.L. 99-272) to ensure public access to 
emergency services, regardless of ability to pay. section 1867 
of the Social Security Act (P.L. 108-173) imposes specific 
obligations on Medicare participating hospitals that offer 
emergency services to provide a medical screening exam when a 
request is made for examination or treatment for an emergency 
medical condition, including active labor, regardless of an 
individual's ability to pay.
    Hospitals are then required to provide stabilizing 
treatment for patients with emergency medical conditions. If a 
hospital is unable to stabilize a patient within its capacity, 
or if a patient requests it, an appropriate transfer must be 
made. The IOM also found that, as the demand on emergency 
services has grown, the nature of how hospitals operate has 
also changed. Between 1993 and 2003, there was a net loss 
198,000 hospital beds in the United States. This, in part, has 
given rise to boarding, which occurs when admitted patients are 
required to stay in emergency departments either because of 
lack of in-patient beds or because the in-patient beds 
available are being reserved for patients not entering the 
hospital through the emergency room.
    These patients may be cared for in settings that are far 
less than optimal and for significant lengths of times. 
Emergency departments are not equipped to board such patients, 
and it's not in the best interests of the patient, and it 
places great strain on the department. Perhaps the most tragic 
example of this are adolescents with psychiatric problems. We 
should truly be ashamed of where we are with that particular 
group needing health care. Additionally, emergency departments 
are responsible for treating the whole spectrum of injuries and 
diseases and are therefore, required to be able to call a 
specialist at any time of day or night to ensure that patients 
receive optimal and appropriate care.
    However, for a number of reasons, including increased 
malpractice premiums, the financial implications of caring for 
the uninsured, and the strain of being on call in addition to a 
full-time physician, means most emergency departments are 
finding it very difficult to have sufficient on-call physicians 
to care for their patients. As we will also hear, this 
situation has given rise to local and regional coordination 
efforts to raise the quality of care within the same resource 
base. Today, we'll first hear from Gail Warden, president 
emeritus of the Henry Ford Health System in Detroit, Michigan. 
I don't believe we will hear from her. Is she here? Oh, Mr. 
Warden. Sorry.
    Mr. Warden will testify to the findings and recommendations 
of the Institute of Medicine's ongoing series of reports on 
emergency departments, pediatric care in emergency departments, 
and emergency medical services. Additionally, Alan Kelly, vice 
president and general counsel of Scottsdale Healthcare in 
Arizona, will speak to the challenges of providing emergency 
care to a population with a significant number of undocumented 
immigrants and the unique challenges hospitals face in caring 
for these individuals. Alan Levine is president and CEO of the 
North Broward Hospital District in Florida, which is one of the 
largest nonprofit public health care systems in the nation. Mr. 
Levine will also speak to the stresses being placed upon 
emergency departments, the complexity of the causes, and the 
need for state and regional flexibility to meet these 
challenges.
    Finally, Dr. Frederick Blum, associate professor of 
emergency medicine, pediatrics, and internal medicine at West 
Virginia University School of Medicine, and president of 
American College of Emergency Physicians, and Larry Bedard, an 
emergency department physician, will provide the physician 
perspective on emergency department care in the United States. 
I look forward to hearing from all of the witnesses and thank 
you for being here today, but I would like to yield at this 
time a moment to my colleague from Arizona for the purposes of 
an introduction.
    Mr. HAYWORTH. Madam Chairman, thank you very much. As you 
mentioned, among the witnesses, and I would be remiss if I did 
not welcome all of our witnesses today to deal with the 
challenges confronting emergency care, but I am very pleased to 
have one of my constituents and friends, Alan Kelly, who serves 
as vice president and general counsel of Scottsdale Health Care 
in my hometown of Scottsdale, Arizona. As one who has not taken 
advantage well, no, strike that. Perhaps not personally, but 
with kids and athletic accidents, for purposes of full 
disclosure, we have availed ourselves of the emergency 
facilities at what we used to call Scottsdale North. We've 
since changed the nomenclature.
    I've seen firsthand the emergency care, and look forward to 
hearing Alan document the challenges that we are encountering 
in Arizona, and challenges that don't simply come to hospitals 
in border states with emergency care to illegal immigrants. So 
Alan, we welcome you, as we welcome all of the witnesses, and 
Madam Chairman, I thank you very much for the generosity of 
your time, and for holding this hearing today. I yield back.
    Chairman JOHNSON OF CONNECTICUT. Thank you very much. We 
are going to proceed, and Mr. Stark will make some comments 
when he arrives. He will be arriving momentarily. Mr. Warden.

  STATEMENT OF GAIL L. WARDEN, PRESIDENT EMERITUS, HENRY FORD 
                HEALTH SYSTEM, DETROIT, MICHIGAN

    Mr. WARDEN. Thank you, Madam Chair and Members of the 
Subcommittee. My name is Gail Warden. I'm the president 
emeritus of Henry Ford Health System in Detroit, Michigan, and 
was the chair of the Institute of Medicine's Committee on the 
Future of Emergency Care in the United States Health System. 
This Committee was formed in September of 2003 to examine the 
emergency care system, explore its strengths, limitations, and 
challenges to create a vision for the future of the system and 
to make recommendations to help the nation achieve that vision.
    Over 40 national experts from fields including emergency 
care, trauma, pediatrics, health care administration, public 
health, and health services research participated as Members of 
the Committee or Subcommittee. The study was requested by 
Congress and funded through a congressional appropriation along 
with additional sponsorship from the Josiah Macy Foundation, 
the Department of Health and Human Services, and the Department 
of Transportation. In my brief time this morning, I'm going to 
basically focus on the findings and recommendations of the 
report as they relate to hospital-based emergency care. As far 
as the findings are concerned, I think it's fair to say that 
beneath the surface, there's a growing crisis in emergency 
care.
    Many emergency departments today are severely overcrowded 
with patients, many of whom are being held in the emergency 
department because of no in-patient bed being available. When 
crowding reaches dangerous levels, hospital often divert 
ambulances to other facilities. In 2003 alone, U.S. hospitals 
diverted more than half a million ambulances, which is an 
average of one per minute. Each diversion adds minutes to the 
time before a patient can be seen by a doctor and these delays 
may mean the difference between life and death for some 
patients. A second finding, which is important, which, Madam 
Chair, you mentioned in your opening statement, is it is 
becoming increasingly difficult for hospitals to find 
specialists who will agree to be on call.
    The rising cost of uncompensated care, the fear of legal 
liability for performing risky procedures, and the disruptions 
of daily medical practice and home lives have led more surgical 
specialists to opt out on taking emergency department (ED) 
calls. The resulting shortage of on-call specialists in 
emergency departments can have a tragic result. Thirdly, 
today's emergency care system is often highly fragmented and 
variable. Coordination of emergency care providers on the 
ground is often poor. Emergency medical services, hospitals, 
and public safety often lack common radio frequencies, much 
less interoperable communications systems, and these 
technological gaps are compounded by cultural gaps between 
public safety providers and emergency care personnel. The 
fourth important finding is that there's a lack of preparedness 
within the system to care for children.
    We have recognized for decades that children require 
specialized care, and although children make up 27 percent of 
all visits to the emergency departments, a recent study found 
only 6 percent of the hospitals have all the supplies deemed 
essential for managing pediatric emergencies. We believe the 
country can do better. As far as recommendations are concerned 
to improve the nation's emergency care system and deal with the 
growing demands placed upon it, the Committee described a 
vision of the emergency system that we would like to see, in 
which we talked about coordination, regionalization, and 
accountability: Coordination of all the components of the 
system, such as EMS, hospital emergency departments, trauma 
centers, local dispatchers working together; Regionalization so 
patients are taken to facilities that are best able to address 
the needs of each patient based upon their particular illness 
or injury; Accountability in that an emergency care system 
should be transparent and accountable to the public it serves 
and their preferences should be measured.
    To achieve that vision, we recommended that Congress 
establish a demonstration program to promote that vision 
through an $8 million appropriation over 5 years for 
demonstrations in 10 states in each phase, Phase 1 and Phase 2. 
We recommended the establishment of a lead agency in the 
Department of Health and Human Services for emergency and 
trauma care, and asked that that lead agency establish a 
working group to consolidate the funding and functions. We also 
recommended that the Federal agencies establish evidence-based 
categorization of systems' pre-hospital protocols and 
indicators of system performance.
    A second recommendation related to the fact that we felt we 
must end the practice of emergency department boarding and 
diversion except in the most extreme circumstances, such as 
community mass casualty events, and recommended that the tools 
developed from engineering and operation research and 
information technology that are available be applied in 
institutions----
    Chairman JOHNSON OF CONNECTICUT. Mr. Warden, could I ask 
you to just start back? You've just gone on to recommendation 
number one. So, if you would start back with your first 
recommendation, that would be useful.
    Mr. WARDEN. Back to describing the vision, ma'am?
    Chairman JOHNSON OF CONNECTICUT. You may proceed.
    Mr. WARDEN. Okay. In the recommendations, there were four 
recommendations that I thought we should highlight today. The 
first was a vision that we establish, as it relates to what we 
thought the emergency system ought to be able to do in this 
country. We emphasized coordination among all components of the 
system; We emphasized regionalization, where patients are taken 
to facilities that are best able to address the needs for each 
patient based upon their particular illness or injury; 
Accountability, in that an emergency care system should be 
transparent and accountable to the public it serves, and their 
preferences should be measured.
    To achieve that vision, we recommended that Congress 
establish a demonstration program to promote a regionalized, 
coordinated, and accountable emergency care system over five 
years. We also suggested that Congress should establish a lead 
agency in the Department of Health and Human Services for 
emergency and trauma care, and a working group should be 
brought together to consolidate functions of funding which are 
now in a multiple number of agencies. We also recommended that 
Federal agencies establish evidence-based categorization of 
systems' pre-hospital protocols and indicators of system 
performance.
    The second recommendation was that we must end the practice 
of emergency department boarding and diversion except in most 
extreme circumstances, such as a community mass casualty event. 
We outlined in much detail about the tools that are available 
from engineering and operations research and information 
technology that would help to accomplish that. We also 
suggested that, since there are few financial incentives for 
hospitals to reduce crowding, that the Joint Commission should 
develop strong standards about emergency department crowding, 
boarding, and diversion. The third important recommendation was 
really related to increasing funding that could help improve 
the nation's emergency care system. Much research is needed.
    We also felt Congress should provide greater reimbursement 
to the large safety net hospitals and trauma centers that bear 
a disproportionate amount of the cost of taking care of 
uninsured patients and that there should be greater funding for 
disaster preparedness. Finally, as the various improvements are 
made to the nation's emergency care system, it will be 
important to keep pediatric patients in mind in all aspects of 
emergency care, because they have not gotten the attention that 
they should. In closing, the Committee believes that the 
nation's emergency care system is in serious peril. Strong 
measures must be taken by Congress, the state, hospitals, and 
others to achieve the level of response that Americans expect 
and deserve. Thank you for the opportunity to testify, and I'll 
be happy to answer any questions that the Subcommittee might 
have.
    [The prepared statement of Ms. Warden follows:]
  Statement of Gail L. Warden, President Emeritus, Henry Ford Health 
                       System, Detroit, Michigan
INTRODUCTION
    Good morning Madame Chair and members of the Subcommittee. My name 
is Gail Warden and I am President Emeritus of Henry Ford Hospital in 
Detroit, Michigan. I served as chair of the Institute of Medicine's 
Committee on the Future of Emergency Care in the U.S. Health System.
THE IOM
    The Institute of Medicine, or IOM as it is commonly called, was 
established in 1970 under the charter of the National Academy of 
Sciences to provide independent, objective, evidence-based advice to 
the government, health professionals, the private sector, and the 
public on matters relating to medicine and health care.
THE STUDY
    The Institute of Medicine's Committee on the Future of Emergency 
Care was formed in September 2003 to examine the full scope of 
emergency care; explore its strengths, limitations and challenges; 
create a vision for the future of the system; and make recommendations 
to help the nation achieve that vision. Over 40 national experts from 
fields including emergency care, trauma, pediatrics, health care 
administration, public health, and health services research 
participated on the Committee or one of its subcommittees. The 
Committee produced three reports--one on prehospital emergency medical 
services (EMS), one on hospital-based emergency care, and one on 
pediatric emergency care. These reports provide complimentary 
perspectives on the emergency care system, while the series as a whole 
offers a common vision for the future of emergency care in the U.S.
    This study was requested by Congress and funded through a 
Congressional appropriation, along with additional sponsorship from the 
Josiah Macy Jr. Foundation, the Agency for Healthcare Research and 
Quality, the Health Resources and Services Administration, the Centers 
for Disease Control and Prevention, and the National Highway Traffic 
Safety Administration.
    I will briefly summarize the Committee's findings and 
recommendations, giving particular attention to those that relate to 
hospital-based emergency care.
GENERAL FINDINGS
    Emergency and trauma care are critically important to the health 
and well being of Americans. In 2003, nearly 114 million visits were 
made to hospital emergency departments (EDs)--more than 1 for every 3 
people in the U.S. While many Americans need emergency care only 
rarely, everyone counts on it to be available when needed.
    Emergency care has made important strides over the past 40 years: 
emergency 9-1-1 service now links virtually all ill and injured 
Americans to an emergency medical response; EMS systems arrive to 
transport patients to advanced, life-saving care; and scientific 
advances in resuscitation, diagnostic testing, trauma and emergency 
medical care yield outcomes unheard of just two decades ago. Yet just 
beneath the surface, a growing crisis in emergency care is brewing; one 
that could imperil everyone's access to care.
Emergency Department Crowding
    The number of patients visiting EDs has been growing rapidly. There 
were 113.9 million ED visits in 2003, for example, up from 90.3 million 
a decade earlier. At the same time, the number of facilities available 
to deal with these visits has been declining. Between 1993 and 2003, 
the total number of hospitals in the United States decreased by 703, 
the number of hospital beds dropped by 198,000, and the number of EDs 
fell by 425. The result has been serious overcrowding. If the beds in a 
hospital are filled, patients cannot be transferred from the ED to 
inpatient units. This can lead to the practice of ``boarding'' 
patients--holding them in the ED, often in beds in hallways, until an 
inpatient bed becomes available. It is not uncommon for patients in 
some busy EDs to board for 48 hours or more. These patients have 
limited privacy, receive less timely services, and do not have the 
benefit of expertise and equipment specific to their condition that 
they would get within the inpatient department.
    Another consequence of overcrowding has been a striking increase in 
the number of ambulance diversions. Once considered a safety valve to 
be used only in the most extreme circumstances, diversions are now 
commonplace. Half a million times each year--an average of once every 
minute--an ambulance carrying an emergency patient is diverted from an 
ED that is full and sent to one that is farther away. Each diversion 
adds precious minutes to the time before a patient can be wheeled into 
an ED and be seen by a doctor, and these delays may mean the difference 
between life and death for some patients. Moreover, the delays increase 
the time that ambulances are unavailable for other patients.
Fragmentation
    Few systems around the country coordinate the regional flow of 
emergency patients to hospitals and trauma centers effectively because 
most fail to take into account such things as the levels of crowding 
and the differing sets of medical expertise available at each hospital. 
Indeed, in most cases, the only time an ED passes along information 
concerning its status to EMS agencies is when it formally goes on 
diversion and refuses to take further deliveries of patients. As a 
result, the regional flow of patients is managed poorly and individual 
patients may have to be taken to facilities that are not optimal given 
their medical needs.
    Adding to the fragmentation is the fact that there is tremendous 
variability around the country in how emergency care is handled. There 
are more than six thousand 9-1-1 call centers around the country and 
depending on their location, they may be operated by the police 
department, the fire department, the city or county government, or some 
other entity. There is no single agency in the federal government that 
oversees the emergency and trauma care system. Instead, responsibility 
for EMS and hospital-based emergency and trauma care is scattered among 
many different agencies and federal departments, including Health and 
Human Services, Transportation, and Homeland Security. Because 
responsibility for the system is so fractured, there is very little 
accountability. In fact, it is often difficult even to determine where 
system breakdowns occur and why.
Shortage of On-Call Specialists
    Emergency and trauma doctors can be called on to treat nearly any 
type of injury or illness, so it is important for them to be able to 
consult with specialists in various fields. It has become increasingly 
difficult, however, for hospitals to find specialists willing to be on 
call for the ED. The resulting shortage of on-call specialists in EDs 
can have dire and sometimes tragic results.
    There are many reasons why specialists are often unwilling to be 
on-call in EDs. Many specialists find that they have difficulty getting 
paid for services provided in the ED because many emergency and trauma 
patients are uninsured. Specialists are also deterred by the additional 
liability risk of working in the ED. Many of the procedures performed 
in EDs are inherently risky and physicians rarely have an existing 
relationship with emergency patients. The result is that insurance 
premiums for doctors who serve as on-call specialists in the ED are 
higher than for those who do not. Finally, many specialists find the 
demands of providing on-call services too disruptive to their private 
practices and their family lives.
Lack of Preparedness for Disasters
    Unfortunately, the nation's emergency care system is very poorly 
prepared to handle disasters. The difficulties begin with the already 
overcrowded nature of the system. With hospitals in many large cities 
operating at or near full capacity, even a multiple-car highway crash 
can create havoc in an ED. A major disaster with many casualties is 
something that most hospitals have limited capacity to handle.
    Much of the problem, though, is due to a simple lack of funding. 
Hospital grants from HRSA's National Bioterrorism Hospital Preparedness 
Program are small--not enough to equip even one critical-care room. 
Although emergency service providers are a crucial part of the response 
to any disaster, they received only 4 percent of the $3.38 billion 
distributed by the Homeland Security Department for emergency 
preparedness in 2002 and 2003. Due to this lack of funding, few 
hospital and EMS personnel have received even minimal training in how 
to prepare for and respond to a disaster. Few hospitals have negative-
pressure units, for instance, which are crucial for isolating victims 
of airborne diseases, such as the avian flu. Nor do many hospitals have 
the appropriate personal protective equipment to keep their staffs safe 
when dealing with an epidemic or other disaster.
Shortcomings in Pediatric Emergency Care
    Children who are injured or ill have different medical needs than 
adults with the same conditions. They have different heart rates, blood 
pressures, and respiratory rates, and these change as children grow. 
They often need equipment that is smaller than what is used for adults, 
and they require medication in much more carefully calculated doses. 
They have special emotional needs as well, often reacting very 
differently to an injury or illness than adults. Unfortunately, 
although children make up 27 percent of all visits to the ED, many 
hospitals and EMS agencies are not well equipped to handle these 
patients.
IOM RECOMMENDATIONS
    To improve the nation's emergency care system and deal with the 
growing demands placed on it, the Committee recommends a broad strategy 
for reform, beginning with a new vision for the future of emergency 
care.
A Vision for the Future of Emergency Care
    The Committee believes the challenges that exist in the system 
today can best be addressed by building a nationwide network of 
regionalized, coordinated, and accountable emergency care systems. They 
should be coordinated in the sense that, from the patient's point of 
view, delivery of emergency services should be seamless. To achieve 
this, the various components of the system--9-1-1 and dispatch, 
ambulances and EMS workers, hospital EDs and trauma centers, and the 
specialists supporting them--must be able to communicate continuously 
and coordinate their activities. When an ambulance picks up a patient, 
for example, the EMS personnel gather information on the patient, and 
the information is automatically passed on to the ED before the 
ambulance even arrives.
    The system should be regionalized in the sense that neighboring 
hospitals, EMS, and other agencies work together as a unit to provide 
emergency care to everyone in that region. A patient should be taken to 
the optimal facility within the region based on his or her condition 
and the distances involved. In case of a stroke, for example, a patient 
might be better served by going to a hospital that is slightly farther 
away but that specializes in treatment of strokes.
    Finally, the system should be accountable, which means that there 
must be a way of determining the performance of the different 
components of the system and reporting that performance to the public. 
This will require the development of well-defined standards and methods 
to collect data and measure performance against those standards.
    To promote the development of these systems, the Committee 
recommends two important roles for Congress. First, Congress should 
establish a federally funded demonstration program to develop and test 
various approaches to regionalize delivery of prehospital and hospital-
based emergency care. Second, Congress should designate a lead agency 
for emergency care in the federal government to increase 
accountability, minimize duplication of efforts, and fill important 
gaps in federal support of the system.
    The Committee recommends that states actively promote regionalized 
emergency care services. This will help insure that the right patient 
gets to the right hospital at the right time, and help hospitals retain 
sufficient on-call specialist coverage. Disaster planning at the local 
and regional level would take place within the context of these 
regionalized systems so that patients get the best care possible in the 
event of a disaster. Integrating communications systems would improve 
coordination of services across the region; not only during a major 
disaster but on a day-to-day basis.
Improving Efficiency and Patient Flow
    Tools developed from engineering and operations research have been 
successfully applied to a variety of businesses, from banking and 
airlines to manufacturing companies. These same tools have been shown 
to improve the flow of patients through hospitals, increasing the 
number of patients that can be treated while minimizing delays in their 
treatment and improving the quality of their care. For example, 
smoothing the peaks and valleys of patient admissions has the potential 
to eliminate bottlenecks, reduce crowding, improve patient care, and 
reduce cost. Another promising tool is the clinical decision unit, or 
23-hour observation unit, which helps ED staff determine whether 
certain ED patients require admission. Hospitals should use these tools 
as a way of improving hospital efficiency and, in particular, reducing 
ED crowding.
    At the same time hospitals should increase their use of information 
technologies with such things as dashboard systems that track and 
coordinate patient flow and communications systems that enable ED 
physicians to link to patients' records from other providers. Such 
increased use of information technologies will not only lead to greater 
hospital efficiency but will increase safety and improve the quality of 
emergency care.
    Since there are few financial incentives for hospitals to reduce 
crowding, the Joint Commission on the Accreditation of Healthcare 
Organizations should put into place strong standards on ED crowding, 
boarding, and diversion. In particular, the practices of boarding and 
ambulance diversion should be eliminated except in the most extreme 
circumstances, such as a community mass-casualty event.
Increasing Resources for Emergency Care
    Increased funding could help improve the nation's emergency care 
system in a number of ways. More research is needed, for instance, to 
determine the best ways to organize the delivery of emergency care 
services, particularly prehospital EMS. And, given that many closings 
of hospitals and EDs can be attributed to financial losses from the 
delivery of emergency and trauma services, Congress should provide 
additional funding to large safety-net hospitals and trauma centers 
that bear a disproportionate amount of the cost of taking care of 
uninsured patients.
    Another area in which more funding is needed is disaster 
preparedness. To date, despite their importance in any response to 
disaster, the various components of the emergency care system have 
received very little of the funding that Congress has dispensed for 
disaster preparedness. In part this is because the money tends to be 
funneled through public safety agencies that often consider medical 
care to be a low priority. Therefore, Congress should make 
significantly more disaster-preparation funds available to the 
emergency system through dedicated funding streams.
Paying Attention to Children
    Finally, as these various improvements are made to the nation's 
emergency care system, it will be important to keep pediatric patients 
in mind in all aspects of emergency care. The needs of pediatric 
patients should be taken into account in developing standards and 
protocols for triage and transport of patients; in developing disaster 
plans; in training emergency care workers, to ensure that they are 
competent and comfortable providing emergency care to children; and in 
conducting research to determine which treatments and strategies are 
most effective with children in various emergency situations.
CLOSING
    The Committee believes that the nation's emergency care system is 
in serious peril. If the system's ability to respond on a day-to-day 
basis is already compromised to a serious degree, how will it respond 
to a major medical or public health emergency? Strong measures must be 
taken by Congress, the states, hospitals, and other stakeholders to 
lead the emergency care system into the future. The Committee's 
recommendations provide concrete recommendations for action.
    Thank you for the opportunity to testify. I would be happy to 
address any questions the Subcommittee might have.

                                 

    Chairman JOHNSON OF CONNECTICUT. Thank you very much, Mr. 
Warden. Mr. Kelly. I should have mentioned to begin with, your 
entire testimony will be included in the record. You each have 
5 minutes. Mr. Kelly.

STATEMENT OF ALAN B. KELLY, VICE PRESIDENT AND GENERAL COUNSEL, 
           SCOTTSDALE HEALTHCARE, SCOTTSDALE, ARIZONA

    Mr. KELLY. Good morning, Chairman, and Members of the 
Committee, and thank you for the find introduction, Congressman 
Hayworth. Again, my name is Alan Kelly. I am vice president and 
general counsel for Scottsdale Healthcare. I'm greatly honored 
to be here today. Scottsdale Healthcare is a three-campus 
health care system located in Scottsdale, Arizona. A full 
description of our hospitals is in the submission given to the 
Committee, but I would like to emphasize a few things.
    Our Osborn facility is the only Level 1 trauma center for 
the Greater Eastern Phoenix area serving over 2.5 million 
people. We provide over 51,000 emergency room visits with over 
3,200 trauma cases. Our Shea facility provides over 50,000 ER 
visits, and our new Thompson Peak facility, which is expected 
to open in 2007, we expect around 20,000 ER visits. On the 
issue of overcrowding, this has existed many years in ERs, the 
origins I think being the increase in the number of uninsured 
and the EMTALA Act. Now, we have new pressures that I would 
like to focus this Committee's attention on, and if the 
Committee will indulge me, I am passionate about these two 
issues.
    The first is the inflow and the influx of illegal 
immigrants which section 1011 tries to address but really does 
not. An example can best be illustrated by telling you about a 
man with many names, and this is a story that recently actually 
transpired in our facility. This is a 63-year-old Hispanic male 
who came into our trauma center via ambulance on January 18th 
of this year. He had sustained a laceration on the neck from a 
branch after falling from a tree, obviously picking fruit. He 
also suffered a stroke. After being treated in our trauma unit, 
the patient was transferred from the ER into our intensive care 
unit.
    As a result of the stroke, he had difficulty swallowing and 
the patient required a feeding tube. On January 31st, the 
patient was considered stabilized and ready for transfer to a 
skilled nursing facility, but as all of the Members of this 
Committee know, no facility would accept him due to a lack of a 
payer source or place or origin. He was turned down from 
coverage from the Arizona Medicaid program, and the Social 
Security number found on his personal belongings was determined 
to be completely invalid. His employer's name was also found in 
his personal belongings. When contacted, however, the employer 
denied knowledge of his name. The next day when we called, the 
phone number was disconnected.
    The Mexican Consulate in Phoenix was contacted, but office 
staff requested information which is impossible for even us to 
get. The Mexican Consulate is extremely difficult and little 
help in these matters. On January 24, 2006, the patient was 
transferred to a medical unit within our facility, and sitter 
care had to be maintained 24 hours, 7 days per week, because 
the patient attempted to get out of bed multiple times. Our 
case management department continued to explore skilled nursing 
care facilities, but was able to make a transfer because of the 
payer issue.
    The Scottsdale Police Department fingerprinted the patient 
for identification purposes, and I authorized the hiring of a 
private investigator to determine the patient's identification. 
The private investigator uncovered several police reports 
indicating that this patient had used at least 10 different 
names, had used at least 10 different date of birth, and at 
least six different Social Security numbers. The private 
investigator's final report also indicated that the patient had 
been arrested 10 times over three decades, released, and 
deported. The arrests included three felony convictions in this 
country, one for aggravated assault, and one for distribution 
of drugs.
    The total investigator's report was finally faxed to the 
Mexican Consulate in Phoenix on April 17, 2006 of this year, 
and I think, Committee Members, they were basically shamed into 
finally giving us the necessary transport papers in order for 
us to get this patient back to Sonora, Mexico, at Scottsdale 
Healthcare's cost, of course. Scottsdale Healthcare incurred 
costs of over $260,000 for this patient's 93-day length of stay 
and $4,000 for ambulance transport to Mexico. Our system 
additionally incurred expenses for the numerous hours and 
clinical staff, including case managers, legal. A 93-day stay 
speaks for itself.
    Unfortunately, this is only one example of the massive 
challenge to treat and care for the undocumented crisis 
patients in this country, just not in border states. The second 
other biggest problem that I face on a weekly basis is the 
shortage of on-call physicians, that my colleague has talked 
about. Scottsdale Healthcare spent over 13 million on stipends 
for surgical specialists to ensure their on-call attention in 
2005. Whatever the Committee's position is on specialty care 
providers, whatever it is, the fact is that physicians have 
many other alternatives to practice, the ER being the least, 
since this cohort of patients are typically high in uninsured 
and under-insured.
    We must, however, provide the coverage, as EMTALA requires, 
and therefore, have to pay handsomely for it. Now, I ask the 
Committee Members, what physician, given the practice choices 
now available, want to cover at difficult hours with little or 
no chance of getting collected for insurance, and with the 
exposure of being sued, what physician would like to take that 
type of coverage? In conclusion, more than 46 percent of the 
patients who are admitted in Arizona hospitals are emergency 
department patients. The cascading impact of ever tightening 
regulations, the flood of undocumented immigrants, and the 
spiraling costs of providing specialty physician coverage is 
foreboding. It is stressing a system that is already under 
considerable pressure.
    Section 1011 is a blunt instrument. Although well-intended 
to help finance illegal alien health services, what we are 
really talking about is the distribution of expensive talent 
and existing resources to provide to our own citizens. Filling 
out the forms section 11 requires, it is almost impossible. 
Committee Members, look at the form yourself. Moreover, it 
turns our registration clerks into immigration officials. 
Members of this Subcommittee, 93-day stays in an in-patient 
setting is becoming more common, more common for illegal 
immigrants because of the special problems I have identified 
today, and therefore profoundly affects overcrowding throughout 
hospitals. section 1011 does not solve our shared 
constitutional obligations to protect our borders. It only 
seeks to help finance it, but it's not the answer to this 
problem.
    Prompt action is necessary to avoid a health care 
catastrophe that will shut the doors of emergency departments 
nationwide and further stress scare in-patient resources. 
Again, Chairman, it has been a pleasure to be here today, and I 
look forward to your questions. Thank you.
    [The prepared statement of Mr. Kelly follows:]
Statement of Alan Kelly, Vice President and General Council, Scottsdale 
                    Healthcare, Scottsdale, Arizona
    Good morning, Madam Chairwoman and members of the Committee, my 
name is Alan Kelly, Vice President and General Counsel for Scottsdale 
Healthcare. I am very pleased to be here today, on behalf of Scottsdale 
Healthcare and discuss issues related to emergency care. Scottsdale 
Healthcare is a three-campus health system located in Scottsdale 
Arizona. Our hospitals were founded in 1962 as a non-for-profit 
provider, led by a volunteer board of local residents.
    The Scottsdale Healthcare Osborn campus is our original hospital 
facility. Expanded numerous times since 1962, it is a 337-bed hospital 
offering the only Level 1 Trauma Center for the eastern portion of the 
greater Phoenix metropolitan area, serving a population of 
approximately two and a half million people. The hospital recently 
expanded it emergency services and conducts the first community-based 
military trauma training program in the United States. Osborn's 
emergency department annually provides care for over 51,000 patient 
visits with over 3,200 trauma cases.
    Scottsdale Healthcare Shea is a 405-bed hospital which opened in 
1984. Also located on the Shea campus is the Virginia G. Piper Cancer 
Center. The Cancer Center combines the talents of community 
oncologists, faculty from the University of Arizona, and genomic 
researchers in one location to serve our cancer patients. Through these 
collaborations, we are able to offer Phase I and Phase II Clinical 
Trials of new cancer therapies. Shea's emergency department provides 
care for over 50,000 emergency department patient visits per year.
    Our third hospital, Scottsdale Healthcare Thompson Peak, will open 
in late 2007. Now under construction, the hospital will initially open 
with 60 beds, expanding to 184 beds with ten dedicated to emergency 
care to meet the needs of our growing community.
Overcrowding
    The Institute of Medicine's June 2006 report on the Future of 
Emergency Care in the United States Health System highlights the 
challenges hospitals and health systems face in providing emergency 
care to our communities. The report correctly indicates that emergency 
departments are the first place patients turn to address illness and 
immediate health care needs. Many of those patients visits could be 
provided by primary care physicians in another care setting. Often, 
insured patients use emergency departments when their physician is not 
available to address their needs. Another cause of is the increasing 
number of uninsured patients who use emergency departments as their 
primary care setting. All of this utilization stretches emergency 
facilities beyond their capability. Many hospitals will divert incoming 
patients from their emergency department to another hospital emergency 
facility. The consequence is a domino effect moving the burden from one 
emergency department to another.
    Nearly five years ago, Scottsdale Healthcare began the discussion 
of reorganizing its patient ``throughput'' processes. The development 
and implementation took three years, with a $1.4 million dollar 
investment and annual commitment in increased staff. The intent was to 
improve patient care and provide for more efficiency through the 
Emergency Department to an inpatient bed or to discharge. The outcome 
was significant reductions in wait times. Scottsdale Healthcare 
averages a turn-around times of two to four hours, from entering the 
Emergency Department to either discharge or a patient bed. Yet, as 
Scottsdale Healthcare has improved its internal patient throughput 
process, we continue to experience increased emergency department 
volumes.
EMTALA
    The Emergency Treatment and Labor Act (EMTALA) directs hospitals to 
provide a medical screening examination to people, regardless of their 
ability to pay, for the purpose of identifying an emergency medical 
condition. There is a provision within EMTALA that requires a hospital 
to accept a transfer from another hospital's Emergency Department if 
the accepting hospital provides the necessary higher level of care for 
that patient, and the hospital has sufficient resources to accept the 
patient (beds, equipment, and personnel, including on-call 
specialists). While the objectives of this Act goes to the heart of 
healthcare's desire to provide all patients with quality care, the 
ramification is a burgeoning patient population flow through Emergency 
Departments and Trauma Centers.
    Aggravating this growth is the population of undocumented 
immigrants, who do not qualify for emergency Medicaid services. Section 
1011 of the Medicare Modernization Act of 2003 targets this population 
with supplemental resources. Unfortunately, access to the funding is 
contingent upon the hospital completing a Provider Payment 
Determination questionnaire. The process to receive reimbursement is 
cumbersome and required additional financial services personnel to 
manage and coordinate the implementation of Section 1011. Additionally, 
hospitals must gather from the patients complicated immigration 
documentation, which is time consuming and rarely forthcoming. We need 
to avoid turning healthcare professionals and hospital financial 
services personnel into immigration experts.
    One undocumented patient from Scottsdale Healthcare's Trauma Center 
serves as a case example of the challenges that healthcare facilities 
face in treating undocumented persons. This patient was a 63 year-old 
Hispanic male brought to the Trauma Center via ambulance on January 18, 
2006 as a Level I emergency. He had sustained a laceration on the neck 
from the branch of a small tree after falling off a ladder. He had a 
stroke secondary to traumatic carotid artery dissection. After being 
treated, the patient was transferred from the Emergency Department and 
admitted to the Intensive care unit. As a result of the stroke and 
difficulty swallowing, the patient required a feeding tube for 
nutritional intake.
    On January 31, 2006, the patient was considered ``stabilized'' and 
ready for discharge to a skilled nursing facility. However, no facility 
would accept the patient due to lack of payor source. He was turned 
down for coverage from Arizona Health Care Cost Containment System, 
Arizona's Medicaid program, since he had no proof of residency. The 
Social Security number found in his personal belongings was determined 
to be invalid. His employer's name was also found in his personal 
belonging. When contacted, however, the employer denied knowledge of 
the patient's name. The following day, the employer's phone number was 
disconnected. The Mexican Consulate in Phoenix was contacted, but 
office staff requested information on where the patient was born in 
order to assist in locating family members.
    On January 24, 2006 the patient was transferred to a medical unit 
and assigned ``sitter care'' for 24 hours, 7 days a week, due to 
repeated attempts to get out of bed unaccompanied. The result of the 
stroke rendered his body unable to support his own weight without 
assistance. Case management continued to explore skilled nursing 
facility options, but were unable to make a transfer due to the lack of 
payor source.
    The Scottsdale Police Department finger-printed the patient for 
identification purposes. Scottsdale Healthcare authorized the hiring of 
a private investigator to determine the patient's identification. The 
private investigator uncovered several police reports indicating that 
the patient had several different names (10 on record). The patient had 
five different dates of birth and at least six different Social 
Security numbers. The private investigator's final report also 
indicated that the patient had been arrested 10 times over three 
decades, released, and deported.
    The investigation report was faxed to the Mexican Consulate in 
Phoenix on April 17, 2006. A representative from the Consulate visited 
the patient on April 19, 2006 and issued a temporary Mexican ID for 
travel. The patient was transfer by ambulance to Hospital Integral in 
Agua Prieta, Mexico, to the services of an accepting physician.
    Scottsdale Healthcare incurred costs of over $260,000 for the 
patient's 93-day length of stay. In addition to the cost for inpatient 
care, which totaled over $230,000, there was a cost of $31,920 for 24 
hour/7 day sitter care, and $4,000 for ambulance transport to Mexico. 
Our system additionally incurred expenses for the numerous hours above 
the clinical care staff, including case managers, legal and government 
relations departments to facilitate the appropriate discharge.
    Unfortunately, that is only one example of the massive challenge to 
treat and care for the undocumented crisis in our country's health care 
system. We have many more examples at Scottsdale Healthcare, including 
the following:

------------------------------------------------------------------------
                                                               Date of
             Citizenship                       Cost              Stay
------------------------------------------------------------------------
Mexico                                $118,151 (including    Nov 5, 2006
                                       $13,519 for air
                                       ambulance, and
                                       $12,240 for
                                       respirator)
------------------------------------------------------------------------
Mexico                                $166,138 (including    Oct 26,
                                       $20,565 for air        2004
                                       ambulance)
------------------------------------------------------------------------
San Salvador                          $87,359 (including     July 11,
                                       $18,500 for air        2004
                                       ambulance)
------------------------------------------------------------------------
Belize                                $107,203, including    May 8, 2004
                                       $19,140 for air
                                       ambulance
------------------------------------------------------------------------
Egypt                                 $377,827 (including    Nov 25,
                                       $32,700 for nursing    2003
                                       home sitter care)
------------------------------------------------------------------------

Shortage of On-Call Specialists
    Scottsdale Healthcare spent $13 million on stipends for surgical 
specialist to ensure their on-call attention to patients in 2005 ($10 
million in 2005 and $8 million in 2004. However, other hospitals in the 
region do not pay for specialist care. As such, patients are 
transferred to Scottsdale Healthcare for services rendered by 
specialists such as those in hand surgery.
    The deficit in specialist care within Emergency Departments is 
directly correlated to the proliferation of specialty hospitals. 
Arizona is one of seven states with more than five specialty hospitals. 
The impact of the new genre of limited service hospitals is 
devastating. The emergence of limited service providers--hospitals that 
limit their scope of service to profitable specialties like orthopedic 
surgery and cardiac care--has exacerbated Arizona's shortage of on-call 
specialty physicians. These hospitals primarily do not provide a full 
range of emergency services cater to a commercially insured and 
Medicare population, and tend not to treat Medicaid or uninsured 
patients. The deadline for the extended moratorium on limited service 
providers is quickly approaching. While the Centers for Medicare and 
Medicaid Services are working to change the reimbursement systems for 
all hospitals including acute care and specialty, implementation will 
take the next two years. The opportunity exists for limited services 
providers to enter the market when the moratorium expires and carve out 
a service niche from community hospitals. Physician owned limited 
service providers will continue to have an advantage with physician 
self referrals.
Pediatric Care Shortages
    In Maricopa County, there are only three hospitals that provide 
specialty pediatric emergency treatment. Hence, the region is severely 
lacking in terms of being able to handle emergency care for children.
Fragmentation
    Complicating the overcrowding and specialist shortages in the 
Emergency Departments is the absence of a communication technology that 
would permit the seamless prioritization and transfer of patients from 
the field. Prehospital agencies are unable to rapidly communicate vital 
signs, scene details, and other information that would expedite 
Emergency and Trauma Center preparations for incoming patients.
    Scottsdale Healthcare has supported the Arizona Department of 
Health Services on its efforts to integrate an automated diversion 
notification and management program, called the EMSystem. The program 
is web-based and coordinated by dedicated dispatch sites throughout the 
State. A linked program, called the EMTrack, is a patient tracking 
device that employs patient banding in the field. PDA-inserted 
information supplements patient data bases. The data is transmitted to 
Emergency Departments to understand patient movement and final 
destinations. What is obviously lacking from the technology is an 
aligned program that conveys critical patient data.
    Scottsdale Healthcare has been working closely with the academic 
research scientists at Arizona State University's BioDesign Institute 
for three years on a device that would automate vital signs and other 
patient information for communication from prehospital agencies to the 
Emergency Department. The technologies for vital sign assessment and 
collection of supplemental information are already available in the 
research arena. Yet, there exists no funding to integrate the 
technologies into a single and usable platform.
    In addition, Scottsdale Healthcare has joined with General 
Dynamics, the Arizona National Guard, and the Fire and Police 
Departments of Scottsdale Healthcare on development an Internet-based 
chat room format for connecting ``command centers,'' or key 
communication centers, together. Developed for a disaster drill in 
Scottsdale, this chat room communication methodology has proven to be 
effective for the military in battlefield settings. The initial phase 
of the communication strategy was tested in April of 2006 (during the 
Coyote Crisis Campaign, the disaster drill). The permits communication 
and coordination across the organizations as well as within them, on a 
secured and confidential patient management system. This technology, 
would also enable partners to address critical resource challenges 
immediately during a disaster (e.g., water, generator, staffing, and 
other resource problems). Yet, again, there is no funding available to 
advance this program.
Lack of Disaster Preparedness
    A major disaster, with many casualties, is an event that many 
hospitals will not be able to manage well. Whether man-made, a disease 
outbreak, or a terrorist attack, Emergency Departments cannot 
accommodate the influx of patients due to facility and staff surge 
capacity deficits.
    The bioterrorism funding available to hospitals for disaster 
preparedness is so minimal that it tends to generate only superficial 
disaster response equipment purchases and mediocre disaster program 
planning. The table-top drills that are generally being conducted by 
states with Homeland Security funding do not test for human error, nor 
do they coherently, comprehensively, or rapidly coordinate players. 
Exacerbating this problem is a grave shortage of medical professionals 
to handle surge increases in the Emergency Departments.
    Scottsdale Healthcare and its community partners have accepted a 
leadership role in defining the future for disaster readiness in the 
nation, focusing on a practical, integrated, and proactively 
coordinated approach to regional disaster readiness. The grass-roots 
and groundbreaking program leverages and blends the resources of the 
Arizona National Guard, the state Air Force medical units, General 
Dynamics, and the City of Scottsdale with Scottsdale Healthcare. In 
April of 2006, the Coyote Crisis Campaign partnership launched its 
first drill to test new technologies and the medical and prehospital 
manpower merged to respond to a terrorist disaster. In 2007, the drill 
will focus on a Pandemic Flu theme. Yet, there exists no funding to 
plan and execute the drills. This is because Homeland Security funding 
is not available for healthcare programs to work on surge capacity 
enhancements with the military. And, there are no dollars to build with 
premier corporate experts the necessary command center technologies for 
resource identification and movement, field triage and transfer of 
large volumes of patients, or other disaster response needs. Homeland 
Security funding is meager, disjointed, and supportive of highly 
fragmented programming. Perhaps the only glimmer of light is found 
within the Department of Defense budget, which could generate 1) cross 
department coordination, 2) support for getting military assets to 
hospitals in a crisis, and 3) strengthen training between the military 
and the civilian worlds.
Concluding Comments:
    More than 46 percent of the patients who are admitted to Arizona's 
hospitals are Emergency Department patients. The cascading impact of 
ever-tightening regulations, the flood of undocumented immigrants, and 
the spiraling of specialty hospitals is foreboding. While funding can 
ameliorate many of the consequences, congressional action offers even 
more hope. Prompt action is necessary to avoid a healthcare catastrophe 
that will shut the doors of Emergency Departments nationwide.

                                 

    Chairman JOHNSON OF CONNECTICUT. Thank you very much, Mr. 
Kelly. Mr. Levine.

    STATEMENT OF ALAN LEVINE, PRESIDENT AND CHIEF EXECUTIVE 
  OFFICER, NORTH BROWARD HOSPITAL DISTRICT, FORT LAUDERDALE, 
                            FLORIDA

    Mr. LEVINE. Thank you, Madam Chair, Representative Stark, 
and Members of the Committee. I'm the president of the North 
Broward Hospital District, one of the largest non-profit, 
public systems in the nation, located in Broward County, 
Florida. We consist of four hospitals, two trauma centers, the 
Chris Everett Children's Hospital, and we serve over 200,000 
emergency department visits a year. I'm also formerly the 
secretary of health care administration for the State of 
Florida under Governor Bush. In Florida. the percentage of our 
population over 65 is nearly 40 percent higher than the 
national average and our over-85 population is almost double 
the national average.
    This offers a perspective of what America is going to look 
like in the coming decades and provides insight on how we 
should prepare. Consistent with national trends, emergency 
department visits to Florida's hospitals reached 7.2 million in 
2004, up 50 percent from 1994, while in-patient admissions grew 
34 percent. Hospital capacity during this period has actually 
decreased, with the ratio of beds per 1,000 population 
decreasing from four in 1994 to three in 2005, again mirroring 
a national trend and those numbers don't include and swelling 
of tourists that we have during the season, as well.
    This decreasing capacity was not an accident. Federal and 
state policies implemented two decades ago were focused on cost 
containment, and hence capacity has been constrained. Indeed, 
the capacity constraints have helped the system become more 
cost effective, with hospital length of stay decreasing from an 
average of 10.2 days in 1981 to as low as 4 days today. On the 
issue of emergency department volume, however, growth in visits 
cannot be solely attributed to population growth, as the use 
rate per 1,000 increased from 348 visits in 1994 to 410 a 
couple years ago, thus demonstrating what could be the impact 
of an aging, more chronically ill, and also increasingly 
uninsured population.
    The contributors to this crisis are numerous and complex 
and the capabilities of our system are being tested to a degree 
that could raise questions not only about our surge capacity in 
a mass emergency, but whether we can sustain the demand we face 
with our aging and more chronically ill population. From an 
operational standpoint, the more substantial causes for ER 
backup and unavailability of services are staffing shortages, 
substantial unavailability of call physician specialists, a 
less than optimal number of critical care and telemetry beds, 
the use of the emergency department as a safety net for routine 
or non-emergent visits which hospital are required by Federal 
law under EMTALA to treat, and the increasing influence the 
uninsured are having on hospital operations.
    Only a decade ago, the average age of a practicing nurse 
was 35, and today it's 45. Vacancy rates for telemetry nursing 
is 13 percent, critical care nurses are 10 percent, and one in 
five emergency nursing positions are vacant. Florida alone will 
need 61,000 additional nurses by 2020, and this is a very 
relevant cause for this crisis. As the population has aged and 
become more chronic, the demand for critical care and telemetry 
beds has increased. Clearly, an inability to staff these beds 
requires hospitals to keep patients boarded in the emergency 
department, or worse, to divert ambulances once the ER beds are 
full.
    Sadly, less than 6 percent of the nursing population is 
male, and only 13 percent represent minorities. I believe that 
represents a huge opportunity for us to draw new people into 
the nursing profession. This shortage does transcend other 
allied health care professions, including EMS, where in 
Florida, 61 percent of the more than 3.2 million EMS calls 
require transport to an emergency department. While new 
hospitals require regulatory approval in Florida, as in most 
states, Governor Bush approved allowing existing hospitals to 
add an unlimited number of beds without seeking state approval.
    We can certainly build more hospital beds, but unless we 
can staff these beds, we only compound the shortage by creating 
additional capacity and demand for staffing, which will have 
the unintended consequence of increasing cost without any 
identifiable means for reimbursement. The issue of medical 
liability, an increase in non-hospital alternatives for 
specialists, and an impending physician shortage overall are 
major contributors to this crisis. Imagine being a neurosurgeon 
at Broward General Medical Center in Fort Lauderdale. Every 
time you get called for an emergency, there is a 55 percent 
likelihood the patient is charity, uncompensated, or Medicaid, 
and since most of the community hospitals in Broward County and 
neighboring Palm Beach County, two of the most populous 
counties in Florida, do not have 24/7 emergency neurosurgery 
coverage, there is a good chance this patient's care has been 
delayed because he or she is being transferred from another 
hospital, perhaps one at least 30 miles away.
    At what point as a physician, given the likelihood of 
litigation and a lack of payment, do you say that you've had 
enough? Many, if not a majority and by the way, there are many, 
many more issues related to the liability issue that we can 
talk about if you choose to ask. Many, if not a majority of the 
specialists have gone bare, and they've opted to limit their 
coverage only to low-risk services within their specialty, 
often leaving many services without any coverage at all. In 
many cases, hospitals are paying enormous call fees in order to 
entice physicians to cover the emergency department, without 
any source of revenue to offset the cost, and are in fact left 
wondering if they will, at some point be accused of violating 
anti-referral or kickback laws.
    Federal EMTALA requirements leave hospitals with no choice 
but to succumb to whatever short-term measures are necessary to 
cover call at any given time, whether or not these measures are 
even rational. Also, given the substantial opportunity for 
physicians to earn income outside the hospitals, their reliance 
on staff privileges and ER coverage has decreased for many 
subspecialties. Another problem on the horizon is the fact that 
one in four physicians in Florida is over the age of 65, and 
another 16 percent are between the ages of 55 and 65. Medical 
school enrollment combined with that fact, medical school 
enrollment has been flat for 10 years now, and new applications 
for 2005-2006, while increasing by 4.6 percent, still remain 21 
percent below 1995 levels.
    The supply of practicing physicians is expected to slow 
considerably after 2010, reflecting the aging physician 
population and the level enrollment in medical schools. 
Intuitively, the demand for physicians will increase as our 
population ages, and by 2015, the rate of population growth 
will exceed the rate of growth in the number of physicians. By 
2020, it's estimated the United States will have a shortage of 
about 96,000 physicians. Many of the Institute of Medicine 
suggestions are plausible and merit our support. While I do not 
agree we need a new national bureaucracy, it is appropriate to 
have national standards with state flexibility, transparency 
using consistent measurement, a review of antitrust laws which 
would allow hospitals to regionalize call coverage, and 
enhanced use of information technology.
    Addressing these issues and seeking resolutions to the 
other concerns I mentioned in my testimony I believe will move 
us toward a goal of an agile and prepared emergency system. I'm 
proud to come from Florida where we've demonstrated we have the 
best, in our opinion, emergency response system in the nation. 
We're proud of that, but we know it's been tested, and we're 
concerned about that. We look forward to answering your 
questions, and I do thank you for this opportunity, Madam 
Chair.
    [The prepared statement of Mr. Levine follows:]
Statement of Alan Levine, President and Chief Executive Officer, North 
          Broward Hospital District, Fort Lauderdale, Florida
    Madam Chair, Representative Stark and Members; thank you for taking 
the time to inquire about the crisis of access to emergency care. I am 
currently the President of the North Broward Hospital District, one of 
the largest non-profit, public hospital systems in the nation, located 
in Broward County, Florida, and I am formerly the Secretary of Health 
Care Administration for the State of Florida. I will do my best to 
highlight the contributory factors to this crisis as I see them, and I 
will answer any questions you may have. In Florida, the percentage of 
our population over 65 is nearly 40 percent higher than the national 
average and our over-85 population is almost double the national 
average. Perhaps this offers a perspective of what America will look 
like in the coming decades and provide insight on how we should 
prepare. Consistent with national trends, Emergency Department visits 
to Florida's hospitals reached 7.2 million in 2004, up 50 percent from 
1994, while inpatient admissions grew 34 percent. Hospital capacity 
during this period has actually decreased, with the ratio of beds per 
1,000 population decreasing from 4 in 1994 to 3 in 2005--again, 
mirroring a national trend. This decreasing capacity was not an 
accident. Federal and state policies implemented two decades ago were 
focused on cost-containment and hence capacity has been constrained. 
Indeed, the capacity constraints have helped the system become more 
cost-effective, with hospital length of stay decreasing from an average 
of 10.2 days in 1981 to as low as 4 days today. On the issue of 
Emergency Department volume, growth in visits cannot be solely 
attributed to population growth, as the use rate per thousand increased 
from 348 visits in1994 to 410 in 2004--thus demonstrating what could be 
the impact of an aging, more chronically ill, and also, increasingly 
uninsured population. The contributors to this crisis are numerous and 
complex and the capabilities of our system are being tested to a degree 
that could raise questions not only about our surge capacity in a mass 
emergency, but whether we can sustain the demand we face with our aging 
and more chronically ill population.
    From an operational standpoint, the more substantial causes for ER 
backup and unavailability of services are; nursing, allied health and 
EMS staff shortages; substantial unavailability of on-call physician 
specialists, a less than optimal number of critical care/telemetry 
beds, the use of the Emergency Department as a safety net for routine 
or non-emergent visits which hospitals are required by federal law to 
treat, and the increasing influence the uninsured are having on 
hospital operations.
    Only a decade ago, the average age of a practicing nurse was 35; 
today it is 45. Vacancy rates for telemetry nurses are 13 percent, 
critical care nurses 10 percent, and one in five emergency RN positions 
are vacant. Florida alone will need 61,000 additional nurses by 2020.
    As the population has aged and become more chronic, the demand for 
critical care and telemetry beds has increased. Clearly, an inability 
to staff these beds requires hospitals to keep patients boarded in the 
Emergency Department, or worse, to divert ambulances once the Emergency 
Department beds are full. Sadly, less than 6 percent of the nursing 
population is male, and only 13 percent represent minorities. This 
shortage transcends other allied health professions, including EMS, 
where, in Florida, 61 percent of the more than 3.2 million EMS calls 
require transport to an ED. While new hospitals require regulatory 
approval in Florida, Governor Bush approved allowing existing hospitals 
to add an unlimited number of beds without seeking approval. We can 
certainly build more hospital beds, but unless we can staff these beds, 
we only compound the shortage by creating additional capacity and 
demand for staffing--which has the unintended consequence of increasing 
cost without any identifiable means for funding.
    The issue of Medical Liability, an increase in non-hospital 
alternatives for specialists, and an impending physician shortage 
overall are major contributors to the problem. Imagine being a 
neurosurgeon at Broward General Medical Center, in Fort Lauderdale. 
Every time you get called for an emergency, there is a 55% likelihood 
the patient is charity, uncompensated or Medicaid. And since most of 
the community hospitals in Broward County and neighboring Palm Beach 
County do not have 24/7 neurosurgery coverage, there is a good chance 
this patient's care has been delayed because he or she is being 
transferred from another hospital--perhaps one 30 miles away. At what 
point, as a physician, given the likelihood of litigation and lack of 
payment, do you say you have had enough? Many--if not a majority--of 
specialists have gone bare, so while the data may show they take call, 
they have opted to limit the coverage to only low-risk services within 
their specialty, often leaving many services without any coverage at 
all. In many cases, hospitals are paying enormous call fees in order to 
entice physicians to cover the Emergency Department--without any source 
of revenue to offset the cost, and are in fact left wondering if they 
will, at some point, be accused of violating anti-referral or kickback 
laws. Federal EMTALA requirements leave hospitals with no choice but to 
succumb to whatever short-term measures necessary to cover call at any 
given time--whether or not these measures are rational. Also, given the 
substantial opportunity for physicians to earn income outside the 
hospitals, their reliance on staff privileges and Emergency Department 
coverage has decreased for many subspecialties, including orthopedics, 
gastroenterology, otolaryngology, cardiology and plastic surgery. 
Another problem on the horizon is the fact that one in four physicians 
in Florida is over the age of 65, and another 16 percent are between 
the ages of 55 and 65. Medical school enrollment has been flat for ten 
years and new applications for 2005-06, while having increased by 4.6 
percent, still remain 21 percent below 1995 levels. The supply of 
practicing physicians is expected to slow considerably after 2010, 
reflecting the aging physician population and the relatively level 
medical school enrollment over the past two decades. Intuitively, 
demand for physicians will increase, and by 2015, the rate of 
population growth will exceed the rate of growth in the number of 
physicians. By 2020, it is estimated the United States will have a 
shortage of about 96,000 physicians.
    Many of the IOM suggestions are plausible and merit our support. 
While I do not agree we need a new national bureaucracy, it is 
appropriate to have national standards with state flexibility; 
transparency using consistent measurement; review of anti-trust laws 
which would allow hospitals to regionalize call coverage; and enhanced 
use of information technology. Addressing these issues and seeking 
resolutions to the concerns I mentioned in this statement will, in my 
opinion, move us toward our goal of an agile and prepared Emergency 
System. I look forward to answering your questions, and I thank you for 
this opportunity.

                                 

    Chairman JOHNSON OF CONNECTICUT. Thank you very much for 
your testimony, Mr. Levine. Dr. Blum.

 STATEMENT OF FREDERICK C. BLUM, M.D., ASSOCIATE PROFESSOR OF 
  EMERGENCY MEDICINE, PEDIATRICS AND INTERNAL MEDICINE, WEST 
VIRGINIA UNIVERSITY SCHOOL OF MEDICINE AND PRESIDENT, AMERICAN 
                COLLEGE OF EMERGENCY PHYSICIANS

    Dr. BLUM. Thank you, Madam Chairman. My name is Rick Blum. 
I am the president of the American College of Emergency 
Physicians. I'm a practicing emergency physician in West 
Virginia. I'm here to deliver a simple message. Mr. Kelly asked 
the question, what physician, if given the options of 
practicing and treating the patients with the problems and in 
the setting that he described would take that option? Well, 
that would be me and the 24,000 people that I represent as the 
American College of Emergency Physicians. We take that 
challenge every day.
    You don't have to have money. You don't have to be clean or 
smell good. You don't even have to be nice to me. You just have 
to come to the emergency department and need what I have to 
give, which is care. I'm very proud of that. I'm here to 
deliver a really simple message today, which is that America's 
emergency departments are underfunded, they're understaffed, 
they're overcrowded, and in fact, they're overwhelmed.
    I'm glad to address the issues raised by the Institute of 
Medicine Report, because they're an independent body that 
confirmed what we've been saying for a long time. Emergency 
physicians are proud of the fact that they could ramp up or 
ramp down as the circumstances allow. We are traditionally the 
most elastic part of any hospital operation. Frankly, we're 
sometimes too good at it, because I think I get the impression 
that people think we have the infinite ability to ramp up and 
ramp down.
    I'm here to tell you that anything that's elastic 
eventually reaches the point where it breaks, and when it does, 
it does to catastrophically, and that's where we are today. 
This Subcommittee has a long history of promoting quality 
health care for the citizens of the U.S. Your leadership on 
EMTALA my associates welcome. EMTALA simply put into law what 
we had long practiced and the values that we hold that I just 
described to you. The original intent of EMTALA we have not a 
single problem with, because we believe what is embodied within 
that law, but the challenges are still there.
    It is a gigantic unfunded mandate for American health care, 
and it's an escalating mandate that has no end in sight, and 
that mandate is increasing in the face of overall declining 
reimbursement from all payers, both in the private and public 
sectors. As other parts of the health care system fail, those 
failures are felt in the emergency departments, and so the 
result is our departments are overcrowded, we have no surge 
capacity to deal with the next big thing that happens with 
regard to natural disasters or terrorist attacks.
    We have an ambulance diverted in this country every minute 
of every hour of every day, and that probably under-represents 
the problem, because many communities have said, ``Well, we're 
not going to divert,'' but yet the ambulance crew will 
sometimes wait in the hallway of the emergency department for 
hours waiting for a bed to open up to offload their patient. 
Patients wait hours for admission. There are millions of 
Americans that come to the emergency department, and we 
determine they need to be admitted to the hospital, who wait 
hours, if not days, to move upstairs to hospital beds that 
don't exist. There's a huge on-call crisis that has already 
been, I think, very, very aptly described. None of this is new 
to emergency physicians. Why has this occurred? Well, we have 
reduced resources. Fifty percent of all emergency care in this 
country is now un-reimbursed.
    We have a lack of in-patient beds that's been described. 
We've tried to control health care spending in this country by 
controlling the number of beds that we've had. I think we now 
believe that that's a flawed public policy. We have a growing 
demand, and by the way, the baby boomers are still pretty 
healthy. They're yet to get sick. When they start getting sick 
in large numbers, I frankly don't know what we're going to do. 
We have a shortage of nurses and a looming shortage of 
physicians. We've already seen it in parts of the country, like 
Phoenix, but in most parts of the country, that is still a 
looming crisis, but I can tell you, the crisis we have right 
now is a shortage of nurses. As was said, we can't staff the 
beds that we have, and we don't have enough beds. From 1993 to 
2003, the number of ED visits have gone up 26 percent in this 
country.
    At the same time, the population only went up 13 percent. 
During that same period of time, 425 emergency departments in 
this country closed. So, we're seeing more and more patients in 
fewer and fewer emergency departments with less and less 
resources. Ladies and gentlemen, that's not sustainable. The 
on-call crisis we talked about already. We did a study a while 
back with Johns Hopkins that showed that 73 percent of ED 
medical directors report regular lack of coverage in their on-
call panels. We have the surgeons who are talking about the 
fact that fewer and fewer specialty surgeons, like 
neurosurgeons and orthopedists, are now taking call to the 
emergency departments, so you have a smaller and smaller number 
of specialists caring for a larger and larger number of people 
again, not sustainable.
    What can we do about all this? We have proposed several 
recommendations. We have included at least three of them in a 
bill that we proposed and have asked for your support for. It's 
House Bill 3875, which includes three provisions. One would 
provide incentives for hospitals to move patients upstairs more 
quickly. Those incentives currently do not exist. They would 
provide some professional liability protection for EMTALA-
mandated services that would basically treat our EMTALA mandate 
the way any other federalized health care worker would be 
treated with regard to professional liability.
    It would provide a 10 percent add-on for Medicaid payments 
to the emergency department to acknowledge this gigantic 
unfunded mandate that we have. Every day we have the privilege 
of impacting and saving people's lives. I guess what I'm here 
to ask for today is your help in allowing us to do that, 
because, quite frankly, it's getting to the point where I 
cannot. Thank you.
    [The prepared statement of Dr. Blum follows:]
 Statement of Frederick C. Blum, M.D., President, American College of 
            Emergency Physicians, Morgantown, West Virginia
Introduction
    America's emergency departments are underfunded, understaffed, 
overcrowded and overwhelmed--and we find ourselves on the brink of 
collapse.
    Madame Chairman and members of the subcommittee, my name is Rick 
Blum, M.D., F.A.C.E.P., F.A.A.P., and I would like to thank you for 
allowing me to testify today on behalf of the American College of 
Emergency Physicians (ACEP) to discuss the current state of emergency 
medical care in this country. In particular, I will address issues 
raised by ACEP's ``National Report Card on the State of Emergency 
Medicine'' and the Institute of Medicine (IOM) reports on the ``Future 
of Emergency Care,'' which must be resolved to ensure emergency medical 
care will be available to the American public during a public health 
disaster.
    ACEP is the largest specialty organization in emergency medicine, 
with nearly 24,000 members who are committed to improving the quality 
of emergency care through continuing education, research, and public 
education. ACEP has 53 chapters representing each state, as well as 
Puerto Rico and the District of Columbia, and a Government Services 
Chapter representing emergency physicians employed by military branches 
and other government agencies.
    At an alarming and increasing rate, emergency departments are 
overcrowded, surge capacity is diminished or being eliminated 
altogether, ambulances are diverted to other hospitals, patients 
admitted to the hospital are waiting longer for transfer to inpatient 
beds, and the shortage of medical specialists is worsening. These are 
the findings of the Institute of Medicine (IOM) report ``Hospital-Based 
Emergency Care: At the Breaking Point,'' which was just released on 
June 14. I would like to say that these findings are new to emergency 
physicians, but they are not.
    ACEP for years now has been working to raise awareness of the 
critical condition that exists in delivering high-quality emergency 
medical care with lawmakers and the public. More recently, these 
efforts included promoting the findings of a 2003 Government 
Accountability Office (GAO) report on emergency department crowding; 
conducting a stakeholder summit in July 2005 to discuss ways in which 
overcrowding in America's emergency departments could be alleviated; 
sponsoring a rally on the west lawn of the U.S. Capitol in September 
2005 attended by nearly 4,000 emergency physicians to promote the 
introduction of H.R. 3875, the ``Access to Emergency Medical Services 
Act;'' and releasing our first ``National Report Card on the State of 
Emergency Medicine'' in January 2006.
ACEP National Report Card on the State of Emergency Medicine
    ACEP's ``National Report Card on the State of Emergency Medicine'' 
is an assessment of the support each state provides for its emergency 
medicine systems. Grades were determined using 50 objective and 
quantifiable criteria to measure the performance of each state and the 
District of Columbia. Each state was given an overall grade plus grades 
in four categories, Access to Emergency Care, Quality and Patient 
Safety, Public Health and Injury Prevention, and Medical Liability 
Reform.
    In addition to the state grades, the report card also assigned a 
grade to the emergency medicine system of the United Sates as whole. 
Eighty-percent of the country earned mediocre or near-failing grades, 
and America earned a C-, barely above a D.
    Overall, the report card underscores findings of earlier 
examinations of our nation's safety net--that it is in desperate need 
of change if we are to continue our mission of providing quality 
emergency medical care when and where it is expected.
Emergency Department Overcrowding
    As the frontline of emergency care in this country, emergency 
physicians are particularly aware of how overcrowding in our nation's 
emergency departments is affecting patients. Here are two true patient 
stories that have been anonymously shared with ACEP that illustrate 
this point:
    I am at a level one trauma center, and we are so overcrowded that 
people are waiting up to 11 hours to be seen, patients are on 
stretchers lined up against the walls waiting for beds for three or 
more hours, and we are filled with patients being held for ICU beds. I 
am only able to see four to six patients in a 6--hour shift because 
there just are not beds to put the patients in to see them. We go on 
diversion, but so do the other hospitals in the area.
    A teenage girl was hit in the mouth playing softball, causing 
injury to her teeth. She arrived in the emergency department, which was 
full, at 6 pm and sat in a waiting room, holding a cloth to her face, 
bleeding for 2 hours. Finally, when a bed opened for her, the doctor 
saw she had significant dental injures, including loose upper front 
teeth. He ordered an x-ray. Once he had the results several hours to 
obtain later, he called an orthodontist who fortunately agreed to see 
her right away. By then, it was 12 midnight.
    The root of this problem exists due to overcrowded emergency 
departments. To be clear, I am not discussing crowded emergency 
department waiting rooms, but the actual treatment areas of emergency 
departments.
    Overcrowded emergency departments threaten access to emergency care 
for everyone--insured and uninsured alike--and create a situation where 
the emergency department can no longer safely treat any additional 
patients. This problem is particularly acute after a mass-casualty 
event, such as a man-made or natural disaster, but we are stretched 
beyond our means on a daily basis as well.
    Every day in emergency departments across America, critically ill 
patients line the halls, waiting hours--sometimes days--to be 
transferred to inpatient beds. This causes gridlock, which means other 
patients often wait hours to see physicians, and some leave without 
being seen or against medical advice. Contributing factors to 
overcrowding include reduced hospital resources; a lack of hospital 
inpatient beds; a growing elderly population and an overall increase in 
emergency department utilization; and nationwide shortages of nurses, 
physicians and hospital support staff.
On-Call Shortage
    ACEP and Johns Hopkins University conducted two national surveys, 
one in the spring of 2004 and another in the summer of 2005, to 
determine how current regulations and the practice climate are 
affecting the availability of medical specialists to care for patients 
in the nation's emergency departments. The key findings of these 
reports include:

      Access to medical specialists deteriorated significantly 
in one year. Nearly three-quarters (73 percent) of emergency department 
medical directors reported inadequate on-call specialist coverage, 
compared with two-thirds (67 percent) in 2004.
      Fifty-one percent reported deficiencies in coverage 
occurred because specialists left their hospitals to practice 
elsewhere.
      The top five specialty shortages cited in 2005 were 
orthopedics; plastic surgery; neurosurgery; ear, nose and throat; and 
hand surgery. Many who remain have negotiated with their hospitals for 
fewer on-call coverage hours (42 percent in 2005, compared with 18 
percent in 2004).

    As indicated by the IOM report, another factor that directly 
impacts emergency department patient care and overcrowding is the 
shortage of on-call specialists due to: fewer practicing emergency and 
trauma specialists; lack of compensation for providing theses services 
to high percentage of uninsured and underinsured patients; substantial 
demands on quality of life; increased risk of being sued and high 
insurance premiums; and relaxed Emergency Medical Treatment and Labor 
Act (EMTALA) requirements for on-call panels.
    Two anonymous reports on emergency crowding explain the on-call 
shortage well:
    A 23 year-old male in Texas arrived unconscious with what turned 
out to be a subdural hematoma. We were at a small hospital with no 
neurosurgical services. Ten minutes away was a hospital with plenty of 
neurosurgeons, but that hospital would not accept the patient because 
the on-call neurosurgeon said he needed him to be at a trauma center 
with an around-the-clock ability to monitor the patient. All the trauma 
centers or hospitals larger were on ``divert.'' The patient was FINALLY 
accepted by a hospital many miles away, with a 90-minute Life flight 
helicopter transfer. The patient died immediately after surgery there.
    A 65 year-old male in Washington State came to an emergency 
department at 4:00 a.m. complaining of abdominal pain. The ultrasound 
showed a six-centimeter abdominal aortic aneurysm (AAA) and he was 
unstable for CT scanning. We had no vascular surgeon available within 
150 miles; a general surgeon was available, but he refused to take the 
patient out-of-state. We reversed the Coumadin and transferred the 
patient in three hours to the nearest Level I trauma center, but he 
died on the operating table. He probably would have had a better 
outcome without a three-hour delay.
EMTALA
    This committee has a long history of promoting quality health care 
for the citizens of this country, including its role leading the way to 
the enact EMTALA in 1986. We are pleased that the Congress, and your 
committee in particular, have begun a focused examination of emergency 
care in this country and thank you for your efforts to create an EMTALA 
Technical Advisory Group (EMTALA TAG) as part of the ``Medicare 
Prescription Drug, Improvement and Modernization Act of 2003'' (P.L. 
108-173), which is looking at important issues facing emergency 
medicine.
    ACEP has long supported the goals of EMTALA as being consistent 
with the mission of emergency physicians. While the congressional 
intent of EMTALA, which requires hospitals with emergency departments 
to provide emergency medical care to everyone who needs it, regardless 
of ability to pay or insurance status, was commendable, the 
interpretation of some EMTALA regulations have been problematic.
    When CMS issued its September 2003 EMTALA regulation, uncertainty 
was created regarding the obligations of on-call physicians who provide 
emergency care that could potentially increase the shortage of on-call 
medical specialists available and multiply the number of patients 
transferred to hospitals able to provide this coverage. Under this new 
rule, hospitals must continue to provide on-call lists of specialists, 
but they can also allow specialists to opt-out of being on-call to the 
emergency department. Specialists can also now be on-call at more than 
one hospital simultaneously and they can schedule elective surgeries 
and procedures while on-call. Without an adequate supply of specialists 
willing to take call, some hospitals may choose not to provide 
emergency care at all, which would only shift the burden to the already 
strained hospital emergency departments that remain open.
Reimbursement and Uncompensated Care
    The patient population can vary dramatically from hospital to 
hospital and the differences in payer-mix have a substantial impact on 
a hospital's financial condition. Of the 110 million emergency 
department visits in 2004, individuals with private insurance 
represented 36 percent, 22 percent were Medicaid or SCHIP enrollees, 15 
percent were Medicare beneficiaries and another 16 percent were 
uninsured. These numbers demonstrate the large volume of care provided 
in the emergency department to individuals who are underinsured or 
uninsured. According to an American Hospital Association (AHA) 
statement from 2002, 73 percent of hospitals lose money providing 
emergency care to Medicaid patients while 58 percent lose money for 
care provided to Medicare patients. Even private insurance plans still 
frequently deny claims for emergency care because the visit was not 
deemed an emergency in spite of the ``prudent layperson standard'' 
which ACEP has strongly advocated for years.
    While emergency physicians stand ready to treat anyone who arrives 
at their emergency department, uncompensated care can be an extreme 
burden at hospitals that have a high volume of uninsured patients, 
which now exceeds 51.3 million Americans and continues to rise. 
Hospital emergency departments are the provider of last resort for many 
people, including undocumented aliens, who have no other access to 
medical care. As such, emergency departments experience a high-rate of 
uncompensated care.
    As pointed out in the IOM report, the estimated annual cost to 
emergency care providers nationwide for undocumented aliens is $1.45 
billion and the cost to the 28 counties along the border in Texas, New 
Mexico, Arizona and California is $232 million. Congress attempted to 
alleviate some of this burden by including a provision in the 
``Medicare Prescription Drug, Improvement and Modernization Act of 
2003'' (P.L. 108-173) that provided $1 billion ($250 million per year) 
between FY 2005--FY 2008 to help pay for unreimbursed emergency health 
care services provided to undocumented aliens and other specified 
aliens. While ACEP strongly supported this provision to help provide 
relief for this uncompensated burden, this program has been 
underutilized due to the overly burdensome and impractical regulations 
that were implemented by CMS in 2005.
Boarding
    Reductions in reimbursement from Medicare, Medicaid and other 
payers, as well as payment denials, continue to reduce hospital 
resource capacities. To compensate, hospitals have been forced to 
operate with far fewer inpatient beds than they did a decade ago. 
Between 1993 and 2003, the number of inpatient beds declined by 198,000 
(17 percent). This means fewer beds are available for admissions from 
the emergency department, and the health care system no longer has the 
surge capacity to deal with sudden increases in patients needing care.
    The overall result is that fewer inpatient beds are available to 
emergency patients who are admitted to the hospital. Many admitted 
patients are ``boarded,'' or left in the emergency department waiting 
for an inpatient bed, in non-clinical spaces--including offices, 
storerooms, conference rooms--even halls--when emergency departments 
are overcrowded.
    The majority of America's 4,000 hospital emergency departments are 
operating ``at'' or ``over'' critical capacity. Between 1992 and 2003, 
emergency department visits rose by more than 26 percent, from 90 
million to 114 million, representing an average increase of more than 2 
million visits per year. At the same time, the number of hospitals with 
emergency departments declined by 425 (9 percent), leaving fewer 
emergency departments left to treat an increasing volume of patients, 
who have more serious and complex illnesses, which has contributed to 
increased ambulance diversion and longer wait times at facilities that 
remain operational.
    According to the 2003 report from the Government Accountability 
Office (GAO), overcrowding has multiple effects, including prolonged 
pain and suffering for patients, long emergency department waits and 
increased transport times for ambulance patients. This report found 90 
percent of hospitals in 2001 boarded patients at least two hours and 
nearly 20 percent of hospitals reported an average boarding time of 
eight hours.
    There are other factors that contribute to overcrowding, as noted 
by the GAO report, including:

      Beds that could be used for emergency department 
admissions are instead being reserved for scheduled admissions, such as 
surgical patients who are generally more profitable for hospitals
      Less than one-third of hospitals that went on ambulance 
diversion in fiscal year 2001 reported that they had not cancelled any 
elective procedures to minimize diversion.
      Some hospitals cited the costs and difficulty of 
recruiting nurses as a major barrier to staffing available inpatient/
ICU beds.

    To put this in perspective, I would like to share with you the 
findings of the IOM report on hospital-based emergency care, which was 
just released on June 14:
    ``Emergency department overcrowding is a nationwide phenomenon, 
affecting rural and urban areas alike (Richardson et al., 2002). In one 
study, 91 percent of EDs responding to a national survey reported 
overcrowding as a problem; almost 40 percent reported that overcrowding 
occurred daily (Derlet et al., 2001). Another study, using data from 
the National Emergency Department Overcrowding Survey (NEDOCS), found 
that academic medical center EDs were crowded on average 35 percent of 
the time. This study developed a common set of criteria to identify 
crowding across hospitals that was based on a handful of common 
elements: all ED beds full, people in hallways, diversion at some time, 
waiting room full, doctors rushed, and waits to be treated greater than 
1 hour (Weiss et al., 2004; Bradley, 2005).''
    ACEP has been working with emergency physicians, hospitals and 
other stakeholders around the country to examine ways in which 
overcrowding might be mitigated. Of note, ACEP conducted a roundtable 
discussion in July 2005 to promote understanding of the causes and 
implications of emergency department overcrowding and boarding, as well 
as define solutions. I have included an addendum to my testimony of 
strategies, while not exhaustive or comprehensive, which still hold 
promise in addressing the emergency department overcrowding problem.
Ambulance Diversion
    Another potentially serious outcome from overcrowded conditions in 
the emergency department is ambulance diversion. It is important to 
note that ambulances are only diverted to other hospitals when crowding 
is so severe that patient safety could be jeopardized.
    The GAO reported two-thirds of emergency departments diverted 
ambulances to other hospitals during 2001, with crowding most severe in 
large population centers where nearly one in 10 hospitals reported 
being on diversion 20 percent of the time (more than four hours per 
day).
    A study released in February by the National Center for Health 
Statistics found that, on average, an ambulance in the United States is 
diverted from a hospital every minute because of emergency department 
overcrowding or bed shortages. This national study, based on 2003 data, 
reported air and ground ambulances brought in about 14 percent of all 
emergency department patients, with about 16.2 million patients 
arriving by ambulance, and that 70 percent of those patients had urgent 
conditions that required care within an hour. A companion study found 
ambulance diversions in Los Angeles more than tripled between 1998 and 
2004.
    According to the American Hospital Association (AHA), nearly half 
of all hospitals (46 percent) reported time on diversion in 2004, with 
68 percent of teaching hospitals and 69 percent of urban hospitals 
reporting time on diversion.
    As you can see from the data provided, this nation's emergency 
departments are having difficulty meeting the day-to-day demands placed 
on them. Overcrowded emergency departments lead to diminished patient 
care and ambulance diversion. We must take steps now to avoid a 
catastrophic failure of our medical infrastructure and we must take 
steps now to create capacity, alleviate overcrowding and improve surge 
capacity in our nation's emergency departments.
    Congress can begin to address these problems today by enacting H.R. 
3875/S. 2750, the ``Access to Emergency Medical Services Act.'' This 
legislation provides: (1) limited liability protections for EMTALA-
related care delivered in the emergency department to uninsured 
individuals; (2) additional compensation for care delivered in the 
emergency department; and (3) incentives to hospitals that move boarded 
patients out of the emergency department in a timely manner. As noted 
in my testimony, and supported by the findings of the GAO and IOM, 
these are three of the most critical issues facing emergency medicine.
Conclusion
    Emergency departments are a health care safety net for everyone--
the uninsured and the insured. Unlike any other health care provider, 
the emergency department is open for all patients who seek care, 24 
hours a day, 7 days a week, 365 days a year. We provide care to anyone 
who comes through our doors, regardless of their ability to pay. At the 
same time, when factors force an emergency department to close, it is 
closed to everyone and the community is denied a vital resource.
    America's emergency departments are already operating at or over 
capacity. If no changes are made to alleviate emergency department 
overcrowding, the nation's health care safety, the quality of patient 
care and the ability of emergency department personnel to respond to a 
public health disaster will be in severe peril.
    While adopting crisis measures to increase emergency department 
capacity may provide a short-term solution to a surge of patients, 
ultimately we need long-term answers. The federal government must take 
the steps necessary to strengthen our resources and prevent more 
emergency departments from being permanently closed. In the last ten 
years, the number and age of Americans has increased significantly. 
During that same time, while visits to the emergency department have 
risen by tens of millions, the number of emergency departments and 
staffed inpatient hospital beds in the nation has decreased 
substantially. This trend is simply not prudent public policy, nor is 
it in the best interest of the American public.
    Every day we save lives across America. Please give us the capacity 
and the tools we need to be there for you when and where you need us . 
. . today, tomorrow and when the next major disaster strikes the 
citizens of this great country.
Attachment
    Overcrowding strategies outlined at the roundtable discussion 
``Meeting the Challenges of Emergency Department Overcrowding/
Boarding,'' conducted by the American College of Emergency Physicians 
(ACEP) in July 2005
Strategies currently being employed to mitigate emergency department 
        overcrowding:

      Expand emergency department treatment space. According to 
a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 
standard (LD.3.11), hospital leadership should identify all of the 
processes critical to patient flow through the hospital system from the 
time the patient arrives, through admitting, patient assessment and 
treatment and discharge.
      Develop protocols to operate at full capacity. In short, 
when emergency patients have been admitted, they are transferred to 
other units within the hospital. This means that the pressure to find 
space for admitted patients is shared by other parts of the hospital.
      Address variability in patient flow. This involves 
assessing and analyzing patient arrivals and treatment relative to 
resources to determine how to enhance the movement of patients through 
the emergency department treatment process and on to the appropriate 
inpatient floors.
      Use queuing as an effective tool to manage provider 
staffing. According to an in article in the Journal of the Society for 
Academic Emergency Medicine, surveyors found that timely access to a 
provider is a critical measure to quality performance. In an 
environment where emergency departments are often understaffed, 
analyses of arrival patterns and the use of queuing models can be 
extremely useful in identifying the most effective allocation of staff.
      Maximize emergency department efficiency to reduce the 
burden of overcrowding and expanding their capacity to handle a sudden 
increase or surge in patients.
      Manage acute illness or injury and the utilization of 
emergency services in anticipatory guidance. In its policy statement on 
emergency department overcrowding issued in September 2004, the 
American Academy of Pediatrics noted: ``The best time to educate 
families about the appropriate use of an emergency department, calling 
911, or calling the regional poison control center is before the 
emergency occurs. Although parents will continue to view and respond to 
acute medical problems as laypersons, they may make better-informed 
decisions if they are prepared.''
      Place beds in all inpatient hallways during national 
emergencies, which has been effectively demonstrated in Israel.
      Improve accountability for a lack of beds with direct 
reports to senior hospital staff, as done in Sturdy Memorial Hospital 
(MA).
      Set-up discharge holding units for patients who are to be 
discharged in order not to tie-up beds that could be used by others. 
The 2003 GAO report found that hospitals rely on a number of methods 
used to minimize going on diversion, including using overflow or 
holding areas for patients.
      Establish internal staff rescue teams. This concept 
involves intense collaboration between emergency department staff and 
other services in the hospital when patient volume is particularly 
high.
      Improve coordination of scheduling elective surgeries so 
they are more evenly distributed throughout the week. For example, 
Boston Medical Center had two cardiac surgeons who both scheduled 
multiple surgeries on Wednesdays. The Medical Center improved the 
cardiac surgery schedule by changing block time distribution so one 
surgeon operated on Wednesdays and the other operated on Fridays.
      Employ emergency department Observation Units to mitigate 
crowding.
      Strive to minimize delays in transferring patients.
      Support new Pay-for-Performance measures, such as 
reimbursing hospitals for admitting patients and seeing them more 
quickly and for disclosing measurements and data.
      Monitor hospital conditions daily, as done by some EMS 
community disaster departments.
      Institute definitions of crowding, saturation, boarding 
by region with staged response by EMS, public health and hospitals. For 
example, the Massachusetts Chapter of ACEP has been working with its 
Department of Public Health (DPH) on this issue for several years, 
which has resulted in the development of a ``best practices'' document 
for ambulance diversion and numerous related recommendations including 
protocols regarding care of admitted patients awaiting bed placement. 
The chapter's efforts also resulted in the commissioner of DPH sending 
a letter to all hospitals outlining boarding protocols.
      Seek best practices from other countries that have eased 
emergency department crowding.
      Improve internal information sharing through technology.
Strategies and innovative suggestions to solve the crowding crisis that 
        are in the planning or testing phases:

      Physicians should work to improve physician leadership in 
hospital decision-making.
      Hospitals should expand areas of care for admitted 
patients. In-hospital hallways would be preferable to emergency 
department hallways. If 20 patients are waiting for admission and there 
are 20 hallways available, putting one patient per hallway would be 
preferable to putting all 20 in the emergency department, which only 
prevents others from accessing care.
      Design procedures to facilitate quicker inpatient bed 
turnover, with earlier discharges and improved communications between 
the housekeeping and admission departments.
      Offer staggered start times and creative shifts that 
would offer incentives to those who couldn't work full-time or for 
those who would benefit from having a unique work schedule.
      Collect data to measure how patients move through the 
hospital.
      Address access to primary care and issues to facilitate 
patient care that supply lists of clinics and other community-based 
sources of care.
      Communities should increase the number of health care 
facilities and improve access to quality care for the mentally ill.
      Policymakers should improve the legal climate so that 
doctors aren't forced to order defensive tests in hopes of fending off 
lawsuits.
      Ensure emergency medical care is available to all 
regardless of ability to pay or insurance coverage and should therefore 
be treated as an essential community service that is adequately funded.
      Lawmakers should enact universal health insurance that 
includes benefits for primary care services.

                                 

    Chairman JOHNSON OF CONNECTICUT. Thank you very much, Dr. 
Blum. Dr. Bedard.

  STATEMENT OF LARRY BEDARD, M.D., SENIOR PARTNER, CALIFORNIA 
          EMERGENCY PHYSICIANS, EMERYVILLE, CALIFORNIA

    Dr. BEDARD. Good morning, Madam Chair and Members of the 
Committee. I'm Dr. Larry Bedard. I'm an emergency physician, a 
pit doctor. I really appreciate the opportunity to share with 
you my perspectives on the growing crisis facing the emergency 
care system in this country. I'm not going to talk about the 
problems. I'm assuming that you agree that there are 
significant problems. I would like to congratulate Mr. Warden 
on the excellent report that came out from IOM. I agree with 
virtually all of their findings.
    What I would like to spend my time on is talking about some 
of the solutions. In my written testimony I submitted to you a 
copy of a ``Top 10 List,'' ``Dr. Bedard's Top 10 List,'' in 
order to try to deal with this crisis. First and foremost, I 
think we need to enforce EMTALA prospectively, not 
retrospectively. I believe hospitals should be surveyed and 
certified that they meet and comply with the EMTALA rules and 
regulations. We've heard 75 percent of emergency department 
directors have a problem with on-call physicians. Seventy-five 
percent of these hospitals do not comply with EMTALA, yet the 
number of investigations and violations is only a handful.
    There are many reasons why physicians are intimidated or 
reluctant to report or deal with this issue. Secondly, I think 
we need to have a different organization than Joint Commission 
on Accreditation of Healthcare Organizations (JCAHO) certifying 
hospitals or certifying the emergency care system. Last year, 
our hospital went through a JCAHO survey. We passed with 
glowing colors. What happened is, the night before the surveyor 
showed up, we took all the gurneys and the patients we board 
and hid them elsewhere in the hospital. Immediately after the 
surveyors left, the gurneys were back in the hallways and 
patients were being boarded in our emergency department. The 
fact that 75 percent of ED directors have problems with on-
call, I'll guarantee you, every one of those medical directors 
practices at a hospital that JCAHO has certified.
    It is obvious to me, and I think that the certification 
process is in effective as currently conducted by JCAHO. Number 
three, I agree that regionalization is one way of helping with 
the on-call problems and you need to get the patient to the 
right hospital, to the right doctors, at the right time. 
However, in order to regionalize emergency care, I believe 
Congress is going to have to enact some antitrust legislation 
which would allow competing hospitals and health systems to get 
together to coordinate and regionalize care. Perhaps, my most 
controversial solution is the way I would reimburse physicians 
for serving on call. I refer to it as the ``play or pay 
system.''
    Every physician in the United States who went to medical 
school here, who has done residency training in the United 
States has been heavily subsidized by the taxpayers. A common 
approach of professional associations, for example, the 
American College of Surgeons, says, ``Gee, give us tax 
deductions or tax credits for the charity care that we 
provide.'' I believe before physicians are given tax credits or 
tax deductions, that they should pay back the debt to the 
taxpayers for our education. In order to do this, you would 
have to do two things: One, Centers for Medicare and Medicaid 
Services (CMS). You do an actuarial study to determine the 
amount of taxpayer subsidy that went into physicians' education 
and training.
    We then have CMS work with American Medical Association's 
Reimbursement Update Committee to set a value or in essence, a 
payment for what it's worth to be on call for 24 hours. Then 
physicians would have the opportunities, say over 20 years, to 
pay back their taxpayer subsidy by serving on call. If you were 
a neurosurgeon who was netting $500,000 a year, you might want 
to take the other option, which is to pay at the going rate, 
say $1,000, so you don't have to take call. You could pay one 
of your other colleagues to provide that service for you. Six. 
I think we do need to come up with some meaningful malpractice 
reform. Physicians should not have to pay an extra premium for 
agreeing to serve on call.
    I think the Congress also needs to support and incentivize 
hospitals to have information technology so we can coordinate, 
we can regionalize emergency care. I think the ultimate 
solution is Congress needs to create a system of universal 
basic health care for all citizens of the United States. I look 
forward to answering any of your questions.
    [The prepared statement of Dr. Bedard follows:]
 Statement of Larry Bedard, M.D., Senior Partner, California Emergency 
                   Physicians, Emeryville, California
    Chair Nancy Johnson and Members of the House Ways and Means 
Subcommittee on Health. I want to thank for the opportunity to share my 
perspective and views about the worsening crisis in the emergency care 
system of the United States.
    In particular, I want to thank, Congressman Pete Stark who invited 
me to testify. In 1985 Congressman Stark introduced legislation, the 
``Emergency Medical Treatment and Active Labor Act'' (EMTALA). When 
President Ronald Regan signed EMTALA into law on April 6, 1986 it 
answered the question for once and for all: ``Is medical care a right 
or privilege?'' EMTALA made emergency care a legal right. Before April 
1986 the only people who had a legal right to health care were 
prisoners. After April 1985 all people had a right to go a hospital 
emergency facility and be evaluated and treated for an emergency 
medical condition. It is difficult to underestimate the impact that the 
passage of EMTALA had on the development and practice of emergency 
medicine in the United States. We needed EMTALA in 1986 and we need a 
strengthened EMTALA in 2006.
    However, from the perspective of Emergency Physicians, the 1986 law 
was fatally flawed. EMTALA defined a responsible physician as one who 
``was employed by or contracted with a hospital.'' Since the vast 
majority of emergency physicians contract with hospitals, we were 
clearly responsible physicians. The California Medical Association's 
position however, was that EMTALA did not apply to on-call physicians. 
California law prohibits hospitals from employing physicians so clearly 
on-call physicians were not employees. The CMA did not consider medical 
staff privileges a contract. In 1987 the California Chapter of the 
American College of Emergency Physicians (CAL/ACEP) working with a 
broad coalition of health care organizations passed SB12 which defined 
on-call physicians as responsible physicians under California transfer 
law.
    In 1988, as an individual, I met with Congressman Stark and two 
aides. I explained to the congressman how EMTALA was fatally flawed. 
Emergency physicians can not stand alone! We and our patients need the 
availability and access to many on-call specialists if we are to 
provide high quality emergency care. In 1989, much to his credit, 
Congressman Stark successfully amended EMTALA to define on-call 
physicians as responsible physicians.
    EMTALA, however, did not solve the access and availability of on-
call physicians to back up hospital emergency departments. Indeed, many 
physicians refuse to take call, sighting the EMTALA unfunded mandates 
and threats of significant fines.
    In 2005, nearly three quarters of emergency department medical 
directors indicate they had a problem with on-call back up.
    The issue in 1985 was availability and access to on-call 
specialists.
    The issue in 1989 was defining the role and responsibility of on-
call physicians.
    The issue in 2006 is the availability and access to on-call 
physicians.
    I view the Institute of Medicine's Committee on the Future of 
Emergency Care in the United States Health System report ``Hospital-
Based Emergency Care At the Braking Point'' from two perspectives. 
First, from the perspective of someone who has been involved in medical 
politics for more then 25 years. I have engaged in policy discussions 
as a Delegate to the American Medical Association and a Trustee of the 
California Medical Association As President of ACEP, my national 
professional association and CAL/ACEP, my state professional 
association, I represented the views and interests of emergency 
physicians in Washington DC. and Sacramento. Locally, I was an elected 
public official, serving on the Marin Hospital District Board. I just 
completed my tenure as President of the county medical society. Today, 
I'm glad to say I represent none of theses organizations!
    Today, I speak from the perspective of an individual emergency 
physician. A pit doctor! A patient advocate. And believe me, when you 
present to the ER with a significant illness or injury you need your 
emergency physician to be your advocate. Your ER doc needs to help you 
navigate the chaotic and difficult world of emergency medicine. You're 
my patient, I'm your doctor.
    I would like to share with the committee a recent experience I had 
in the ER. A mid 60ish Asian male got up from the dinner table, 
complained of a severe headache and collapsed. 911 was called and the 
patient was brought to the nearest hospital, our overcrowded ER. You do 
not need to a rocket scientist or a brain surgeon to know that an 
intracerebral bleed was the most likely diagnosis. The CAT obtained and 
read by the radiologist within 45 minutes did in fact reveal a large 
bleed. Since we had no neurosurgeon or neurologist on--call at our 
hospital, I contacted the neurosurgeon on call at the premier private 
hospital in San Francisco. When I asked for him to accept the patient 
in transfer, he informed me that he was not on call for my hospital and 
then hung up the phone. I next phoned San Francisco General Hospital, a 
nationally renowned trauma center. I was informed that they were 
holding their neurosurgeon in reserve for any trauma cases. At that 
time I thought maybe I should have told them the patient tripped and 
hit his head. I next called the University of San Francisco Medical 
Center, one of the premier academic centers in the country. The 
neurosurgery fellow indicated that he needed to talk with the 
neurosurgery attending and the hospital admissions staff. He promised 
to get back to me shortly. A half hour latter I received his call: 
``This is the kind of patient we would like to accept but we are 
boarding patients in the ED for 2 days. We will be happy to accept him 
in 2 days.'' At that time I called the patients personal physician, the 
ED Medical Director and the Chief of Staff of the Hospital to apprise 
them of the situation and seek their assistance in arranging an 
appropriate transfer. Hopefully, one of these physicians could call in 
a favor from a colleague. I next called Stanford University Hospital 
but their ICU was full and they were also boarding patients in their 
ER. Four physicians worked for more then 4 hours but we failed in our 
attempts to arrange a safe transfer for this patient. The emergency 
physicians guardian angel came to my and the patients rescue. The man's 
daughter, who worked for an internist, called her boss for help. This 
internist asked a neurosurgeon, who was not on call to accept the 
patient in transfer. After nearly 5 hours the patient was transferred 
to the premier private hospital for neurological care. What is wrong 
with this picture? How ironic that the patients daughter could arrange 
for a transfer when four physicians could not. This situation occurred 
in San Francisco, everybody's favorite city. In San Francisco, a city 
with one of the highest physician to patient ratios in the country.
    This single situation epitomizes many of the problems revealed in 
the IOM report. ``Hospital Based Emergency Care At the Breaking 
Point.'' A fragmented system was unable to provide, coordinated 
effective emergency care. The ER was overcrowded, hospitals were on 
diversion, and boarders jammed up other ERs preventing transfer and the 
necessary on-call specialists were not available.
    I want to congratulate the IOM's Committee on the Future of 
Emergency Care in the United States Health System for a comprehensive, 
thought provoking report on the current state of emergency care. I 
agree with virtually all their key findings. I believe they did an 
excellent job of evaluating and diagnosing the afflictions of the 
emergency care system. In my comments I will offer additional or 
alternative treatments or solutions to cure the problems identified in 
the IOM Report. Hopefully, my comments will help the committee to take 
appropriate actions in solving some of the problems that we face.
    I applaud and share the committee's ``vision for the future of 
emergency care that centers around three goals: coordination, 
regionalization, and accountability.''
    REGIONALIZATION: ``The committee recommends that hospitals, 
physician organizations, and public health agencies collaborate to 
regionalize critical specialty care on-call services.'' I strongly 
support this recommendation.
    Take the patient to the doctor, instead of taking the doctors to 
the patients. Take the patient to the right hospital with the right 
doctors the first time. If a hospital doesn't have a readily available 
on-call neurologist they should not receive stroke patients. 
Regionalization makes a lot of sense.
    However, when such a regional system was proposed for the 
Sacramento area by the 1998-1999 CMA,CAL/ACEP,CHA ``On-Call'' Task 
Force, lawyers from Sutter, Kaiser and Catholic Health Care West (CHW) 
immediately cautioned their hospital systems that regionalizing 
emergency care may violate federal anti-trust law. They advised them 
against sitting down with competitors to allocate and divide market 
share. If we are to implement regionalized on-call services Congress 
needs to amend, federal anti-trust laws to expressly permit competing 
hospital and health care systems to regionalize emergency care.
    ACCOUNTABILITY: ``Accountability is perhaps the most important of 
the three goals of the emergency care system envisioned by the 
committee because it is necessary to achieving the other two. Lack of 
accountability has contributed to the failure of the emergency care 
system to adopt needed changes in the past. Without accountability, 
participants in the system need not accept responsibility for failure, 
and can avoid making changes necessary to avoid the same outcomes in 
the future.'' IOM Pg 73
    ``We don't need new laws, we just need to enforce the ones already 
on the books.'' Is a well worn cliche in Washington In the case of the 
emergency care system this is probably true.
    I believe that we could address and solve many of the problems 
confronting the emergency care system if we proactively audited and 
enforced the EMTALA rules and regulations and interpretative 
guidelines. Under current law, EMTALA is only reactively enforced. The 
only times there is an investigation is when some one complains. Isn't 
it a little strange that when 73% of ED medical directors have problems 
with on-call coverage there are only a handful of EMTALA 
investigations? ``To get along, go along'' is often an essential 
requirement for a medical director. Working on a contract that can be 
cancelled in 90 days is another inducement to go along. I believe that 
a proactive enforcement of EMTALA many years ago would have helped us 
address, mitigate and solve some of the problems facing us.
    The IOM request that ``The federal government should support the 
development of national standards for: emergency care performance 
measurement; categorization of all emergency care facilities; and 
protocols for the treatment, triage, and transport of prehospital 
patients''
    The question arises: Who should do the certification, monitoring, 
and auditing of emergency care facilities and pre-hospital systems?
    ``The committee recommends that the Joint Commission on the 
Accreditation of Healthcare Organizations (JCAHO) reinstate strong 
standards that sharply reduce and ultimately eliminate ED crowding, 
boarding, and diversion. Pg 122
    I disagree with this recommendation. I believe that JCAHO is not 
the appropriate organization to accredit and certify emergency care 
systems. I am disappointed but not surprised to learn that JCAHO 
``under pressure from the hospital industry'' withdrew requirements for 
hospitals ``to take serious steps to reduce crowding, boarding and 
diversion'' IOM pg 122. In some respects, having JCAHO regulate the 
emergency care system is like having the proverbial fox guarding the 
hen house.
    In my career, I have participated in several JCAHO inspections both 
as the Medical Director of the Emergency Department and as an attending 
emergency physician. We passed a recent inspection with glowing colors. 
What a joke. We moved the gurneys and the patient boarders from the 
hallways the night before JCAHO came and immediately returned them the 
moment they left. JCAHO had no interest in looking at the on-call 
schedule. If they saw the numerous holes for specialty coverage, 
perhaps they would have to do something about it.
    In a 2005, ACEP study, 73 percent of EDs reported problems with on-
call coverage, in contrast to 67 percent the year before. How many of 
these EDs and hospitals did JCAHO refuse to certify? How does JCAHO 
address and resolve the ``problems with on-call coverage.''? I think 
the committee should have answers to these questions before deciding 
which agency should certify and regulate the emergency care system.
    Lead agency. ``The federal government should consolidate functions 
related to emergency care that are currently scattered among multiple 
agencies into a single agency in the Department of Health and Human 
Services (OHHS).'' I believe that there should be such a lead agency. I 
believe that the lead agency should monitor, audit, accredit and 
certify emergency care facilities The federal government should not 
outsource the regulation of the emergency care system, a vital national 
interest, to JCAHO.
    TRANSPARENCY Make the system transparent to patients. Educate the 
public about the access and availability of on-call specialists and 
hospital capability. Require hospitals to post in the daily paper, on 
TV or on the internet which on-call specialists are available. This 
would save tourists in San Francisco from bringing their sick kid to a 
hospital that did not have a pediatric department or service.
    Make the system transparent to EMS pre-hospital providers. 
Ambulance destination guidelines should take into consideration the 
availability of on-call specialist. Dispatchers and paramedics need to 
know in real time what on call physicians are available.
    Boarding and diversion. ``Current CMS payment policies should be 
revised to reward hospitals that appropriately manage patient flow. 
Conversely, hospitals that fail to properly manage patient flow should 
be subject to penalties'' IOM Pg 121
    The IOM recommendation is both a carrot and stick. I recommend 
trying the carrot first. Have The Centers for Medicare and Medicaid 
Services (CMS) s develop Pay For Performance (P4P) (P$P) incentives to 
award hospitals for improving efficiency in admitting patients from the 
ED. It would be relatively easy to monitor, record and audit admission 
times--the time from the moment the emergency or other admitting 
physician writes the admit order until the time the patient arrives in 
their hospital room or surgical suite.
    Disaster Management: The IOM notes: ``With many EDs at or over 
capacity, there is little surge capacity for a major event, whether it 
takes the form of a natural disaster, disease outbreak, or terrorist 
attack.'' The truth be told that in many metropolitan area in the U.S., 
the emergency care system is not equipped to handle a busy Saturday 
night this weekend. One of the scariest aspects of the IOM report was 
how poorly we are prepared for a major disaster.
    ON-CALL Specialist: ``One of the most troubling aspects of the 
current emergency and trauma care system is the lack of available 
specialists to provide on-call services to hospital EDs and trauma 
centers. This is particularly true for highly skilled specialties such 
as neurosurgery, interventional cardiology, and orthopedic surgery.'' 
IOM Pg 17
    Critical specialists are often unavailable to provide emergency and 
trauma care. This is a chronic and increasing problem in emergency 
medicine. Nothing is more painful, frustrating and depressing for an 
emergency physician then to have a patient suffer or die because there 
is no on-call specialist to back you up. Solving the on-call crisis is 
a dilemma with no easy solutions. However, I don't believe that you can 
solve boarding or ambulance diversion without solving the on-call 
problem.
    One promising solution is to regionalize the services of certain 
on-call specialties, so that every hospital need not maintain on-call 
services for every specialty.'' 
IOM 8
    Another issue that needs to be addressed is the malpractice 
liability exposure and costs for being an emergency physicians and an 
on-call specialist. You can not expect a physician to pay a 25-50% 
premium on their malpractice insurance because they have volunteered to 
serve on-call. for the ER.HR 3875, the Access to Emergency Medical 
Services Act of 2006 is a vehicle to address the malpractice issue.
    A common approach and request is to throw more money at the 
problem. Physicians are resentful of EMTALA's unfunded mandate. 
Personally, I would welcome this solution but I realize that this is 
unlikely. The projected Medicare shortfall in 2040 is $63 trillion 
dollars. Society security is a relatively easy fix at $8 trillion. 
dollars. Medicare and Medicaid are much, much bigger problems.
    Another approach is to ask the federal government to provide tax 
credits or tax deductions for charitable or uncompensated care. This is 
the policy of the American College of Surgeons.
    Increasingly, physicians have responded to the on-call issues by 
demanding and receiving stipends from hospitals for agreeing to serve 
on-call. In essence, we are witnessing a transformation from an 
``implicit social contract'' whereby physicians voluntarily provided on 
call services to their communities and hospitals to an ``explicit 
financial contract'' whereby physicians demand and receive significant 
stipends from hospitals for providing on-call services to their 
communities. On-call stipends which vary from a few hundred dollars to 
several thousands of dollars a day can only be afforded by some 
hospitals. These hospitals tend to be located in more affluent areas 
with good payer demographics. Hospitals located in areas with poor 
payer demographics cannot afford such stipends and are in danger of 
losing their on-call panels.
    Congress created an EMTALA Technical Advisory Group (TAG) to review 
the interpretation and implementation of EMTALA. The EMTALA tag is very 
limited in scope. It can only recommend regulations or interpretative 
guidelines to the Center on Medicare and Medicaid Services (CMS). At 
one of the TAG's earliest meeting the American Hospital Association 
proposed requiring physicians to serve on-call as a condition of 
Medicare participation. This proposal was quickly rejected when it was 
pointed out that physicians would stop participating in or possibly 
boycotting Medicare. I have very little optimism that the EMTALA TAG it 
will develop necessary and creative solutions to the on-call crisis.
    I offer the following Play or Pay system as a possible solution.
    ``Play or Pay'' is a policy whereby an organization or group is 
required to participate in activities or programs or pay into a fund to 
support such activities or programs. For example, a ``Play or Pay'' 
policy has been advocated by many national specialties to require small 
businesses to either ``play'' by providing health insurance for their 
employees or ``pay'' into a fund that would then be used to purchase 
health insurance for their employees.
    The On-Call Play or Pay system would requires physicians to 
``play'' by serving on a hospitals on-call panel or ``pay'' into a fund 
that would be used to compensate physicians for serving on-call.
    Every physician who graduates from an American medical school or 
who trains in a specialty residency program is heavily subsidized by 
the taxpayers. The tuition paid to attend medical school pays only a 
small proportion of the total cost to educate that physician. The 
difference between the total educational costs and the student's 
tuition is the amount of the of the taxpayers subsidy.
    Implementation of an On Call Play or Pay system requires that the 
following issues be addressed.
    EDUCATION/TRAINING ACCOUNT: An actuarial study would determine the 
amount of tax subsidy provided for medical school and residency 
training. Such actuarial studies could be done for individual medical 
schools and training programs or the average cost for medical school 
and residency could be used to determine each physician's tax subsidy. 
The tax subsidy would vary by specialty. Some specialties such as 
neurosurgery or cardiovascular surgery which are longer then family 
practice probably receive a larger taxpayer subsidy. Upon completion of 
their education and residency training each physician would be assigned 
their individual education/training account. The physician could then 
payoff their taxpayers' subsidy by ``playing'' by serving the community 
by being on-call at a local hospital or the physician could ``pay'' 
into a fund which would be used to pay for physicians who serve on-
call. Another possibility would be for a physician to have a colleague 
serve on-call on their behalf. Each physician could pay off their 
individual education/training account over a 20-30 year period. For 
physicians who do not have hospital privileges, a Domestic Peace Corp 
for Health Care or some other public service could be established
    PAY RATES: A system needs to be developed to determine the monetary 
value of serving on-call. One process would be to use the AMA's 
Reimbursement Update Committee (RUC) to determine the relative value of 
being on-call. The RUC use a consensus process to develop 
recommendations for CMS to assign relative value to new or modified 
physician services. CMS, although not required to, usually accepts the 
RUC's recommendations for assigning relative values to the Common 
Procedural Terminology (CPT) codes.
    CMS then uses the CPT codes to reimburse physicians for providing 
necessary services to Medicare patients. Since the Medicare system is a 
`zero sum game' if some codes increases in value all other codes 
decrease in value. This is a strong incentive for the RUC not to 
overvalue codes.
    Currently on-call stipends are based upon the ability of physicians 
to negotiate such stipends. Specialties in short supply such as 
neurosurgeons have used the EMTALA mandate to leverage on-call stipends 
of large and in some cases exorbitant amounts. The use of the RUC to 
establish on-call fees would probably result in more fair, equitable 
and reasonable stipends.
    Disproportionate Share Hospitals: Currently the federal government 
has a policy whereby some hospitals are classified as disproportionate 
share hospitals (DSH). DSH hospitals by definition provide excess 
amounts of uncompensated or charity care. Because of their poor payer 
demographics physicians may avoid seeking medical privileges at such 
hospitals. Physicians who serve on-call at such hospitals should have a 
significantly higher ``On call Pay Rate'' in order to attract 
physicians to serve on call at these DSH hospitals. In addition, the 
money paid by physicians to pay off their education/training debt could 
be used to pay physicians for serving on call at DSH hospitals.
    The lack of availability and access to on-call physicians backing 
up our ERs is a chronic and worsening problem. The transformation from 
an implicit social contract whereby physicians voluntarily served on 
call for the benefit of hospital privileges to an explicit financial 
contract whereby physicians receive stipends for serving on call is a 
solution that can only used by some hospitals and communities. 
Community hospitals that cannot afford to provide such solutions as 
paying large stipends require new creative solutions. Taxpayers in all 
communities have paid both federal and state taxes to educate and train 
physicians in the United States. The ``On-call Play or Pay'' program 
whereby physicians either play by serving on-call or pay off their 
education/training debts is a solution to the on-call problem.
    The ultimate solution to the on-call crisis is to develop a 
universal basic health care system. The vision of Dr. John Kitzhaber, 
the former two term governor of Oregon is to ``maximize the health of 
the population by creating a sustainable system which reallocates the 
public resources spent on health on health care in a way that ensures 
universal access to a defined set of effective health services.'' 
Governor Kitzhaber is working on a legislative approach to bring such a 
system to Oregon. His policies and perspectives can be viewed on the 
Archimedesmovement.org web site. Perhaps the committee should study 
this as a possible solution for providing universal care for the 
country.
    I hope I have given you some ideas and solutions to think about. 
Thank you listening to the voice of this emergency physician. I will 
conclude by where the IOM report begins.
    ``Knowing is not enough, we must apply.
    Willing is not enough; we must do''
    Goethe
    I urge you; Do reform the emergency care system. It is desperately 
needed.
    Larry A. Bedard, MD FACEP

                                 

    Chairman JOHNSON OF CONNECTICUT. Thank you. Now, I'd like 
to yield to Mr. Stark.
    Mr. STARK. Thank you, Madam Chair for holding this hearing, 
and I apologize for being late. Mr. Warden, I'm sorry I missed 
the beginning of your testimony. Had I been here on time to 
charm you with my opening remarks, Madam Chair, I would have 
reviewed the experience of a New York Times reporter in 
Washington, D.C. recently who died--was attacked, robbed on the 
street, mugged. They thought he was drunk, so there was a 
failure on the part of the first responders.
    Then the ambulance driver took him to a hospital--well, 
took him to Howard, because it was closer to his home and he 
was going to go home after he dumped this guy off, when Sibley 
was much closer. Then he sat around in the emergency room 
because they said he was a drunk, and evidently had massive 
brain trauma. A guy beat him up, hit him over the head. He 
died. A lot of failures on a lot of people's part. I'm not sure 
that we don't have those same problems in every branch of 
medical care.
    We can hear the horror stories all the time about the wrong 
the pharmacist giving you the wrong pill, somebody else cutting 
off the wrong leg, and I think that the emergency room 
physicians take a bad rap for a system that perhaps the 
population at large has failed to address. I think our entire 
medical care delivery system really is the fault. You guys are 
a critical part of it. If we had universal coverage, a great 
portion, I suspect, of the work you do in the emergency room 
would be handled by nighttime pediatrics or a ``doc in the 
box,'' or clinics that would get reimbursed for preventive care 
and treatment of minor aches and pains, whereas people today 
don't go, because they don't have the money.
    They know if they go and take their kid with an earache to 
the doc in the box nighttime pediatrics it's going to cost them 
65 or 70 bucks and their insurance may or may not cover it if 
they have insurance, and they ain't got $65 or $70 bucks, so 
they come and wait 2 or 3 hours in the emergency room for you 
to see the child and give them the antibiotics they need for 
their earache.
    I do, as I would have suggested in my opening remarks, 
think that if we had a system where people could pay and high 
deductible insurance isn't going to be the answer. I would love 
to have the Institute of Medicine or the emergency room, Dr. 
Blum, your organization, tell us how many people show up with 
high deductible policies, but you guys hit them in the first 
$1,000 bucks, and they don't have the cash to get over that 
deductible amount, so you still end up treating them for free. 
I'd be curious to know what percentage you see there.
    Mr. Kelly, his description of the patients that come into 
Phoenix as Larry Bedard knows, you've just described nine out 
of 10 people who come to Highland Hospital in Alameda County, 
only they have a longer rap sheet than this poor guy from 
Mexico. We treat them all the time. We can only send them back 
to county jail. That's standard procedure in our neighborhood 
for the people coming to our emergency rooms, and I don't 
know--as that's any I can just tell you a story.
    We have an emergency at a classroom, at an elementary 
school. We have lockdown. It isn't a fire drill. This is a gun 
drill. You never heard of gun drills, but our teachers have 
learned when they heard a gunshot outside the elementary 
school, they put the kids under the desk, lock the doors, pull 
the blinds, and wait until the cops come. Two cars come to the 
intersection. One guy gets out of the car, starts shooting at 
the other guy. One guy gets shot up and gets hauled away.
    The cops come. They aren't going to chase the cars. They're 
just going to wait for them at the emergency room. They're 
going to show up at Dr. Bedard's office, and that's where 
they'll haul the guy that got shot. This is part of a system 
wherein the rest of us are paying, and I don't think that cost 
shifting in the hospital system is going to do it. I think we 
have to, I think what you bring to us today is a problem that 
goes all through our delivery system, and I hope that at some 
point we can deal with how every resident, not necessarily 
citizen, but every resident if you go to Canada, you'll get 
treated as an American whether you got the money to pay or not, 
and they won't drive you home in an ambulance, they'll treat 
you. They may try and collect later, but they won't send bill 
collectors into America to do it.
    I think the underlying system in both Dr. Blum and Dr. 
Bedard, in their remarks for how to correct the system have 
suggested that universal payment system or universal access is 
one of the critical parts. So, I hope that we can find a way. I 
like Larry's idea of a code, which I think the physicians to 
develop, under resource-based scale (RBS), as to what do you 
pay the neurosurgeon who is sitting at home in Arinda waiting 
to drive into Oakland because he's on call for an emergency 
room. $3,000 a night? I don't know.
    There's got to be some kind of a system, and I think you 
guys should work it out, and we should, because we do pay you, 
for better or for worse, under Medicare and Medicaid. It's 
those people who are uninsured that you don't collect from, and 
how are we going to do that? I don't know. I certainly 
appreciate all of you being willing to be here, particularly 
Larry, who came at his own expense, to bring his expertise to 
this. As the--I hate to admit it, Madam Chair, as the author of 
EMTALA some 20 years ago, I'd still like to continue to work to 
get it right, and with your help, maybe we can. Thank you.
    Chairman JOHNSON OF CONNECTICUT. Thank you, Mr. Stark. I 
think one of the reasons that we're here today is that most of 
the laws we wrote 20 years ago no longer work, just because of 
the explosion of knowledge in medicine, the explosion of 
technology, the explosion of diagnostic and treatment 
capabilities, and a variety of other things. If you look at the 
physician payment law, it doesn't work; you look at the 
hospital payment law, it doesn't work; and it's not surprising 
that our EMTALA doesn't work. I just want to ask a few 
questions and then go on to the other Members, and then we can 
come back for a second round if we have time.
    First of all, as you know from the proposed changes in the 
in-patient rule, we are moving from the system we invented in 
the eighties of diagnosis-related groups (DRGs) toward a system 
that is much more, going to be much more directly aligned with 
the cost of care, so as we adopt the International 
Classification of Diseases (ICD-10), we will have a more 
granular system by which to look at what we're going to pay for 
and to align cost and payment. As we do that, the ability of 
hospitals to shift the cost of emergency room care across all 
other categories will be diminished.
    Are you prepared to help us understand exactly what the 
cost of emergency room care is, what the base cost of an 
emergency room facility is, what the base cost facility is, 
what the base cost of a trauma capability is, and how we should 
look at more accurately reimbursing for emergency care? Are you 
capable of working with us yet, you know, at this time, on that 
issue? Because right now, the hospitals are not capable of cost 
reports that honestly or uniformly allocate costs to categories 
all across America. We have a lot of difficulty in 
understanding ourselves and I need to know, is our first work 
to begin understanding how you cost emergency room care and 
whether it is consistent across the country and what's the 
relationship between the cost to you and the payment you get? 
Mr. Warden.
    Mr. WARDEN. Madam Chair, the Institute of Medicine 
Committee spend considerable time talking about that topic, and 
one of the things that we concluded was that we do not have the 
data that you're suggesting is needed, and it reflects the fact 
that very little money has been put into research and studies 
to really document what's going on in emergency medicine, other 
than the clinical side; and secondly, that if we're going to be 
able to address those issues, we're going to have to set some 
performance standards, we're going to have to have a much 
better understanding of what the cost is.
    Chairman JOHNSON OF CONNECTICUT. Well, I want you all to 
think about, I don't want to dwell on this, because there's so 
many other questions, but I want you all to think about this, 
because it may be that even this year we could develop a 
requirement that at least we start the process of finding out, 
because emergency room care costs now, just because of all the 
diagnostic equipment you're capable of, and years ago, are 
completely different, and not only do we not have any real 
understanding of that nor does the payment system reflect that, 
but we haven't developed any criteria for appropriateness.
    I recently learned that one of my hospitals is seeing 
Magnetic Resonance Imagining (MRIs) for every appendectomy. 
Now, this is nice, because in court, it's absolute proof, but 
we cannot afford MRIs for appendectomy. So, I ask you to think 
with this Subcommittee about what we do do now to find out what 
it does cost, because as changes in hospital payment move 
forward, we're going to need to know, and if we don't pay you 
more accurately, you won't be there. Then two other questions, 
and you can fold back in. You're dealing with a lot of 
uncompensated care, for whatever reason. How do we honestly 
recognize that? What is the spectrum of your payments from 
Medicaid, Medicare, real cost, non-payers? We need to better 
understand that piece of it.
    Then we need to better understand what we can do to change 
EMTALA law so that those who are just who could be using 
regular facilities use the community health center system, 
because we pay for that, too. We need to think, where is our 
money going, and what incentives do we need to put in place so 
people get to the point where we already pay for care. So, 
that's one issue. Then on this malpractice, I think if we don't 
do something about that, you will not survive, and what we did 
about that in the community health center, because I passed 
that law, was we took that liability onto the Federal 
Government, period, the community health centers pay if they 
get sued. We would need to know how many of the uninsured that 
come through emergency rooms end up suing. Probably not a lot 
of them. Yet, we're paying huge premiums for that possibility.
    Okay. Those are the things I need to know, because we need 
to pick out which portions of this problem we need information 
about and we need to start that aggressively now, which portion 
of these problems we could at least for a year or 2 years 
absorb malpractice costs or such and such, and what are the 
incentives for flow management, because I need to know why we 
can't do more of this through enlightened management and why we 
can't do more of this through regional planning. Mr. Levine.
    Mr. LEVINE. Yes, ma'am. You asked a lot of questions there. 
Let me start with the last one first, related to liability, and 
some of the nuances of how this actually plays out and how it 
relates to the first question you asked about cost and coming 
up with a true cost. We stand absolutely ready. I think the 
weakness in our health care system generally has been a lack of 
transparency in understanding the cost structure and the inputs 
to what the actual cost of care is. For example, in the 
emergency department, in the last few years, the costs have 
changed so dramatically, being able to pin those down is very 
difficult. Let me explain. For example, the cost of paying for 
on-call coverage can exceed $1,000, $2,000, $3,000 a day 
sometimes for certain specialists. That's a new cost that isn't 
built into any of the reimbursement structures.
    Number two, what do you do about the fact for example, 
we're a public system, and as a result, we have sovereign 
immunity. So, perhaps the only tool we have at our disposal is 
to employ physicians, and we employ over 200 physicians, for 
the purpose of trying to deal with, to extend our sovereign 
immunity to those doctors. Think about the thousands of other 
doctors in the community who are not employees of our health 
system. Here's what happens to us. We're the public safety net 
system. More than half of our ER visits are charity, 
uncompensated, or Medicaid. What happens when they show up in 
our emergency department?
    For a specialist in the community, who is a private doctor, 
who has insurance of their own, because we're public and we 
have sovereign immunity, now that doctor is the deep pocket. 
So, the doctors don't want to cover the safety net hospitals 
for that reason, so they go to the private hospitals and 
they'll cover those hospitals, but not ours. So, that creates, 
you know, a really interesting wrinkle for us. The other 
problem is, and what I've seen really from our physicians, is 
now the incentive is to go bare, because for example, if you 
have a patient that has multiple system problems and they have 
four specialists taking care of that patient, if only one of 
the doctors has coverage and the other three doctors don't have 
any insurance, they're bare, the doctor that has insurance all 
of a sudden is the only target. They have a big bullseye on 
their back. So, they don't take the consults.
    So, this contributes to the ER problem, in that that 
patient may be sitting in an in-patient bed needing a consult, 
but we can't get a doctor to see the patient, so the patient 
occupies a bed and that disrupts the flow of patients. Those 
things are interwoven, and those costs what winds up happening 
in those cases, we will sometimes have to pay a specialist to 
come see that patient in the hospital. So all of those costs 
are built into the system that we don't have a way right now of 
disclosing to the Federal Government. As far as EMTALA, you 
know, the hammer does work. As the secretary of health care 
administration for the State of Florida, it was our 
responsibility to administer EMTALA, and what we found was it 
was becoming increasingly difficult.
    On top of EMTALA, the State of Florida has a law that says 
if you offer us an elective service like orthopedics, and you 
don't cover the emergency department for that specialty, then 
you can't offer the elective service. On the surface, that 
sounds great, except here's what can happen. What happens when 
an elderly patient falls in the hospital? If the ER didn't have 
full orthopedic coverage, and you don't offer the elective 
service, you now have no doctor to take care of the in-patient 
who needs the service. These are all interwoven problems that 
are, I think, relevant.
    Now, in terms of EMTALA, and I have to disagree a little 
bit with what the doctor at the end said with regard to forcing 
doctors to pay, when you're40 percent of the doctors in south 
Florida are foreign medical graduates. Twenty-five percent of 
the doctors in our country are foreign medical graduates. We've 
got to get more people to go into medicine, and putting hammers 
over their head and telling them they're going to be punished 
is not the right way to do it, though I do think EMTALA needs 
to take into consideration if we have a patient that's in our 
emergency department, and a doctor, we can't get a doctor to 
cover, how does EMTALA apply to the medical community?
    That's part of the issue for the hospitals. When we go out 
and we survey hospitals for EMTALA violations, we fine them 
$10, $20, $50 thousand dollars an incident. We publish it in 
the newspaper. We embarrass the heck out of them. Then, really, 
the hospital isn't the one that wasn't covering the ER. Even 
though they were willing to pay for it, they didn't have a 
doctor to cover it. So, who do you punish in that circumstance? 
I think that's a relevant issue to talk more about.
    Chairman JOHNSON OF CONNECTICUT. Dr. Blum, I think that is, 
Mr. Levine, a very relevant issue, and when I look at JCAHO, to 
some extent, how can you impose on institutions standards they 
couldn't possibly meet because we've been unable to deal with 
the underlying problems? Dr. Blum.
    Dr. BLUM. There were a lot of questions.
    Chairman JOHNSON OF CONNECTICUT. Incidentally, you know, my 
time has expired, so let's do this. Let's go on to the others 
and we'll come back. I wanted you to know what my concerns are, 
because we need to pick out and see what's the first step we 
can take on as many fronts as possible. My colleague from 
Arizona.
    Mr. HAYWORTH. I thank the gentlelady from Connecticut, our 
Chairman, and again, to our witnesses, thank you. Perhaps, 
Madam Chairman, it's just with the appointment to the Health 
Subcommittee, but I find myself, this merger of public policy 
and medicine almost involved I guess offering political 
diagnoses, and to hear the array of maladies in terms of public 
policy confronting emergency rooms, it sounds as if the case is 
almost terminal, that the sclerosis, the inertia of public 
policy, and the failure to deal with a variety of competing 
interests, and the inability to enforce laws have contributed 
to a state of crisis that is very troubling.
    Mr, Kelly, since you hail from the Fifth Congressional 
District of Arizona, and for obvious purposes, I have more than 
a casual interest in what transpires in that geopolitical 
subdivision, let's talk more about what transpired at the 
Osborn facility with the illegal immigrant. As I recall from 
your testimony, Scottsdale Healthcare incurred over $260,000 in 
costs. Can you describe the lengths to which your hospital 
system has had to go to ensure that these patients are returned 
safely to their home country and to ensure they are receiving 
proper care once they get there?
    Mr. KELLY. Yeah. In many instances, the consulate will not 
permit transport papers to be issued unless we can arrange for 
a facility, let's say in Mexico or in another country to accept 
that patient, and will not provide transportation. So, we have 
in the past also provided certain equipment for the care of 
that patient. For example, I believe, I have some figures here 
where we have given hospitals in Mexico and in other areas 
ventilators and other equipment and provided the transportation 
necessary along with the arrangements, the very complicated 
arrangements to get that patient from our facility to that 
foreign country.
    Mr. HAYWORTH. So, on one hand, the Republic of Mexico 
oftentimes refuses to be involved in extradition of suspected 
murderers back to the United States, and yet the transfer of 
patients I guess we wouldn't call it extradition, medical 
extraditionists as if they say, ``No, we're to set 
preconditions upon you in the United States to ensure the 
health care once they return to the sovereign nation.'' That's 
been something else that's happened recently within Maricopa 
County, Arizona, where we live, in Scottsdale. There have been 
threats by the Mexican Consulate to get involved in court 
action----
    Mr. KELLY. Yes.
    Mr. HAYWORTH. To ensure what I don't believe again, I'm not 
a lawyer, don't even play one here in Congress, much less on 
TV, but what I believe we would have to accurately describe not 
as rights, but as privileges, privileges they assume illegals 
should have in the United States. In your course of discourse 
in negotiations with the Mexican Consulate, were there any 
threats of legal action against Scottsdale Healthcare during 
the course of this episode or any others?
    Mr. KELLY. Indirectly, Congressman, yes. ``You cannot 
definitively prove that, that we will take whatever action is 
necessary, including court action, to ensure that, you know, 
you are not going to transport this person back. We will not 
issue transport papers.'' Yes, sir, that is correct. In 
furtherance of your point, though, I'd like to point something 
out, and it's just not relative to Mexico. In my submission to 
this Committee, there is an Egyptian there. The cost of 
transportation, special air transportation back to Egypt was in 
excess of $8,000. That patient came through our emergency room. 
That patient sued us. That patient sued the physician, the 
patient sued the hospital. The physician paid over $400,000 and 
the hospital paid over $70,000 with both $100,000 in defense 
costs with the physician paying over $120,000 in defense costs. 
These are just not Mexicans that we're dealing with.
    Mr. HAYWORTH. No, indeed. It is a problem almost 
encyclopedic in scope.
    Mr. KELLY. My colleague here has even some more shocking 
length of stay statistics that just blew me away in this chair 
right now.
    Mr. LEVINE. Madam Chair, we have awe actually have cases 
in-house now, patients on ventilators from several South 
American countries. We have one case, a patient who needed a 
liver transplant, from another country, in the hospital for 85 
days, ran up $800,000 worth of charges. We have another patient 
that was in the hospital for 373 days, came in through the ER 
as a gunshot wound. Actually, the consulate from Guatemala 
called an attorney to try to delay the patient's discharge from 
the hospital. So, these are cases where they've cost us in 
excess of millions of dollars, just at our one trauma center in 
Broward County.
    Mr. HAYWORTH. Madam Chair, you've been generous with the 
time. I look forward to the second round of questioning. 
Suffice it to say now, just as you're preparing your thoughts, 
panelists, again, a merger of medical and public policy terms, 
what do we do in terms of public policy triage to be reasonable 
and compassionate, and yet not bled dry financially by the 
abuse of our system? Think about that and we'll get back, I'll 
yield back, because you've been very generous with the time.
    Chairman JOHNSON OF CONNECTICUT. Thank you. The gentleman 
from California.
    Mr. THOMPSON. Thank you, Madam Chair. Thanks for having 
this hearing. This is a problem that I think that we all 
experience, irrespective of where we live, and I would 
certainly hope that we get an opportunity, Madam Chair, to work 
on this, even if it's incrementally trying to bring about some 
of the changes that may in the big picture not fix it all, but 
would certainly deliver some relief to folks who are having to 
deal with these problems every day in real life. Thank you all 
for being here to make presentations. I appreciate it very 
much. Mr. Warden, in your testimony you talked about the lack 
of surge capacity and what could happen if there was a big car 
crash and how that could really impact things.
    I live in a district that is a rural district, and it has a 
whole set of problems just because of that, but in addition, 
we've had all kinds of natural disasters. We have earthquakes 
and wildfires and floods, and we've even had a tsunami in my 
district that wiped out an entire town. There's one building 
standing today that was standing in 1964. So, the whole issue 
of surge capacity is of great concern to the people that I 
represent. Given the propensity for natural disasters across 
sequence of events of the different areas, is there one thing 
that you would recommend that Congress could do to improve our 
disaster preparedness?
    Mr. WARDEN. Yes, sir. I think that one of the biggest 
challenges is that there's been very little funding available 
for disaster preparedness in hospitals, or for that matter, the 
health care system, and when you look at the amount of money 
that has been appropriated for those kinds of things, it just 
doesn't filter down to the level of the hospital and the 
hospital emergency room, and consequently, we're put in a 
situation where we have to react. Every hospital has an 
emergency preparedness plan, but at the same time, it's not as 
sophisticated as it should be, and they don't have the funding 
to do the kinds of things and get the equipment they need to be 
able to do it; and I think that's where it has to start.
    Mr. THOMPSON. I would appreciate it, I don't know if it's 
appropriate to ask that it be shared with the whole Committee, 
I don't know what the rest of my colleagues' level of concern 
is in this regard, but if you could, I'd like to see some ideas 
that you might have, not just we need more money, but, you 
know, what we could--what we actually need to do and how we 
would go about doing that. I'd find that very helpful.
    Mr. WARDEN. There is information in the report, and we can 
see that that's provided to you.
    Mr. THOMPSON. If you could get that to me, I would really 
appreciate it.
    Mr. WARDEN. Yes, sir.
    Mr. THOMPSON. Two of the witnesses, I think Mr. Levine and 
Dr. Blum both talked about the nursing shortage issue that 
faces us. In my home state, in California, it's projected that 
by 2010 we're going to have over a 100,000 nurse shortage, and 
it affects, I suspect, every place around the state. I see it 
at home. My wife is a nurse practitioner, and she's worked more 
in the last year on an on-call basis than she has probably in 
the last 5 years. So it's a real problem. I suspect that it has 
a real impact in regard to backups in emergency departments 
across there in every hospital. I'd like to know what your 
thoughts might be as to how we could help reduce that by doing 
a better job recruiting nurses.
    Mr. LEVINE. Sir, you hit the problem right on the head. You 
know, you have to make nursing more attractive to a broader 
population. Historically, nursing has been a population and by 
the way, this isn't limited just to nursing. It's EMS 
professionals, it's allied health professionals, pharmacists, 
therapists, and so forth. You know, like I said in my 
testimony, only 5 percent of nurses are male and only 13 
percent are minority, which is not reflective of the 
population. So, I think trying to make nursing more attractive 
as a profession for non-traditional populations is very 
critical. We can't do it without them, frankly. So, more 
recruitment, more incentives through the Federal and state 
government. I also think more faculty is a problem. There's not 
enough faculty to train the additional nurses.
    In fact, what was antithetical for me was the fact that we 
actually had waiting lists of people applying for nursing 
programs, but there's just not enough faculty to train them. To 
your question, if I may, on emergency preparedness, one of the 
best tools that we've got, and we used them for the eight 
hurricanes in Florida, at the Department of Health and Human 
Services is the use of the Disaster Medical Assistance Team 
(DMAT), and it is a tremendous it relieved a tremendous burden 
for the state and for the hospitals when we needed that surge 
capacity. Unfortunately, in a large-scale disaster, I don't 
think that there's enough resources there for those teams, but 
those are terrific tools that we made great use of during those 
disasters.
    Dr. BLUM. On the nursing issue, I'm probably not the best 
person to ask about recruiting nurses, but I can tell you 
another aspect of the nursing shortage from the emergency 
medicine standpoint is not only the fact that we have not 
enough nurses in the entire hospital, therefore impacting the 
emergency department, but because the emergency department is 
asked to be infinitely elastic, we've asked our nurses to be 
infinitely elastic, and we've simply burnt them up and burnt 
them out.
    I've lost hundreds of years of emergency nursing experience 
in my emergency department in the last few years. I have nurses 
with 25 and 30 years experience in emergency nursing who in the 
last couple years have decided, ``I can't do this anymore, I'm 
going to take a lesser-paying job working in radiation therapy 
or somewhere else in the hospital.'' Many of them have not left 
the hospital, but they've left the emergency department. So, 
our workforce now in emergency medicine is much younger than it 
has been relative to the past. It used to be that you had to 
have several years of critical care experience before you could 
even work in the emergency department. That's not true anymore.
    Mr. THOMPSON. Thank you very much.
    Chairman JOHNSON OF CONNECTICUT. Thank you. We'll start the 
second round of questions. Mr. Stark.
    Mr. STARK. Thank you, Madam Chair. I just want to put in a 
plug for my bill, which eliminates mandatory overtime for 
nurses. There's 500,000 nurses in this country who are not 
working, principally, we understand, because they don't want 
the mandatory overtime. So, we have that resource out there if 
we could somehow encourage them to come back into the system 
with a more friendly workplace. That might help somewhat. I 
want to get back to the payment thing for the on-call 
physicians. Just help me a little bit. I don't know whether, 
Mr. Warden, you remember. I mean, your former hospital system 
used to staff Kieren Mountain where I once went. They had 
doctors, all they had to know is how to pick fishhooks out of 
people, and that was a plum assignment for the Henry Ford 
physicians in the summer.
    Recently, we had a guy from Indiana who ran a bunch of 
hospitals in Indiana, and it turned out that in this hospital 
system, the not-for-profit hospital system, so he could see the 
990, the five highest-paid people in the hospital system were 
radiologists. It ran from $600,000 bucks a year for the lead 
guy to $490 thousand for the next lowest. Is that we can't do 
that in California. It's against the law to hire, for a 
hospital to hire a physician. Do any of you, Mr. Warden, 
anybody who runs a hospital, know, what say, neurosurgeons do, 
any hospitals hire neurosurgeons, teaching hospitals? If so, 
what do they earn? Larry?
    Dr. BEDARD. Our hospital had an incident where we did not 
have a neurosurgeon. I live and practice in Marin County, one 
of the wealthiest counties. They were outraged. So, the 
hospital administrator started to pay. It was $1,000 a day. 
Once you paid the neurosurgeons, you had to pay the surgeons, 
the orthopedists. Now, we're paying $10 million a year to get 
on call. The going rate for neurosurgeons now is $3,000 per 
day.
    Mr. STARK. Where they're hired--what I'm trying to get at 
is, when they're hired by the year, on salary.
    Dr. BEDARD. No, they were contracted, so----
    Mr. STARK. What does Kaiser pay, do you know?
    Dr. BEDARD. I'm not sure what Kaiser pays----
    Mr. STARK. Do you know what----
    Mr. KELLY. I know what I pay neurosurgery, Congressman 
Stark. It's $3,000 per day.
    Mr. STARK. Does anybody have a hospital, Mr. Levine, Mr. 
Warden, where they hire, where the hospital hires a 
neurosurgeon on salary? It
    Mr. WARDEN. I think in university teaching hospitals, 
medical centers----
    Mr. STARK. Okay.
    Mr. WARDEN. Or institutions like ours, which has an 
organized medical group, all the specialists are on salary, and 
they are expected to cover the emergency room. If you have a 
trauma center, you have to have that coverage----
    Mr. STARK. Can you give me to the nearest $50 or $100 
thousand bucks what a neurosurgeon would make?
    Mr. WARDEN. In our system, a neurosurgeon makes about 
$350,000.
    Mr. STARK. Okay.
    Mr. KELLY. In my previous experience at Jefferson, I would 
concur with that.
    Mr. STARK. Okay. So, I guess what I'm getting at is, it 
doesn't seem to me unreasonable, though maybe there aren't 
enough of them, to increase that salary or to expect that 
person on salary to be available one or two nights a week when 
they're on salary. I just, I'm just trying to, I'm sure that we 
find that many of these people have a high income and they 
don't want to sit around for a couple hundred bucks. That seems 
wrong. Mr. Levine.
    Mr. LEVINE. I don't know that you can--I don't know that 
you can make an accurate comparison in academic medicine 
salaries, because in academic medicine they don't cover ER call 
themselves. They have residents and interns that do it. So----
    Mr. STARK. I'm just trying to, and I want to kick this back 
to the, you know, onto the AMA and the people who do the 
resource-based relative value scale (RVRVS), and say, as I 
think you recommended, Dr. Bedard and Dr. Blum, we ought to 
figure out whether there's we can't make Blue Cross do that. If 
we had a code under Medicare, it pretty soon trickles down to 
the other insurers, and say, ``Look, here's what we pay.'' I 
would hope, and I would hope the chair would join with me, that 
we could encourage the medical societies to come up with a 
resource-based charge that we would then institutionalize 
through Medicare and say, ``Okay, this is the way to do it.'' 
Perhaps, we could get that problem solved for you, and I would 
ask any of you who are involved in this if you would have any 
other ways that we could do it, but one of you in your 
testimony said that's what we should do, is go back and find a 
code to reimburse for this. Dr. Blum.
    Dr. BLUM. Well, first of all, I explained the mindset of my 
colleagues and myself. To us, paying for on-call services is 
kind of antithetical. We believe a better solution is to remove 
the barriers that keep physicians like neurosurgeons and 
orthopedists from taking call in the hospital. That makes much 
more sense to us. We believe being on call is part of as part 
of being on the medical staff of a hospital is a 
responsibility. What has happened is there have been 
significant barriers to being on call for those folks, and if 
we remove those, I think that would solve the problem.
    If we could ensure, you know that they get some payment for 
what they do, if we could ensure they have some protection from 
unreasonable liability, I think that that would help them. 
Quite frankly, part of the issue is that it's very uneven. You 
have some of those specialists that are willing to take call 
and others who are not, and so again, fewer and fewer 
specialists are caring for more and more patients, and I can 
tell you, in a busy trauma center, a neurosurgeon may be up all 
night caring for the emergency department patients, and then he 
can't do his regular, you know, operating room (OR) schedule 
the next day.
    Mr. STARK. I would come back to you guys and the 
neurosurgeon. You don't want us to define that for you, believe 
me. If you all would come up, as you did with the RVRVS or 
others, something that the physicians are comfortable with, and 
come back to us, I think we could move ahead. I warn you that 
having us design that system, you wouldn't be very comfortable 
with it. I'm over my time, Madam Chair, but maybe Mr. Levine 
and Dr. Bedard could respond----
    Mr. WARDEN. Can I just speak one comment?
    Mr. STARK. Go ahead.
    Mr. WARDEN. I think, just two comments, Madam Chair and Mr. 
Stark. Number one, I think that one of the issues that is 
silent, that we're not recognizing, in some of the specialties 
where there's a shortage, it's because the specialists are not 
being turned out because they have basically limited the number 
of education or training positions and residencies in the 
particular specialties, so we're never going to catch up as 
long as that occurs.
    The second thing is that in the report, in our discussion 
on regionalization, we talk about the regionalization of 
specialty coverage, and, you know, in a community like Detroit, 
there's no reason why every institution has to offer every 
specialty, and if we regionalized it and had a coordinated 
plan, we could solve a lot of the problems, and I think that's 
one of the other things that has to be considered.
    Mr. LEVINE. I think that would, the second part of what the 
doctor just said is accurate, in that one thing that the 
Congress could do is look at the antitrust issues related to 
hospitals----
    Mr. STARK. Could antitrust help solve that?
    Mr. LEVINE. I believe so. We have hospitals in Palm Beach 
County, for example, that have been trying to do that, but are 
afraid to move forward for fear of antitrust. Also, too, I 
don't think you have to reinvent the wheel, if we look at 
what's been tried and has worked. For example, in Texas, they 
implemented reforms in 2003. Since they implemented their 
reforms in 2003, their medical liability reforms, they've 
brought 4,000 new doctors to Texas, including neurosurgeons, 
pediatric surgeons, obstetricians and gynecologists (OB/GYNs). 
It's been a huge, huge change, a sea change in Texas, and 
they've gone from a net exporter of physicians to they're 
bringing them back in the state.
    Mr. STARK. Even in the summer?
    Dr. BEDARD. I served on the AMA's RUC, the Reimbursement 
Update Committee, and there's about 50 different organizations 
of specialty represented. The interesting thing, it's a zero-
sum game. So, if we increase the fees of one physician 
specialist, the other ones take a slight cut. That has a very 
mild effect on the overall, I think, cost of health care. In 
California, I know where neurosurgeons are getting $3,000 a day 
for being on call from three separate hospitals, so they're 
getting $9,000 for being on call. So, regionalization makes a 
lot of sense. Have them at one hospital. Take the patient to 
where the neurosurgeon is. Don't allow them to be on three 
different hospitals. They use EMTALA as a tremendous leverage 
in any negotiation with the hospital, and I think that's one of 
the reasons why there are such high rates and somewhat 
exorbitant costs.
    It's also, I think, interesting to note, the physicians 
with the highest income neurosurgeons, orthopedic surgeons, 
ear-nose-and throat (ENT) surgeons are the ones that are most 
difficult to get to serve on call. The lowest-paid specialty is 
pediatrics, and in my career, I've never had a problem getting 
a pediatrician to come in, smile on his face, taking care of a 
little kid. So, it's kind of paradoxical that neurosurgeons, 
who may be making, you know, $500,000 a year, or $9,000 a 
night, want to complain about the fact that they're going to 
have to take care of somebody who has no insurance and they may 
be uncompensated.
    Chairman JOHNSON OF CONNECTICUT. The gentleman from 
Arizona.
    Mr. STARK. Can we do that, Madam Chair?
    Chairman JOHNSON OF CONNECTICUT. Well, we'll certainly look 
at it.
    Mr. STARK. I'm not sure it's our jurisdiction.
    Chairman JOHNSON OF CONNECTICUT. I think we can, you know, 
ask the Judiciary Committee to look at it with our staff over 
the break and see what comes out. The gentleman from Arizona.
    Mr. HAYWORTH. Thank you, Madam Chair. Gentlemen, as we 
listen to this, I return back to the dynamic I presented at the 
conclusion of our first round. What do we do, specifically, as 
we talk about patients from foreign nations, wherever they may 
come from, receiving a quality type of care I mean, it seems 
that undergirding western jurisprudence, and what we've done in 
the United States is the basic test of what is reasonable, and 
to hear the cases brought forward today, reasonableness went 
out the window. Mr. Kelly and others on the panel, what should 
we do? Should we set in statute and maybe it goes back to the 
way EMTALA was drafted or the threat of legal action.
    What parameters could we set in terms of what is reasonable 
that certainly wouldn't be like triage in the wake of a 
disaster, but something that's reasonable to get people up and 
then get their on their way back to their home country without 
continuing to ask American taxpayers to foot the bill?
    Mr. KELLY. That's an excellent question, Congressman. Let's 
treat these people and stabilize them, and the cost of their 
transport should be met by the government which they're a 
citizen of. We cannot afford this type of what's causing the 
backlog, the overcrowding, the length of stay, just not from 
the ER, but from the transport from the ER into the in-patient 
setting, because we can't get that foreign country or that 
foreign government or that person to cooperate with us. So, we 
should be able to treat and stabilize and that person should be 
taken back to their country at their country's expense. The 93-
day length of stay, the 200-day length of stay that you heard 
from my colleague to my left here, this is what's causing 
tremendous amount of backlog and an enormous amount of expense. 
So, let's treat to stabilize in a humanitarian way, these 
illegal immigrants, and let's get them back to their country of 
origin.
    Mr. LEVINE. There is nowhere, once they are in our 
emergency department, and we've identified they need treatment, 
even once we're done treating them, unless they can be 
discharged to the street, basically, there's nowhere for them 
to go. No post-op, post-acute facility will take them, so 
they're stuck in the hospital until we can find somebody. I 
think that my colleague is right on target. Stabilizing and 
transferring back and having some requirement that the foreign 
government take responsibility. In fact Canada does that. You 
know, when they come down from Canada, they either pay for the 
treatment or they pay to return them back, and that's exactly 
what other governments ought to do.
    Mr. HAYWORTH. Dr. Blum?
    Dr. BLUM. Well, I don't know that----
    Mr. HAYWORTH. Excuse me, Dr. Blum, could you----
    Dr. BLUM. I'm sorry. I'm not sure I'm the best person to 
answer how best to transfer them back once they're stabilized. 
I can tell you what does not work for emergency physicians is 
denying people care that need it, no matter what they are. You 
know, they could be, you know, felons in other countries, but 
if they need our care, you know, we don't want to be put in the 
position where we have to deny care. Neither one of these 
gentlemen have said that, but that has been proposed by some 
people, actually, in some cases. So, I just want to be real 
clear about that.
    Mr. HAYWORTH. Likewise, let me be clear, doctor. I think 
perhaps the best way, not to put words in your mouth, but I 
think we're describing compassion and our sense of humanity. 
When the question is asked of me, and we'll get into political 
theater, because it's inevitable as people try to draw 
distinctions and perhaps exaggerate distinctions, the law 
should deal in humane fashion. Medical ethics is not a 
contradiction in terms, as perhaps political ethics might be, 
and you obviously have responsibility as a physician to treat 
people, and indeed the law caught up with your sense of ethos, 
but the question becomes how then do we deal in a humane manner 
and also show some compassion in terms of public policy for 
those who get stuck with a bill that continues to drain your 
system and deny care to the mom and dad with a youngster who is 
waiting three and four and five hours, not just in border 
states, and I don't know anecdotally what happens in West 
Virginia where you practice there at the university, Dr. Blum, 
but all these things are interrelated. I think the point is 
well taken. Yes, sir.
    Dr. BLUM. It's a very complex problem. It's not even just 
the patients that get admitted. I'm aware, I do not practice in 
a border state, but I'm aware from my colleagues in the 
specialty of patients that come and present to the emergency 
department a couple times a week for dialysis. You know, they 
get treated, they get dialyzed, they go back across the border, 
and then they repeat the whole process again, you know, later 
in the week, which isn't that person doesn't even necessarily 
need admitted to the hospital, but they present with an acute 
problem, which is the need for dialysis, and we treat them. 
So,----
    Mr. HAYWORTH. Is it fair to call that serial abuse of our 
medical system, because that comes not with malice 
aforethought, with gaming our system, taking advantage of our 
laws?
    Dr. BLUM. I do want to say something. This is not directly 
related to this. But several comments now have alluded to this. 
One of the important points that I want to make today is to 
correct what I believe to be a widespread misconception that 
the nation's emergency departments are crowded with people who 
do not need to be there. Our waiting rooms sometimes are 
crowded with people who do not need to be there, but our 
emergency departments are usually crowded with people that need 
to be there. They often are there because they can't get 
primary care somewhere else and their medical condition 
advances to the point where they need emergency care. It would 
be a great misconception to say, ``If we could just remove all 
the patients that are inappropriately using the emergency 
department, we could solve this problem.'' That would not be 
the case.
    Mr. HAYWORTH. Dr. Bedard, with your indulgence, Madam 
Chair?
    Dr. BEDARD. First of all, the current law under EMTALA only 
requires treatment up to the point of stabilization, so I think 
it is compassionate and I think it addresses the issue. When 
that person was stabilized, his right to any future medical 
care ended. So, the issue, though, how do you repatriate that 
person to Nicaragua or Mexico, is obviously something that the 
medical profession can't do or deal with; that's something, 
whatever, treaty or an agreement to send them back. Also, with 
Dr. Blum, we have to take care of these people. You can't deny 
them care. We're not going to let them bleed to death on the 
street. But once they're stable, we can discharge them.
    Mr. HAYWORTH. Again, just one point about this. The root 
cause, however, as you say, law simply stipulates we stabilize. 
What is the exterior threat? Is it lawsuit? Why over and above? 
Is that it, the threat of lawsuit?
    Mr. KELLY. It's the threat of lawsuit of abandonment, that 
is correct. When they go from the emergency room, there's 
nowhere else to go. There is no long-term care facility that 
will take them.
    Dr. BLUM. It goes way beyond that. I mean, oftentimes, they 
have medical conditions that simply do not allow you to send 
them out. You know, we talk about patients that require long-
term ventilation or long-term feeding tubes. You know, you 
can't take a patient on a ventilator and roll them up to the 
border and say, you know, ``There, take them back.'' I mean, 
that doesn't work unless you have a receiving facility with the 
ability to care for the kind of problems that patient has. So 
no medical professional, I don't care who he is, whether it's 
an emergency physician or whatever, is not going to discharge 
that patient to an inappropriate environment, whatever that 
might be. So we all kind of suck it up and, you know, try to do 
the best we can. What these gentlemen have described is just 
that.
    Mr. LEVINE. The practical reality is just what you said, 
sir. The fact is, if we have a woman in the hospital who needs 
a liver transplant and, you know, she's stable, we could 
certainly discharge her, but practically speaking, it would be 
she would die. So, you know, we hold her until we figure out 
what we're going to do, and in that particular case, that 
patient stayed, in that case, it was over 300 days, over a 
year, actually, in the hospital, because and to the dialysis 
issue, as well. If other states, if other governments, rather, 
don't do dialysis for people over the age of 55, they show up 
in our emergency department, and at that point, they may not be 
stable, and we have to dialyze them.
    Mr. HAYWORTH. Madam Chair, you have been very indulgent 
with the time, and I'm grateful for that. As you and the 
Ranking Member were talking about jurisdictional issues perhaps 
beyond the purview of this Committee, I'd certainly take a look 
at international relations, at not so much treaties, but the 
whole establishment of diplomatic relations. I'd take a look at 
the funds we spend on international Committees dealing with 
health. Certainly, there is a cross-jurisdictional challenge to 
prioritize the payment of these bills and to ensure that there 
is more than a diplomatic exchange, that there is 
responsibility on the part of nations with whom we have 
diplomatic relations to likewise be accountable.
    The failure to see that, and the dynamic of the threat of 
lawsuits adding to what is obviously the ethos of the 
profession to care for people, and understanding that this is 
not just a simple cut-and-dried matter, all of this combines, 
and it's going to require some thought, and even into the whole 
realm of foreign relations and diplomacy with foreign nations, 
as we're dealing with the question. It's really, it's 
interesting the inter-relatedness of all these different topics 
coming to bear today in this hearing before our Health 
Subcommittee. Madam Chair, I thank you, and gentlemen, again, 
thanks to all of you for your thoughts.
    Chairman JOHNSON OF CONNECTICUT. Thank you very much. The 
advantage of having one panel is that you do get a chance to 
allow Members to pursue their questions and the panelists to 
contribute. There is one other issue that I want to raise that 
we haven't had a chance to plumb, that is important as we begin 
to think in this area. Mr. Warden, the Institute of Medicine 
report recommends that we establish an office of emergency 
care, emergency and trauma care. That certainly has some appeal 
when you see the chaos and mess of that service. However, 
establishing offices in the Federal Government has not always 
assured progressive, thoughtful, and effective law or 
management. A number of other things you recommend remind us 
that regional performance, institutional performance is really, 
in the end, what matters.
    I want you each to make comment on what do you think. The 
recommendation to coordinate regional EMS and emergency room 
care is very logical. We certainly have to remove the legal 
barriers, and maybe even require that, as a condition of 
Medicare eligibility, you have to have in place a regional 
system that can bring a neuro patienta patient needing a 
neurologist to the emergency room that has a neurologist on 
call and a bed available, I mean, that we could do a lot about 
the many problems we've talked about if we could bring patients 
where there is space for them and expertise available for their 
care. So, that's a kind of simple example. Mr. Levine, in your 
testimony, you referred to things that you've done in Florida 
to better manage the resources of an institution so you don't 
have some of the problems that we've talked about.
    Now, putting malpractice aside because we've discussed that 
a lot, and I think a solution to that is absolutely essential 
both in regard to the illegals and in regard to the liability 
of the individual physician. I was shocked the last time I was 
in Florida to see how many of the physicians there are just 
going bare, bare. People in America don't know that. So, it's 
ludicrous to say that somehow malpractice insurance provides 
you with some inalienable right when it is now so expensive 
that you have no right at all. So, putting malpractice kind of 
off to the side, and the problem of the illegals off to the 
side, just looking in terms of Federal structure because after 
all, in Medicare, we have a lot of leverage to pull. We can 
require that you do certain things.
    So, whether we establish an office versus what has the 
institutional aspect of this, what can be done institutionally, 
what can be done regionally, and do you or do you not, each one 
of you, think some of you may have heard this idea for the 
first time and want to get back to us? We really need your 
thinking on the structure of not only responsibility but 
oversight. Mr. Warden, maybe you'd like to start with a clearer 
explanation of the Institute of Medicine's recommendation.
    Mr. WARDEN. The Institute of Medicine's recommendation 
about the lead agency really stems from the fact that as we did 
the study and sought testimony from all the stakeholders, it 
was very clear that there were eight or 10 different agencies 
that were coming to bear on the issues that we've been talking 
about this morning. Each one of those agencies, in their own 
right, has contributed a lot, and a good example is NHSTA, the 
National Highway Safety and Traffic Administration. Yet at the 
same time, no one of those agencies had enough reach to be able 
to influence things sufficiently in any integrated fashion. 
We're not suggesting that we create a huge bureaucracy. We're 
suggesting that there needs to be an agency that takes 
responsibility for basically leading the coordination among 
these various organizations, establishing work groups, 
stimulating demonstrations that will begin to address the kinds 
of things----
    Chairman JOHNSON OF CONNECTICUT. So, for example, a lead 
office within CMS, since both Medicare and Medicaid are located 
there, is that----
    Mr. WARDEN. Well, we actually suggested that a lead office 
be within HHS, and were kind of silent on CMS, but----
    Chairman JOHNSON OF CONNECTICUT. We'll have to look at 
that, because there are some advantages and some disadvantages 
to not being, right, working with the people who are running 
these two big systems.
    Mr. WARDEN. It's really kind of beyond----
    Chairman JOHNSON OF CONNECTICUT. Yeah, okay----
    Mr. WARDEN. It's not just payment. The second point in 
terms of your question about regionalization, we believe that 
regionalization, wherever possible, ought to be accomplished at 
the state and local level, but that there ought to be some 
guidelines for making that happen. If we can do that, we don't 
need a large bureaucracy over seeing it if we can get these 
various organizations and the providers and all the 
stakeholders to buy into it. We really think that if we can get 
the regionalization and coordination and accountability 
developed at the state and local level and we can have 
basically a seamless experience for the patient, then it will 
solve a lot of the problems that we've been talking about.
    Chairman JOHNSON OF CONNECTICUT. Mr. Levine.
    Mr. LEVINE. I think my first reaction when I read that was 
at first to say I didn't like the idea of a national 
bureaucracy. I'm encouraged to hear that wasn't what they had 
in mind. I'm going to borrow a little bit from our emergency 
disaster experience in Florida and how we've handled the 
emergency system, because I think, I view the safety net in 
that from that perspective. It's bottom up. I think probably 
the one word that we want to use to describe our emergency 
system is we want it to be agile. We want there to be agility 
in the system. For example, after several of our hurricanes, 
dialysis centers became a problem. They didn't have water and 
they didn't have power.
    So the emergency response system, the way it's established 
is locally they're responsible for coming up with a regional 
plan that the local emergency operations centers have to 
approve on an annual basis. There needs to be more 
regionalization and more coordination locally at that level for 
deciding, what we re going to do in the event there's a problem 
with dialysis, what are we going to do in the event one of our 
trauma centers is knocked out of commission or we don't have 
water? It's always better to have it be bottom up rather than 
top down, because each state is so different and each community 
is so different in unique.
    I think if you have national standards for what the 
expectations are of our emergency system that are transparent, 
and then incentivizing states to implement those standards 
because typically states will look to the local leadership and 
encourage local leadership through grants or even financial 
incentives to participate. To me, then you get the right bottom 
up approach, as opposed to a Federal office that grows a life 
of its own and then develops its own mechanisms for us to have 
to follow, and d I think that would be additive and not 
necessarily constructive.
    Chairman JOHNSON OF CONNECTICUT. Yes, Mr. Kelly.
    Mr. KELLY. Yes. At Scottsdale, with the lead of the City of 
Scottsdale, our hospital, and the National Guard, we have one 
of the largest disaster drills in the country, at least west of 
the Mississippi, and it's called the Coyote Crisis. It has been 
a very successful drill, in bringing about all of the 
components necessary for everyone to talk to each other, 
whether it be the police departments, highway patrol, other 
hospitals, specialists, physicians, emergency rooms. I would 
hate to see it to be federalized or a specific office. I think 
that this can be done cooperatively among the various hospitals 
and states, and done on a regional basis. It's been done very 
successfully in Arizona. I think part of that has been placed 
in my report to the Committee. It is called the Coyote Crisis. 
It is really a fantastic partnership between the city, state, 
the medical profession, and it's worked.
    Chairman JOHNSON OF CONNECTICUT. Thank you. Dr. Bedard.
    Dr. BEDARD. First of all, I would support the concept of a 
lead agency, emergency medicine is really an essential public 
service. I think we provide a vital function for the country 
and I think it deserves to be carved out, looked at, standards 
set. As I mentioned, JCAHO, when they come to a hospital, the 
ER is frequently almost virtually ignored. I mean, I ask them, 
gee, I hope they ask me to show them the on-call list, because 
half the days are blank. They never ask the question.
    So, if you had a lead agency, I think it would also be 
effective in proactively surveying hospitals' health care 
system. I think regionalization and coordination is critical. I 
think medicine is one of the more inefficient, wasteful 
services that we provide. I mean, I'm still astounded. Somebody 
has a Computerized Axial Tomography (CAT) scan done at a 
hospital 2 days ago because they had a seizure, I can't get 
that information. So, I think to regionalize and coordinate, 
you're going to have to have much more investment in 
information technology, have electronic medical records or some 
way for patients to carry their records with them, but I think 
to do that, you're really going to be it's essential to have 
superb information technology.
    Chairman JOHNSON OF CONNECTICUT. Dr. Blum.
    Dr. BLUM. I would cautiously support the idea of a lead 
agency. It depends on what that lead agency is charged with 
doing. I think it makes sense for a lead agency to do things 
like coordinate national response to disasters, and so forth, 
and so forth, things of national scope. I think to overdo that 
bureaucracy, though, does not make sense to a system that has 
so many fundamental flaws. The analogy that I would use is it 
would be like putting a sophisticated computer control module 
on a car that has no gas in the tank; and in emergency medicine 
right now, we have no gas in the tank, you know, and someone 
stole the engine, so that control wouldn't really help us very 
much.
    We have much more fundamental problems, quite frankly. You 
alluded to costs earlier. You talked about costs earlier. You 
know, we currently pay for the uninsured by cost shifting, but 
that's becoming increasingly difficult. No payer wants to have 
costs shifted to them, including the Federal Government. Yet we 
still have to figure out a way to care for these people. We 
could call it a single payer system, but quite frankly, that's 
cost shifting. Anytime you provide care to a bunch of people 
who cannot pay for it, that's cost shifting, and you could call 
it a single payer system, you could call it taxes, you could 
call it whatever you want to, or you could call it what we call 
it now, which is cost-shifting, charging people more to pay for 
the people who can't pay at all.
    I don't run away from cost-shifting. Quite frankly, it's 
the way we've figure out how to provide care under this kind of 
strange sort of system that we're in. Let's recognize it for 
what it is. You could call it something else, but it's still 
the same thing. It's those people who can pay paying for those 
people who can't.
    Chairman JOHNSON OF CONNECTICUT. Thank you. Thank you all 
for your--Mr. Stark?
    Mr. STARK. Can I just take another slice of the apple here, 
Madam Chair?
    Chairman JOHNSON OF CONNECTICUT. All right. While I hold no 
brief for the state of the art of medical care in Mexico, we 
did get from the Mexican Embassy the laws there about treating 
people who were either in Mexico legally or illegally, and all 
I can suggest to you, I'd make these part of the record.
    Mr. STARK. Madam Chair, they're very generous. In other 
words, basically, they say, regardless of why you're there, 
you're treated. I would make those rules part of the record. I 
did want to ask, particularly Dr. Bedard, Dr. Blum, I guess 
everybody but Mr. Warden, who may not have a horse in this 
race, but one of the issues that we've been talking about, and 
initially this hearing was designed to talk about, the burden 
placed on you all by immigration, by immigrants. That was 
changed for some reason.
    Nonetheless, in the House bill that we're talking about, 
there's a question whether the possibility that providers of 
care to people who are here illegally would criminalize them, 
they would be subject to felony charges if that came about. 
Also, that would, I suspect, put your emergency departments 
somewhat in the position of being de facto immigration agents. 
I wanted to ask each of you if you think that's a good idea for 
you to you have enough trouble figuring out whether they may 
what their blood type is. Do you think it's a good idea for us 
to impose on Medicare emergency medical care providers the need 
to certify a citizenship? Just, I'll start with Doctor Bedard, 
go down the line.
    Dr. BEDARD. Absolutely not. I'm a physician. I'm there to 
help people. I'm not an Immigration and Naturalization Service 
(INS) agent.
    Mr. STARK. Dr. Blum?
    Dr. BLUM. Absolutely not. Physicians have a contract with 
the patient to do what's in their best interests, and that 
would violate that.
    Mr. STARK. Now, as the representative of a kindly 
bureaucracy, Mr. Levine, what would you feel from an 
administrative standpoint?
    Mr. LEVINE. Let me clarify the question. Are you asking if 
we would support our staff or physicians being criminalized if 
they treat someone who is----
    Mr. STARK. And/or the fact that they would have to somehow 
certify if investigate the people who came in were in fact 
citizens or here legally.
    Mr. LEVINE. Well, we would not support that. Indeed, we 
don't even ask that question until we've started treatment, 
because of EMTALA requirements.
    Mr. STARK. Mr. Kelly.
    Mr. KELLY. Congressman Stark, we believe that that would 
have an extremely chilling effect upon our health care workers. 
You know, we can't do that now. We can't even ask that question 
on Form 1011. So, we would be very, very opposed to that.
    Mr. STARK. As I say, I have no quarrel with the fact that 
people who can't pay, wherever they come from, are a burden to 
the system, but I'd like to think that there are better ways to 
resolve that than putting you all in the position of having to 
be law enforcement people. Thank you, each of you, for your 
interest and efforts and I hope you won't want not that the 
Chairman won't have another hearing, but I hop you won't wait 
until she does to offer us suggestions as to what we might do 
to help solve this problem by minor adjustments. I'm not sure 
we're going to run around and immediately have universal health 
care.
    For example, the antitrust thing might be something that we 
could move on more quickly, and we really would appreciate, I'm 
sure I know that I don't want to speak for the chair, but I 
know that she is very receptive to these ideas from the 
providers, and I would join with her in asking for your 
assistance. Thank you all.
    Chairman JOHNSON OF CONNECTICUT. Thank you. I certainly 
join with Mr. Stark in his last comments. We won't have another 
hearing until we have something to say or we see that there's 
some part of it we didn't hear, but you've laid out all aspects 
of the problem pretty completely, and we do invite you to share 
your thoughts, having listened to one another, you know, as to 
what are one or two things we could do now, what are the big 
issues that we ought to be laying a more substantial record 
knowledge base?
    For instance, we really do have to get into medical 
education. We all know that. How do we fund it? But also, what 
do we teach? I mean, to what extent is our current medical 
education system going to prepare the doctors that are going to 
serve us in the future for a very different environment? It's 
got to be one based entirely in health information technology. 
It's got to be capable of absorbing new medical knowledge more 
rapidly, delivering it more accurately, providing necessary but 
not unnecessary care. It is going to be a different world that 
we're moving into, and we want the base of law that we lay in 
the next round of shaping our medical education system to 
understand that. That's going to be a big challenge just in and 
of itself.
    It's clear that our old legal system doesn't work now with 
the way medicine is moving in America. It doesn't work partly 
because the state of the art is moving so rapidly you can't 
hold physicians liable for knowledge that wasn't available 2 
months ago. So, we're having a lot of problems. Failure to 
diagnose is a terrible threat to the medical profession, and so 
on and so forth. I just want to say the problems are big. We 
understand that. You've done a very good job for us today. We 
appreciate that.
    If you want to follow up with specific recommendations as 
to what steps need to be taken in what order, that would be 
very helpful to us. I'm going to submit for the record two 
things that Mr. Stark asked me to submit. One is the District 
of Columbia Inspector General Report on the assault of David 
Rosenbaum. I'm submitting that for the record.
    [The information follows:]

    GOVERNMENT OF THE DISTRICT OF COLUMBIA OFFICE OF THE INSPECTOR 
GENERAL SUMMARY OF SPECIAL REPORT: Emergency Response to the Assault on 
David E. Rosenbaum
    CHARLES J. WILLOUGHBY INSPECTOR GENERAL OIG No. 06-I-003-UC-FB-FA-
FX June 2006 This Summary describes the D.C. Office of the Inspector 
General's review of the emergency response efforts provided by District 
agencies and-hospital personnel in light of applicable policies and 
procedures. The OIG is providing this Summary in lieu of the full 
report in accordance with the exemptions provided in the District of 
Columbia Freedom of Information Act (D.C. Code  2-531-539 (Supp. 
2004)) to preserve the privacy interests of Mr. Rosenbaum and other 
individuals mentioned in the full report.
Background and Perspective
    ``Man Down.'' On January 6, 2006, at approximately 9:20 p.m., a 
resident of Gramercy Street, N.W. went to his car to retrieve an item 
and found an unknown man lying on the sidewalk in front of his home. 
The resident's wife called 911, and the Office of Unified 
Communications dispatched emergency responders to the scene for a ``man 
down.'' The fire (first responders), police, and ambulance (second 
responders) personnel who were at the scene did not detect serious 
injuries, illness, or evidence that the then-unknown man had been 
physically attacked. He had no identification in his pockets, but was 
wearing a wedding band and a watch. Stereo headphones were found near 
him on the grass. Because he was vomiting, and because one or more 
responders thought they smelled alcohol, the man was presumed to be 
intoxicated. Consequently, the man was classified as a low priority 
patient and transported to the Howard University Hospital (Howard) 
Emergency Department where, after lying in a hallway for more than an 
hour, medical personnel discovered that he had a critical head injury.
    At approximately 11:31 p.m., Rosenbaum's wife reported to the 
Metropolitan Police Department (MPD) that her husband, David E. 
Rosenbaum, had gone for an after-dinner walk at approximately 9 p.m., 
but had not returned. The police broadcast a descriptive lookout, and a 
police officer who had responded to the Gramercy Street ``man down'' 
call realized that the description of the missing person matched that 
of the man who had been found lying on the sidewalk. It was later 
determined that the ``man down'' was David Rosenbaum.
    Mr. Rosenbaum's head injury was discovered at Howard in the early 
morning hours of January 7 and reported to MPD. MPD officers then 
returned to the Gramercy Street scene to look for evidence that might 
indicate the cause of the head injury. Later, on January 7, the 
Rosenbaum family was alerted by credit card companies to unusual 
activity on Mr. Rosenbaum's credit cards. MPD subsequently linked Mr. 
Rosenbaum's injuries, his missing wallet, and the unusual credit card 
activity, and initiated an assault and robbery investigation.
    Despite surgery and other medical interventions to save him, Mr. 
Rosenbaum died on January 8, 2006. The autopsy report issued on January 
13, 2006, by the Office of the Chief Medical Examiner concluded that 
Mr. Rosenbaum was a victim of homicide due to injuries sustained to his 
head and body.
Scope and Methodology
    Following Mr. Rosenbaum's death, numerous questions were raised and 
complaints made by both citizens and District government officials 
about the emergency medical services provided to him by D.C. Fire and 
Emergency Medical Services Department (FEMS) and Howard personnel. 
Questions were also raised regarding the delayed recognition by MPD 
officers that a crime had been committed.
    In a letter to the Inspector General dated January 19, 2006, City 
Administrator Robert C. Bobb requested that the Office of the Inspector 
General conduct a review of the response to David E. Rosenbaum's 
assault and subsequent death. Mr. Bobb indicated that he and Mayor 
Anthony A. Williams wanted the review ``to ensure the maintenance of 
public confidence in the emergency services provided by the District 
government.'' In his letter to the Inspector General, Mr. Bobb asked 
that the Office of the Inspector General's review specifically include 
answers to the following questions: ? Did the Office of Unified 
Communications properly handle, dispatch, and monitor the incident? ? 
Did FEMS employees follow all rules, policies, protocols, and 
procedures? ? Did first responders properly assess the patient? ? Were 
FEMS written reports and oral communication adequate? ? Did MPD 
responders properly assess the situation at the scene, and were steps 
taken by MPD responders prior to opening an investigation adequate? ? 
Did the second responders arrive with all due and proper haste? ? Did 
the second responders properly assess the patient? ? Did the second 
responders select an appropriate hospital? ? Are there any identifiable 
improvements to FEMS rules, policies, protocols, and procedures? ? Did 
Howard properly triage and assess the patient upon his arrival at the 
hospital? ? Did the Office of the Chief Medical Examiner promptly and 
completely discharge its review and report of the death?
    In addition to Mr. Bobb's questions, the Office also received 
inquiries from Councilmembers Phil Mendelson and Kathy Patterson 
regarding issues of concern with respect to this matter. Finally, the 
Rosenbaum family requested that the Office of the Inspector General 
answer questions they posed ``so that errors [they] experienced are not 
repeated in the future. . . .'' We believe that this report is 
responsive to many of the questions that have been raised. The scope of 
the Inspector General's review included the entire emergency response 
provided to Mr. Rosenbaum on January 6, 2006, and the review conducted 
by the Office of the Chief Medical Examiner.2 To conduct the review, 
the Inspector General appointed a team of inspectors and investigators 
to examine the circumstances surrounding the January 6, 2006 incident. 
The team members have training and experience in law enforcement, 
firefighting, medical, and pre, 1 FEMS and MPD also conducted inquiries 
into the actions of their responders to the Gramercy Street emergency. 
In addition, the District's Department of Health conducted a 
``complaint investigation'' into Howard University Hospital's response. 
2 The care and treatment provided to Mr. Rosenbaum at Howard University 
Hospital subsequent to the discovery of his head injury, and the MPD 
assault and robbery investigation that was opened on January 7, 2006, 
were not part of the Inspector General's review. hospital care.3 The 
team reviewed policies, procedures, protocols, General and Special 
Orders, personnel files, patient care standards, hospital and ambulance 
medical records, certification and training records, and reports issued 
by FEMS, MPD, the Office of the Chief Medical Examiner, and the 
Department of Health. The team also interviewed all District government 
and Howard personnel involved in Mr. Rosenbaum's emergency care and 
autopsy. Upon conducting its review, the OIG team noted multiple 
discrepancies in statements made by interviewees. (See Appendix 1)
Findings and Recommendations
Office of Unified Communications
      The Office of Unified Communications properly handled, 
dispatched, and monitored the Gramercy Street call. The call taker and 
dispatchers who handled the 911 call carried out their duties 
appropriately.
Recommendation None.
Fire and Emergency Medical Services Department Engine 20
      Engine 20 personnel did not follow all applicable rules, 
policies, protocols, and procedures. The firefighter in charge of the 
Engine 20 crew on January 6 did not have a current CPR certification as 
required. In addition, the firefighter/Emergency Medical Technician 
(EMT) with the highest level of pre-hospital training did not take 
charge of patient care during the Gramercy Street call.
      Firefighter/EMTs did not properly assess the patient. 
None of the firefighter/EMTs performed a complete assessment of the 
patient, and not one of the patient's vital signs4 was recorded at the 
scene. Once the firefighter/EMTs perceived an odor of alcohol coming 
from the patient, they did not focus on other possibilities as the 
cause of his altered mental status such as stroke, drug interaction or 
overdose, seizure, diabetes, head trauma, or other injury.
      Oral communication and standard reports were not 
adequate. Firefighter/EMTs did not pass on key information to the 
ambulance crew such as observing blood on the patient and detecting the 
patient's constricted pupils. Engine 20 personnel did not prepare a 
written report on the Gramercy Street incident because the FEMS form 
for such purpose is being revised.

    3 Emergency response by fire and ambulance personnel. 4 Heartbeat, 
breathing, and blood pressure. Recommendations
    1. That FEMS ensure all personnel have current required training 
and certifications prior to going on duty.
    2. That FEMS immediately implement a reporting form for 
firefighter/EMTs who respond to medical calls so that first responder 
actions and patient medical information can be documented.
    3. That FEMS develop and implement a standardized performance 
evaluation system for all firefighters. The Office of the Inspector 
General team determined that FEMS employees are not evaluated on a 
regular basis, in the manner that other District government employees 
are evaluated. Consequently, FEMS lacks standards to guide 
firefighters' performance and for use in evaluating their performance.
    4. That FEMS assign quality assurance responsibilities to the 
employee with the most advanced training on each emergency medical 
call. The designated employee should: (a) have in-depth knowledge of 
the most current protocols, General Orders, Special Orders, and other 
management and medical guidance; (b) monitor compliance with FEMS 
protocols by all personnel at the scene; and (c) provide on-the-spot 
guidance as required.
Metropolitan Police Department Responders
      MPD officers did not properly assess the situation upon 
arrival. The three responding MPD officers did not secure the scene, 
did not conduct an adequate preliminary investigation in accordance 
with MPD General Orders, and did not take adequate steps to determine 
if a crime had been committed. They also did not complete a report on 
the incident pursuant to the relevant MPD General Order.
Recommendations
    1. That MPD immediately review and reissue the pertinent General 
Orders relating to officer responsibilities at emergency incidents. In 
addition, MPD should consider implementing or revising as necessary a 
quality assurance program that includes supervisory review of required 
reports, and a tracking system to ensure that reports are written and 
retrievable for every call.
    2. That MPD assign quality assurance responsibilities to the senior 
officer responding to each call.
Fire and Emergency Medical Services Department Ambulance 18
      EMTs did not follow applicable rules, policies, and 
protocols. The highest-trained EMT, an EMT-Advanced, was not in charge 
of the patient as required by protocol. The EMT-Advanced did not assess 
the patient, or help her partner assess him. Neither EMT adequately 
questioned the first responding firefighter/EMTs about the patient's 
vital signs, or other care and treatment. The patient's low Glasgow 
Coma Scale results were disregarded, and not brought to the attention 
of Howard Emergency Department personnel.

    The ambulance did not arrive on the scene expeditiously. The 
ambulance driver got lost after being dispatched from Providence 
Hospital, and then did not take a direct route to Gramercy Street. This 
error added 6 minutes to the trip. (See Appendix 2)

      EMTs did not thoroughly assess the patient. The EMT who 
assessed the patient failed to conduct all of the required assessments, 
and did not fully document his assessment and treatment on the FEMS 151 
Run Sheet. (See Appendix 3)
      Transport of the patient to the hospital did not follow 
FEMS protocol. EMTs are required to transport patients to the ``closest 
appropriate open facility.'' Although Ambulance 18 was closest to 
Sibley Hospital, the EMT in charge, for personal reasons, decided to 
transport the patient to Howard. Howard is 1.85 miles further from 
Gramercy Street than the Emergency Department at Sibley Hospital. (See 
Appendix 4)
      EMTs did not properly document actions. The EMT who cared 
for the patient did not completely fill out the FEMS 151 Run Sheet. For 
example, the form shows no times when treatment, care, or testing was 
provided or performed. An entire page of the form relating to patient 
care was left blank.
Recommendations
    1. That FEMS ensure all personnel have current required 
certifications prior to going on duty.
    2. That FEMS take steps to comply with its own policy on evaluating 
EMTs on a quarterly basis.
    3. That FEMS promptly reassign, retrain, or remove poor performers.
    4. That FEMS assign quality assurance responsibilities to the most 
highly-trained pre-hospital provider for each incident. This individual 
should: (a) have in-depth knowledge of the most current FEMS protocols 
and other management guidance; (b) monitor compliance with protocols 
and other guidance by all personnel at the scene; and (c) include the 
results of on-scene compliance monitoring in all reports required by 
management.
    5. That FEMS consider installing global positioning devices in all 
ambulances to assist EMTs in expeditiously reaching their destinations 
on emergency calls.
Howard University Hospital
      Nurses did not properly triages and assess Mr. Rosenbaum. 
The triage nurse did not perform basic assessments and did not 
communicate an abnormal temperature reading. The patient was 
incorrectly diagnosed as intoxicated, but employees did not follow 
triage policy on treating an intoxicated patient. Howard's Patient Care 
Standards--including monitoring airway and breathing, assessing for 
trauma, conducting routine lab tests, and monitoring vital signs every 
15 minutes--were not followed.
Recommendations
    1. That Howard develop a system in the Emergency Department that 
will allow staff to readily identify patients' priority level while 
they are awaiting care.
    2. That Howard consider adopting a patient records system that 
would enable nursing and medical staff to review documents when they 
are at a patient's side. The current system prevents staff access to 
such information in a timely manner.
Office of the Chief Medical Examiner
      The Office of the Chief Medical Examiner conducted the 
Rosenbaum autopsy expeditiously and promptly issued a report.
Recommendation
    That Office of the Chief Medical Examiner consider using digital 
camera technology to photograph all autopsies. The Office of the 
Inspector General was unable to review requested autopsy pictures 
because of photo processing delays and mislaid slides.
    5 The process of sorting out and classifying patients to determine 
the priority of needs and where a patient should be treated.
Conclusion
    The OIG team concludes that personnel from the Office of Unified 
Communications properly monitored the 911 call from Gramercy Street and 
immediately dispatched adequate resources to respond to the emergency. 
However, FEMS, MPD, and Howard personnel failed to respond to David E. 
Rosenbaum in accordance with established protocols. Individuals who 
played critical roles in providing these services failed to adhere to 
applicable policies, procedures, and other guidance from their 
respective employers. These failures included incomplete patient 
assessments, poor communication between emergency responders, and 
inadequate evaluation and documentation of the incident. The result, 
significant and unnecessary delays in identifying and treating Mr. 
Rosenbaum's injuries, hindered recognition that a crime had been 
committed.
    On January 6, 2006, David E. Rosenbaum consumed alcohol, both 
before and during dinner prior to leaving home for a walk. Neighbors 
discovered Mr. Rosenbaum lying on the sidewalk in front of their home 
and called 911. Upon assessment, emergency responders concluded that 
Mr. Rosenbaum's symptoms, which included poor motor control, inability 
to speak or respond to questions, pinpoint pupils, bleeding from the 
head, vomiting, and a dangerously low Glasgow Coma Scale, were the 
result of intoxication. Hospital laboratory and other tests, however, 
confirmed that Mr. Rosenbaum's symptoms were caused by a head injury. 
Emergency responders' approach to Mr. Rosenbaum's perceived 
intoxication resulted in minimal intervention by both medical and law 
enforcement personnel.
    FEMS personnel made errors both in getting to the scene and in 
transporting Mr. Rosenbaum to a hospital in a timely manner. Ambulance 
18 did not take a direct route from Providence Hospital to the Gramercy 
Street incident. In addition, for personal reasons, the EMTs did not 
take the patient to the nearest hospital. As a result of that decision, 
it took twice as long for Ambulance 18 to reach Howard than it would 
have taken to get to Sibley Hospital. Once FEMS personnel at the 
Gramercy Street scene detected the odor of alcohol, they failed to 
properly analyze and treat Mr. Rosenbaum's symptoms according to 
accepted pre-hospital care standards. Failure to follow protocols, 
policies, and procedures affected care of the patient and the 
efficiency with which the EMTs completed the call. In addition, FEMS 
employees' failure to adequately and properly communicate information 
regarding the patient affected subsequent care givers' abilities to 
carry out their responsibilities.
    MPD officers initially dispatched in response to the Gramercy 
Street call failed to secure the scene, collect evidence, interview all 
potential witnesses, canvass the neighborhood, conduct other 
preliminary investigative activities, or properly document the 
incident. Both FEMS and MPD failures were later compounded by similar 
procedural failures on the part of Howard Emergency Department 
personnel, who also initially believed Mr. Rosenbaum's condition to be 
the result of intoxication.
    Upon Mr. Rosenbaum's arrival at Howard, Emergency Department 
personnel failed to properly assess his condition and failed to 
communicate critical medical information to each other, thereby 
delaying necessary medical intervention, all in violation of Howard's 
own patient care standards. Further, a number of Emergency Department 
staff members passed Mr. Rosenbaum in the hallway and neglected to 
provide clinical and therapeutic care.
    The Office of the Inspector General's review indicates a need for 
increased oversight and enhanced internal controls by FEMS, MPD, and 
Howard managers in the areas of training and certifications, 
performance management, oral and written communication, and employee 
knowledge of protocols, General Orders, and patient care standards. 
Multiple failures during a single evening by District agency and Howard 
employees to comply with applicable policies, procedures, and protocols 
suggest an impaired work ethic that must be addressed before it becomes 
pervasive. Apathy, indifference, and complacency-apparent even during 
some of our interviews with care givers-undermined the effective, 
efficient, and high quality delivery of emergency services expected 
from those entrusted with providing care to those who are ill and 
injured.
    Accordingly, while the scope of this review was limited, these 
multiple failures have generated concerns and perceptions about the 
systemic nature of problems related to the delivery of basic emergency 
medical services citywide. Such failures mandate immediate action by 
management to improve employee accountability. Specifically, we believe 
that several quality assurance measures may assist in reducing the risk 
of a recurrence of the many failures that occurred in the emergency 
responses to Mr. Rosenbaum: systematic compliance testing, 
comprehensive and timely performance evaluations, and meaningful 
administrative action in cases of employee misconduct or incompetence.

                                 

    Chairman JOHNSON OF CONNECTICUT. Also this one-page memo on 
Mexican medical care for foreigners.
    [The information follows:]

                   ACCESS TO EMERGENCY CARE IN MEXICO

                 FOR U.S. CITIZENS AND OTHER FOREIGNERS

    A foreigner in Mexico is legally entitled to medical care in cases 
of emergency, according to the following laws:
Political Constitution of the United Mexican States
    Article 1 stipulates that in the United Mexican States, all persons 
shall enjoy the fundamental rights recognized by this Constitution, 
which may not be abridged nor suspended except in those cases and under 
such conditions as herein provided.
    Article 4 sets forth that every person has the right to health 
protection while in Mexican territory.
    Article 33 stipulates that aliens are entitled to the 
constitutional rights granted under Chapter I, First Title of this 
Constitution.
    International Convention on the Protection of the Rights of All 
Migrant Workers and Members of Their Families (Ratified by Mexico on 
March 8, 1999)
    This Convention stipulates that migrant workers and members of 
their families shall have the right to receive any medical care that is 
urgently required for the preservation of their life or the avoidance 
of irreparable harm to their health on the basis of equality of 
treatment with nationals of the State concerned. Such emergency medical 
care shall not be refused them by reason of any irregularity with 
regard to stay or employment.
    Convention for the Coalition between the Secretariat of Governance, 
through the National Migration Institute, and the Mexican Red Cross. 
Signed on April 21, 2006.
    The purpose of this Convention is to take joint actions to protect 
the physical integrity of migrants, regardless of their nationality or 
whether they are documented or undocumented migrants. This is done by 
granting prehospital care in cases of emergency, humanitarian 
assistance, help, and rescue, if necessary, as well as the equipment 
and training to carry out these measures.
Performance standards for the National Migration Institute migration 
        centers
    Chapter X Article 23 stipulates that, whether independently or by 
way of other institutions, the National Migration Institute shall grant 
medical care to any foreigner who may require it.
Regulation of the General Population Act
    Article 209 sections I and VII. Foreigners in migration centers 
will receive all necessary medical care while in said migration center.

                                 

    Chairman JOHNSON OF CONNECTICUT. I would say that a cursory 
reading of it means that their standards are roughly ours: 
treat and stabilize, and that there is explicitly the right to 
receive any medical care that is urgently required. Well, of 
course, that's the difficulty. What happens when you provide 
urgently required care and then you can't discharge the 
patient? So, we do have work to do. There are some difficult 
issues to face around what the charge should be in EMTALA.
    I hope some of you have had some experience with Health 
Resources and Services Administration (HRSA) grants, which have 
been very successful in helping communities weed out how can we 
get people into the legal/medical systems, and so on and so 
forth. So, we look forward to hearing from you. We thank you 
for your participation and the excellent of your testimony and 
your patience with the individual Members as we have had the 
time to question today. Thank you. The hearing is adjourned.
    [Whereupon, at 12:08 p.m., the Subcommittee was adjourned.]


    [Submissions for the record follow:]
              Statement of American Academy of Pediatrics
    The American Academy of Pediatrics appreciates this opportunity to 
submit testimony for the record of the Ways and Means Subcommittee on 
Health's hearing regarding emergency care. The American Academy of 
Pediatrics is a non-profit professional organization of 60,000 primary 
care pediatricians, pediatric medical sub-specialists, and pediatric 
surgical specialists dedicated to the health, safety, and well-being of 
infants, children, adolescents, and young adults.
BACKGROUND
    Emergency medical services are the foundation of our nation's 
defense for public health disasters. The emergency care community is 
largely unified in communicating a concern shared by emergency care 
providers and healthcare consumers throughout our nation regarding the 
ability of a fragmented, over-burdened and under-funded emergency and 
trauma care system to meet the day-to-day needs of acutely ill and 
injured persons. The Institute of Medicine recently released a seminal 
report which indicates that our nation's emergency care delivery system 
is in a state of crisis. Without a strong emergency medical services 
system foundation, we will never be able to build an effective response 
for mass casualty events, including natural disasters or acts of 
terror.
    In addition to the many concerns raised within the IOM report 
regarding the overall health of our nation's emergency medical 
services--issues that impact the day-to-day ability of pre-hospital and 
hospital-based emergency care providers to respond to the needs of all 
Americans--our emergency care systems also bear some specific and 
persistent limitations in their ability to meet the medical needs of 
children.\1\ Adding further to this gap in the level of emergency 
readiness between adult and pediatric care is the long-standing 
observation that federal, state and local disaster planning efforts 
have traditionally overlooked the unique needs of children. This 
testimony focuses on issues concerning pediatric emergency preparedness 
so Congress may better understand the unique challenges faced by 
emergency medical care professionals as they treat ill and injured 
children, as well as the readiness gap in pediatric emergency care.
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    \1\ Committee on Pediatric Emergency Medicine. Overcrowding Crisis 
in Our Nation's Emergency Departments: Is Our Safety Net Unraveling? 
Pediatrics, Vol. 114 No. 3 September 2004.
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Children Are More Vulnerable Than Adults
    It has been said that children are not little adults, and this is 
especially pertinent in a medical emergency or during a disaster. Their 
developing minds and bodies place children at disproportionate risk in 
a number of specific ways in the event of a disaster or terrorist 
attack:

      Children are particularly vulnerable to aerosolized 
biological or chemical agents because they normally breathe more times 
per minute than do adults, meaning they would be exposed to larger 
doses of an aerosolized substance in the same period of time. Also, 
because such agents (e.g. sarin and chlorine) are heavier than air, 
they accumulate close to the ground--right in the breathing zone of 
children.
      Children are also much more vulnerable to agents that act 
on or through the skin because their skin is thinner and they have a 
larger skin surface-to-body mass ratio than adults.
      Children are more vulnerable to the effects of agents 
that produce vomiting or diarrhea because they have smaller body fluid 
reserves than adults, increasing the risk of rapid progression to 
dehydration or shock.\2\
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    \2\ Committee on Environmental Health and Committee on Infectious 
Disease. Chemical-Biological Terrorism and Its Impact on Children: A 
Subject Review. Pediatrics, Vol. 105 No. 3 March 2000. (update 
scheduled for publication in Pediatrics September 2006.)
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      Children have much smaller circulating blood volumes than 
adults, so without timely intervention, relatively small amounts of 
blood loss can quickly tip the physiological scale from reversible 
shock to profound, irreversible shock or death. An infant or small 
child can literally bleed to death from a large scalp laceration.
      Children have significant developmental vulnerabilities 
not shared by adults. Infants, toddlers and young children may not have 
the motor skills to escape from the site of a hazard or disaster. Even 
if they are able to walk, young children may not have the cognitive 
ability to know when to flee from danger, or when to follow directions 
from strangers such as in an evacuation, or to cooperate with 
decontamination.\3\ As we all learned from Katrina, children are also 
notably vulnerable when they are separated from their parents or 
guardians.
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    \3\ American Academy of Pediatrics. Children, Terrorism & Disasters 
Toolkit. The Youngest Victims: Disaster Preparedness to Meet Children's 
Needs. http://www.aap.org/terrorism/topics/PhysiciansSheet.pdf
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Children Have Unique Treatment Needs
    Once children are critically ill or injured, their bodies will 
respond differently than adults in similar medical crises. 
Consequently, pediatric treatment needs are unique in a number of ways:

      Children need different dosages and formulations of 
medicine than adults--not only because they are smaller, but also 
because certain drugs and biological agents may have adverse effects in 
developing children that are not of concern for the adult population.
      Children need different sized equipment than adults. In 
fact, emergency readiness requires the presence of many different sizes 
of key resuscitation equipment for infants, pre-school and school-aged 
children, and adolescents. From needles and tubing, to oxygen masks and 
ventilators, to imaging equipment and laboratory technology, children 
need equipment that has been specifically designed for their size.
      Children demand special consideration during 
decontamination efforts. Because children lose body heat more quickly 
than adults, mass decontamination systems that may be safe for adults 
can cause hypothermia in young children unless special heating 
precautions or other warming equipment is provided.\4\ Hypothermia can 
have a profoundly detrimental impact on a child's survival from illness 
or injury.
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    \4\ American Academy of Pediatrics. Children, Terrorism & Disasters 
Toolkit. The Youngest Victims: Disaster Preparedness to Meet Children's 
Needs. http://www.aap.org/terrorism/topics/PhysiciansSheet.pdf
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      Children sustain unique developmental and psychological 
responses to acute illness and injury, as well as to mass casualty 
events. Compared to adults, children appear to be at greater risk for 
acute- and post-traumatic stress disorders. The identification and 
optimal management of these disorders in children requires 
professionals with expertise in pediatric mental health.\5\
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    \5\ Hagan, J and the Committee on Psychosocial Aspects of Child and 
Family Health and the Task Force on Terrorism. Psychosocial 
Implications of Disaster or Terrorism on Children: A Guide for the 
Pediatrician. Pediatrics, Vol. 116, No. 3, September 2005.
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      Children may be developmentally unable to communicate 
their needs with health care providers. The medical treatment of 
children is optimized with the presence of parents and/or family 
members. Timely reunification of children with parents and family-
centered care should be a priority for all levels of emergency care.
Children Need Care From Providers Trained to Meet Their Unique Needs
    Because children respond differently than adults in a medical 
crisis, it is critical that all health care workers be able to 
recognize the unique signs and symptoms in children that may indicate a 
life-threatening situation, and then possess the experience and skill 
to intervene accordingly.\6\ As already noted, a child's condition can 
rapidly deteriorate from stable to life-threatening as they have less 
blood and fluid reserves, are more sensitive to changes in body 
temperature, and have faster metabolisms. Once cardio-pulmonary arrest 
has occurred, the prognosis is particularly dismal in children, with 
less than 20% surviving the event, and with 75% of the survivors 
sustaining permanent disability. Therefore, the goal in pediatric 
emergency care is to recognize pre-cardiopulmonary arrest conditions 
and intervene before they occur. While children represent 25 to 30% of 
all emergency department visits in the U.S., and 5 to 10% of all EMS 
ambulance patients, the number of these children who require this 
advanced level of emergency and critical care, and use of the 
associated cognitive and technical abilities, is quite small. This 
creates a special problem for pre-hospital and hospital-based emergency 
care providers, as they have limited exposure and opportunities to 
maintain their pediatric assessment and resuscitation skills. In a 
practice such as a pediatric emergency department located in a tertiary 
urban children's hospital and trauma center, providers are able to 
maintain those skills. However, over 90% of children receive their 
emergency care in a non-children's hospital or non-trauma center 
setting. Emergency care professionals in many of these settings, and 
most pre-hospital emergency care providers, simply may not have 
adequate ongoing exposure to critically ill or injured children.
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    \6\ Markenson D, Reynolds S, Committee on Pediatric Emergency and 
Medicine and Task Force on Terrorism. The Pediatrician and Disaster 
Preparedness. Pediatrics, Vol. 117 No. 2 February 2006.
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    This vital clinical ability to recognize and respond to the needs 
of an ill or injured child must be present at all levels of care--from 
the pre-hospital setting, to emergency department care, to definitive 
inpatient medical and surgical care. The outcome for the most severely 
ill or injured children, and for the rapidly growing number of special 
needs children with chronic medical conditions, is optimized in centers 
that offer pediatric critical care and trauma services and pediatric 
medical and surgical subspecialty care. As it is not feasible to 
provide this level of expertise in all hospital settings, existing 
emergency and trauma care systems and state and federal disaster plans 
need to address regionalization of pediatric emergency care within and 
across state lines and inter-facility transport as a means to maximize 
the outcome of the most severely ill and injured children.
    Children with special health care needs \7\ are the fastest growing 
subset of children, representing 15 to 20% of the pediatric 
population.\8\ These children pose unique emergency and disaster care 
challenges well beyond those of otherwise healthy children. Our 
emergency medical services systems, and our disaster response plans, 
must consider and meet the needs of this group of children.
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    \7\ MacPherson M et.al. A New Definition of Children with Special 
Health Care Needs. Pediatrics, Vol. 102, No. 1, July 1998.
    \8\ Van Dyck P et.al. Prevalence and Characteristics of Children 
With Special Health Care Needs. Arch Pediatr Adolesc Med, Vol. 158, No. 
9, September 2004.
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Pediatric Emergency Care Preparedness
    Our nation's EMS system was developed in response to observed 
deficiencies in the delivery of pre-hospital and hospital-based 
emergency care to patients with critical illness or injury, with adult 
cardiovascular disease and trauma representing the sentinel examples. 
The Emergency Medical Services Act of 1973 helped to create the 
foundation for today's EMS systems, stimulating improvements in the 
delivery of emergency care nationally. Despite those improvements, 
significant gaps remained evident in EMS care, particularly within the 
pediatric population.\9\\,\\10\
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    \9\ Seidel JS, et al: Emergency medical services and the pediatric 
patient: Are the needs being met? Pediatrics, Vol. 73, June 1984.
    \10\ Seidel JS, et al.: Emergency medical services and the 
pediatric patient: Are the needs being met II. Training and equipping 
emergency medical services providers for pediatric emergencies. 
Pediatrics, Vol. 78, December 1986.
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    These gaps were present because early efforts at improving EMS care 
did not appreciate that acutely ill and injured children could not be 
treated as ``small adults.'' Children possess unique anatomic, 
physiologic, and developmental characteristics which create vitally 
important differences in the evaluation and management of many serious 
pediatric illnesses and injuries. Unique pediatric health care needs 
make it difficult for emergency care providers to provide optimal care 
in adult-oriented EMS systems (e.g. personnel training, facility 
design, equipment, medications).
    In 1993, the Institute of Medicine (IOM) released a comprehensive 
report, ``Emergency Medical Services for Children,'' on the status of 
pediatric emergency care. This study identified numerous concerns in 
several major areas, including gaps in the pediatric training and 
continuing education of emergency care providers, deficiencies in 
necessary equipment, supplies and medications needed to care for 
children, inadequate planning for pediatric emergency and disaster 
readiness, and insufficient evaluation of patient outcomes and research 
in pediatric emergency care.\11\
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    \11\ Durch JS, Lohr KN (eds): Emergency Medical Services for 
Children. Report of the Institutes of Medicine Committee on Pediatric 
Emergency Medical Services. Washington, D.C., The National Academies 
Press, 1993. Available at: http://books.nap.edu/catalog/2137.html.
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    Over a decade later, last month's IOM report ``Emergency Care for 
Children: Growing Pains,'' demonstrates that while some improvements 
have been achieved, the pediatric emergency readiness gap still 
remains, noting:

      Only 6% of emergency departments across the nation have 
all of the supplies necessary for managing pediatric emergencies.
      Only half of hospitals have at least 85% of those 
critical supplies.
      Of the hospitals that lack the ability to provide care 
for pediatric trauma victims, only half have written transfer 
agreements with hospitals that possess that ability.
      Many medications used in the emergency room setting for 
children are prescribed ``off label,'' i.e. without Food and Drug 
Administration approval for use in children.
      Pediatric emergency care skills deteriorate quickly 
without practice, yet training is limited and continuing education may 
not be required for emergency medical technicians (EMTs) in many areas.
      Pediatric emergency treatment patterns and protocols vary 
widely across emergency care providers and geographic regions.
      Shortages of equipment and devices and deficiencies in 
pediatric training are exacerbated in rural areas.\12\
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    \12\ Institute of Medicine. Future of Emergency Care Series, 
``Emergency Care for Children: Growing Pains.'' National Academies 
Press, June 2006.
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      Disaster preparedness plans often overlook the needs of 
children even though their needs differ from those of adults.

    As stated in the IOM report, ``If there is one word to describe 
pediatric emergency care in 2006, it is uneven.'' The specialized 
resources available to treat critically ill or injured children vary 
greatly based upon location. Some children have ready access to a 
children's hospital or a center with distinct pediatric capabilities 
while others must rely upon hospitals with limited pediatric expertise 
or equipment. Some states have implemented pediatric readiness 
guidelines for hospital emergency departments, but most have not. Some 
states have organized trauma systems and designated pediatric 
facilities while others do not. As trauma remains the leading cause of 
death and disability for children, the absence of a trauma system is 
particularly problematic for children. Lastly, state requirements for 
the pediatric continuing education and certification for EMTs vary 
widely. As a result, not all children have access to the same quality 
of care.
    Finally, more research is needed in all aspects of pediatric 
emergency care. Due to the lack of scientifically validated research in 
this area, most recommendations are the result of expert consensus, not 
scientific evidence. More study is needed to advance the field and 
ensure that the measures we are taking are effective.
Pediatric Disaster Readiness
    Each of these shortcomings in day-to-day emergency care has major 
implications for disaster preparedness. Emergency departments and 
emergency medical services systems that are unable to meet everyday 
pediatric care challenges are, by definition, unlikely to be prepared 
to deliver quality pediatric care in a disaster.\13\
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    \13\ American Academy of Pediatrics Committee on Pediatric 
Emergency Medicineand American College of Emergency Physicians 
Pediatric Committee. Care of Children in the Emergency Department: 
Guidelines for Preparedness. Pediatrics, Vol. 107 No. 4 April 2001.
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    A unique consideration in pediatric emergency care and disaster 
planning is the role of schools and day care facilities. Children spend 
up to 80% of their waking hours in school or out-of-home care. Schools 
and day care facilities must be prepared to respond effectively to an 
acutely ill or injured child, and likewise, must be fully integrated 
into local disaster planning, with special attention paid to 
evacuation, transportation, and reunification of children with 
parents.\14\ Families should also be encouraged to engage in advance 
planning for emergencies and disasters.\15\
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    \14\ Schools and Terrorism: A Supplement to the National Advisory 
Committee on Children and Terrorism Recommendations to the Secretary. 
August 12, 2003. http://www.bt.cdc.gov/children/PDF/working/school.pdf.
    \15\ Family Readiness Kit. http://www.aap.org/family/frk/frkit.htm.
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    One key area of deficiency in our current disaster planning is in 
pediatric surge capacity. Most hospitals have limited surge capacity 
for patients of any kind. Even if beds may be available, appropriately 
trained or experienced staff and the necessary equipment, drugs and 
devices may not be. The use of adult critical care or medical/surgical 
inpatient beds in hospitals with limited pediatric expertise will 
likely prove to be an unacceptable option for the needs of many ill or 
injured children. Optimal outcomes for these children will only be 
achieved through regionalization of pediatric care and surge capacity.
    One federal program provides a clear example of the general neglect 
of children's issues in disaster planning. The National Bioterrorism 
Hospital Preparedness Program (NBHPP), administered by the Health 
Resources and Services Administration (HRSA), is tasked with providing 
funds to states and localities to improve surge capacity and other 
aspects of hospital readiness. In the most recent grant guidance, HRSA 
required that all states establish a system that allows for the triage, 
treatment, and disposition of 500 adult and pediatric patients per 1 
million population. While pediatric patients are referenced, it is 
unclear whether they are required to be represented in proportion to 
their numbers in the state's population. A state could arguably plan 
for 499 adults and 1 child and satisfy the guidance. Moreover, that 
guidance removed critical language that stated that NBHPP funds must 
not supplant funding received under federal Emergency Medical Services 
for Children grants and that strongly urged the incorporation of 
behavioral health and psychosocial interventions for adults and 
children into facility drills and exercises. Outside the pediatric 
mention in the benchmark for bed surge capacity, children's issues are 
essentially absent from the NBHPP guidance.\16\
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    \16\ National Bioterrorism Hospital Preparedness Program FY 2005 
Continuation Guidance, HRSA Announcement Number 5-U3R-05-001, http://
www.hrsa.gov/bioterrorism/hrsa05001.htm.
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    Equipment and devices, as noted above, are a crucial component of 
readiness. Because ``children'' encompass individuals from birth 
through adolescence, it is often insufficient to have a single size 
device to serve all children. In the case of respiratory masks, for 
example, different sizes are needed for infants, young children, and 
teenagers. Both individual facilities and large-scale programs, such as 
the Strategic National Stockpile, must take this into account and 
provide for these needs.
    Similarly, drugs and antidotes must be available in appropriate 
formulations and dosages for children. Infants cannot be expected to 
take pills. Needles must be provided in smaller sizes. In many cases, 
dosages for children should be determined not by age but by weight. A 
simple device known as a Broselow tape can allow health care providers 
to calculate dosages quickly and accurately. However, one study showed 
that 46% of Disaster Medical Assistance Teams were lacking these tapes, 
in addition to other critical pediatric equipment.\17\
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    \17\ Mace SE and Bern AI. Needs Assessment of Current Pediatric 
Guidelines for Use by Disaster Medical Assistance Team Members in 
Response to Disaster and Shelter Care. Annals of Emergency Medicine, 
44(4): S35.
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    Training is vital to pediatric preparedness. Many health care 
providers have few, if any, opportunities to use critical pediatric 
resuscitation and treatment skills. Skills that are not exercised 
atrophy quickly. Presently, there is great variation in state standards 
for required pediatric training and continuing education for pre-
hospital care providers and other first responders. Regular training 
and education is central to ensuring that health care providers will be 
able to treat children in a crisis situation. The same holds true for 
facility and community emergency exercises and drills.
    The issues of family reunification and family-centered care in 
evacuation, decontamination and in all phases of treatment are 
frequently overlooked. In the event of a disaster, both evacuation and 
treatment facilities must have systems in place to minimize family 
separation and methods for the timely and reliable reunification of 
children with their parents. In addition, facilities must take into 
account the need for family-centered care in all stages of care. 
Infants and young children are typically unable to communicate their 
needs to healthcare providers. Children of all ages are highly reliant 
upon the presence of family during an illness or periods of distress. 
Nearly all parents will be unwilling to be separated from their 
children in a crisis situation, many even willing to forego emergency 
treatment for themselves to be with their child. Hospitals must be 
prepared to deal with these situations with compassion and 
consistency.\18\
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    \18\ Committee on Hospital Care. Family-Centered Care and the 
Pediatrician's Role. Pediatrics, Vol. 112, No. 3, September 2003.
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    It has been a source of great frustration for many pediatric and 
emergency medicine providers, including the American Academy of 
Pediatrics, that our repeated calls for improved pediatric emergency 
preparedness have gone unheeded for the better part of a decade. As 
long ago as 1997, the Federal Emergency Management Agency raised the 
concern that none of the states it had surveyed had pediatric 
components in their disaster plans.\19\ That same year, the American 
Academy of Pediatrics issued its first policy statement entitled, ``The 
Pediatrician's Role in Disaster Preparedness,'' with recommendations 
for pediatricians and communities.\20\ In 2001, the American Academy of 
Pediatrics formed its Task Force on Terrorism and issued a series of 
detailed recommendations on various aspects of chemical, biological, 
radiological and blast terrorism.\21\ In 2002, Congress created the 
National Advisory Committee on Children and Terrorism to prepare a 
comprehensive public health strategy related to children and terrorism. 
In 2003, the federal government sponsored a National Consensus 
Conference on Pediatric Preparedness for Disasters and Terrorism which, 
again, issued a laundry list of dozens of specific recommendations.\22\ 
Just last month, the IOM issued its report on the pediatric aspects of 
the emergency care system.\23\ Despite all of this, progress in 
pediatric preparedness has been slow, fragmented, disorganized, and 
largely unmeasured and unaccountable.
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    \19\ National Advisory Committee on Children and Terrorism. 
Recommendations to the Secretary. Washington, DC: DHHS, 2003.
    \20\ Committee on Pediatric Emergency Medicine. The Pediatrician's 
Role in Disaster Preparedness. Pediatrics, Vol. 99 No. 1, January 1997.
    \21\ AAP Task Force on Terrorism. All related documentation at 
www.aap.org/terrorism.
    \22\ Pediatric Preparedness for Disasters and Terrorism: A National 
Consensus Conference. 2003. http://www.ncdp.mailman.columbia.edu/files/
pediatric_preparedness.pdf.
    \23\ Institute of Medicine. Future of Emergency Care Series, 
``Emergency Care for Children: Growing Pains.'' National Academies 
Press, June 2006.
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The Emergency Medical Services for Children (EMSC) Program
    The federal government has a crucial role in assuring pediatric 
emergency and disaster preparedness through a variety of agencies and 
programs, including the Department of Homeland Security, the Federal 
Emergency Management Agency, the Centers for Disease Control and 
Prevention, HRSA's National Hospital Bioterrorism Preparedness Program, 
and others. Perhaps the most important and successful federal program 
in improving emergency health care providers' ability to provide 
quality care to children has been HRSA's Emergency Medical Services for 
Children (EMSC) program. Created in 1984, the EMSC program was 
established after data and clinical experience showed major gaps 
between adult and pediatric emergency care at all levels. The program 
has funded pediatric emergency care improvement initiatives in every 
state, territory and the District of Columbia, as well as national 
improvement programs.
    Despite a modest budget allocation, EMSC has driven significant 
improvements in pediatric emergency care, including disaster 
preparedness. To its credit, EMSC has managed to effect these changes 
despite the lack of pediatric emphasis in other related government 
programs. EMSC has funded the development of equipment lists for 
ambulances and hospitals, pediatric treatment protocols, and handbooks 
for school nurses and other providers that would be critical in the 
event of an emergency. EMSC supports training for emergency medical 
technicians and paramedics who often have little background in caring 
for children, and has underwritten the development of vital educational 
materials and treatment guidelines. In the 21 years since the program 
was established, child injury death rates have dropped by 40%.
    As outlined in the IOM report, the EMSC program's resources and 
over 20 years of effective leadership and collaboration with key 
stakeholders have indeed led to important changes in pediatric 
emergency care at the state level:

      44 states employ pediatric protocols for online medical 
direction of pre-hospital care at the scene of an emergency;
      48 states have identified and require all EMSC essential 
equipment on EMS advanced life support ambulances;
      36 of 42 states with state-wide computerized data 
collections systems now produce reports on pediatric care;
      20 states have pediatric emergency care laws or pediatric 
emergency care related rules or regulations; and
      12 states have adopted and disseminated pediatric 
guidelines that characterize the facilities that have trained personnel 
and equipment, medications and facilities to provide pediatric care.

    EMSC supports a National Resource Center (NRC) which acts as a 
clearinghouse for educational resources on pediatric emergency care, 
enabling countless communities to learn from each other's experience 
and adopt proven models. EMSC also supports the National EMSC Data 
Analysis Resource Center (NEDARC) which assists EMSC grantees and State 
EMS offices to improve their ability to collect, analyze, and utilize 
data to improve the quality of pediatric care.
    EMSC has also been a very important source of funding for grants 
that have contributed to increasing evidence-based care for acutely ill 
and injured children. Research is an essential element in the 
development of an evidence-based practice of medicine. The practice of 
evidence-based pediatric emergency medicine is needed to provide the 
best treatment for acutely ill or injured children. Unfortunately, in 
many situations, emergency care providers must rely upon limited or 
anecdotal experience, or an extrapolation from adult care standards 
when treating children, because reliable research studies involving 
acutely ill and injured children are few.
    In recent years, EMSC has funded the establishment of the Pediatric 
Emergency Care Applied Research Network (PECARN), the only network of 
its kind supporting pediatric emergency care research. PECARN is 
providing the infrastructure for critical research on the effectiveness 
of interventions and therapies used in pediatric emergencies.
    The recent IOM report contained a strong endorsement of the EMSC 
program: ``the work of the EMSC program today remains relevant and 
vital.'' The report acknowledged the need to address the serious gaps 
that remain in pediatric emergency care and stated that ``The EMSC 
program, with its long history of working with federal partners, state 
policy makers, researchers, providers and professional organizations 
across the spectrum of emergency care, is well positioned to assume 
this leadership role.''\24\
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    \24\ Institute of Medicine. Future of Emergency Care Series, 
``Emergency Care for Children: Growing Pains.'' National Academies 
Press, June 2006.
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    The American Academy of Pediatrics fully endorses the IOM's 
comments regarding the value of the EMSC program. While enormous 
strides have been made in pediatric emergency care, much more remains 
to be done. The program should be reauthorized and funded at or above 
the level recommended by the IOM, which we hope would allow EMSC to 
pursue pediatric emergency and disaster preparedness thoroughly and 
aggressively.
POLICY RECOMMENDATIONS
    The American Academy of Pediatrics has specific recommendations for 
all policymakers regarding children and emergency and disaster 
preparedness:

      If our nation's over-burdened emergency and trauma care 
systems are to respond effectively to a significant mass casualty 
event, we must invest in creating effective local, state and federal 
disaster response systems involving a healthy, adequately-funded, well-
coordinated and functional emergency medical services system.
      Standards for pediatric emergency readiness for pre-
hospital and hospital-based emergency services, and regionalization of 
pediatric trauma and critical care, should be developed and implemented 
in every state.
      Evidence-based clinical practice guidelines for the 
triage, treatment and transport of acutely ill and injured children at 
all levels of care should be developed.
      Pediatric emergency care competencies should be defined 
by every emergency care discipline and professional credentialing 
bodies should require practitioners to achieve the level of initial and 
continuing education necessary to maintain those competencies.
      Primary care pediatricians and pediatric medical and 
surgical subspecialists should be included in emergency and disaster 
planning at every organizational level--at all levels of government, 
and in all types of planning.
      Emergency preparedness efforts should use an ``all-
hazards'' model that allows for holistic planning and multipurpose 
initiatives, and should support family-centered care at all levels of 
treatment.
      Pediatric health care facilities (e.g. children's 
hospitals, pediatric emergency departments, and pediatricians' offices) 
should be included in all aspects of preparation because they are 
likely to become primary sites for managing child casualties.
      Financial support should be provided to health care 
facilities to address pediatric preparedness, including maintaining 
surge capacity and creating specialized treatment areas for children, 
such as isolation and decontamination rooms.
      Schools and day care facilities must be prepared to 
respond to emergencies and must be fully integrated into local, state 
and federal disaster plans, with special attention paid to evacuation, 
transportation, and reunification of children with parents.
      Federal, state, and local disaster plans should include 
specific protocols for the management of pediatric casualties, 
including strategies to:
          Minimize parent-child separation and implement 
        systems for the timely and reliable reunification of families;
          Improve the level of pediatric expertise on disaster 
        response teams (e.g. Disaster Management Assistance Teams);
          Improve access to pediatric medical and surgical 
        subspecialty care and to pediatric mental health care 
        professionals;o Address the care requirements of children with 
        special health care needs; and
          Ensure the inclusion of pediatric mass casualty 
        incident drills at both federal and state planning levels.
      More research is needed regarding all aspects of 
pediatric emergency planning, response, and treatment to support the 
development of effective emergency therapies, prevention strategies, 
and evidence-based clinical standards in pediatric emergency medicine.
      The Emergency Medical Services for Children (EMSC) 
program should be reauthorized and funded at the level of $37.5 million 
per year, as recommended by the Institutes of Medicine report, to 
support the continued improvement in pediatric emergency and disaster 
preparedness.
Other Issues of Concern
    In addition to hospital surge capacity and emergency room 
preparedness, a number of other critical issues continue to be 
neglected in the area of pediatric readiness.
    Government organizational issues: Pediatric concerns must be 
represented in all aspects of disaster planning and at all levels of 
government, including issues such as evacuation strategies and large-
scale protocols.
    Federal systems issues: Children's needs must be taken into account 
in various federal systems. The Strategic National Stockpile must 
contain equipment, devices and dosages appropriate for children. 
Disaster Medical Assistance Teams must include individuals with 
appropriate pediatric expertise. Pediatric casualties should be 
simulated in all disaster drills.
    Special disasters: Children have unique needs in certain types of 
disasters. For example, in the event of a radioactive release, children 
must be administered potassium iodide as quickly as possible and in an 
appropriate form and dosage to prevent long-term health effects.\25\
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    \25\ Committee on Environmental Health. Radiation Disasters and 
Children. Pediatrics, Vol. 111, No. 6, June 2003.
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    School and day care issues: Children spend up to 80% of their 
waking hours in school or out-of-home care. Schools and day care 
facilities must be integrated into disaster planning, with special 
attention paid to evacuation, transportation, and reunification with 
parents.\26\
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    \26\ Schools and Terrorism: A Supplement to the National Advisory 
Committee on Children and Terrorism Recommendations to the Secretary. 
August 12, 2003. http://www.bt.cdc.gov/children/PDF/working/school.pdf
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    Credentialing. Health care providers are critical volunteers in 
time of disaster. A comprehensive system for verifying credentials and 
assigning volunteers appropriately is vital. HRSA's Emergency System 
for Advance Registration of Volunteer Health Professionals (ESAR-VHP) 
must be supported and accelerated.
    Psychosocial concerns: Children's reactions vary greatly depending 
on the child's cognitive, physical, educational, and social development 
level and experience, in addition to the emotional state of their 
caregivers. This presents unique challenges to providing quality mental 
health care.\27\
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    \27\ Hagan, J and the Committee on Psychosocial Aspects of Child 
and Family Health and the Task Force on Terrorism. Psychosocial 
Implications of Disaster or Terrorism on Children: A Guide for the 
Pediatrician. Pediatrics, Vol. 116, No. 3, September 2005.
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    Evacuation and shelter issues: A top priority must be placed on not 
separating parents from children in evacuations. In shelters, special 
arrangements must be made for pregnant women and children with special 
health care needs, as well as for the safety and security of all 
children.
CONCLUSION
    In conclusion, the American Academy of Pediatrics greatly 
appreciates this opportunity to present its views and concerns related 
to pediatric emergency care and disaster preparedness. While great 
strides have been made in recent years, with many of these improvements 
the direct result of the federal EMSC program, much more remains to be 
done. America's children represent the future of our great nation, our 
most precious national resource. They must not be an afterthought in 
emergency and disaster planning. With focused, comprehensive planning 
and the thoughtful application of resources, these goals can be 
achieved. The American Academy of Pediatrics looks forward to working 
with you to protect and promote the health and well-being of all 
children, especially in emergency and disaster situations.

                                 

                              National Coalition on Hispanic Health
                                               Washington, DC 20005
                                                     August 9, 2006

Dear Members of Congress:

    On behalf of the National Coalition on Hispanic Health, an 
association of major national Latino associations with extensive 
expertise, I write to urge Congress to get the facts about immigrants 
and health care. Study after study has proven that immigrants actually 
use much less of our nation's health resources than U.S. citizens. This 
was first carefully studied and documented by the prestigious National 
Research Council, in The New Americans, published in 1997. More recent 
reports have only served to reconfirm these findings. For instance, a 
recent study in Health Affairs shows that 6.3% of non-citizens used the 
emergency room in 2003, compared to 31.8% of the general population in 
the total U.S.
    It is critical that Congress base decisions about immigration and 
health issues upon factual, comprehensive, longitudinal studies of the 
type cited above. Rhetorical examples will only serve to divert public 
policy from its essential goal of protecting our nation's health and 
well-being.
    If you have any further questions, please do not hesitate to 
contact me.
            Sincerely,
                                               Elena Rios, MD, MSPH
                                                  President and CEO

                                 

 Statement of William A. Sanger, Emergency Medical Services Corporation
    Emergency Medical Services Corporation (``EMSC'') is pleased to 
submit comments to the Health Subcommittee of the House Ways & Means 
Committee on the Institute of Medicine (``IOM'') reports on Emergency 
Care in America. These reports were the subject of a public hearing 
held before the Subcommittee on July 27, 2006.
    EMSC has extensive experience in emergency medicine delivery and 
emergency care operations. Operating under the recognized brands of 
EmCare and AMR, EMSC is a leading provider of emergency medical 
services in the United States, serving more than nine million patients 
each year. EmCare provides outsourced emergency department staffing and 
management services to more than 340 hospitals in 39 states. AMR--
American Medical Response--is America's leading provider of ambulance 
services, with local operations serving more than 250 communities in 35 
states.
    Because of EMSC's unique position in these healthcare sectors, we 
are very familiar with the complexities and challenges facing emergency 
departments, hospitals, emergency physicians, first responders, EMS and 
ambulance service providers, and all others associated with the 
delivery of emergency medical services across the nation. As identified 
in the IOM reports, some of the key issues facing emergency medical 
service providers include regionalization, coordination, the practices 
of ``boarding'' and ``parking'' emergency care patients, and patient 
flow management. We believe that Congress and others need to take 
immediate steps to address these issues in order to improve patient 
care delivery and maximize the efficiency of emergency department 
operations.
    While no one organization can provide answers to the many problems 
facing emergency care in America, EMSC believes that our breadth and 
depth of experience makes us uniquely qualified to confront the many 
issues raised in the IOM reports. We, therefore, would like to share 
some of our experiences with the Subcommittee and others involved in 
policymaking in this important area. We believe our experiences and 
insights will help inform the next phase of deliberation and 
consideration of these critical issues.
Regionalization and Coordination
Regionalization of Emergency Services
    In today's world, an emergency in one town or one section of a city 
can quickly become a much larger incident requiring a response across 
jurisdictions and disciplines. The IOM Emergency Medical Services 
report makes clear that the objective of regionalization of emergency 
medical care services is to ``improve patient outcomes by directing 
patients to facilities with experience in and optimal capabilities for 
any given type of illness or injury.'' (Emergency Medical Services: At 
the Crossroads at p. 58.) Getting the patient to the best provider to 
treat their specific medical condition is a primary requirement to meet 
this stated goal. Our physicians, EMS professionals, and other 
emergency care providers have seen the benefits of regionalization. 
This helps ensure that patients receive the best available care with 
the result of better outcomes. Unfortunately, we have also experienced 
instances where a lack of regionalization has resulted in poor patient 
outcomes.
    EMSC's unique role in emergency medicine delivery and emergency 
care operations has given our team significant ``on the ground'' 
experience in finding the best ways to make regionalization work to 
improve emergency medical care for patients.
    The EMS report also noted the concept of an ``inclusive trauma 
system'' for the treatment of all illnesses and injuries across the 
entire spectrum of emergency care. (Id. at p.58.) We share this vision 
for the future of emergency care and are already implementing methods 
to achieve this concept. EMSC has worked over the past years to develop 
procedures and processes to help our physicians and professionals 
ensure top quality emergency medical care to all patients but 
especially to those patients in immediate danger of death from 
traumatic injury or illness.
    The Emergency Medical Services report notes a specific 
recommendation for a panel to develop ``evidence-based categorization 
systems for EMS, EDs and trauma centers based on adult and pediatric 
service capabilities.'' (Id. at p. 59.) We strongly support this 
proposal and believe that our depth of experience in delivering 
emergency care services would be useful considering ways to develop 
such categorization systems. We offer our expertise and experience to 
those individuals and organizations committed to this undertaking.
    While we believe that regionalization is a positive development in 
the improvement of emergency medical care, it is a concept that will 
require some changes to current laws to realize its full potential. 
Issues like antitrust laws, physician licensure across state lines, 
obsolete corporate practice of medicine laws in certain states, and 
Good Samaritan laws potentially present certain legal issues that we 
and others in the profession will need to consider before 
regionalization can be accomplished. We, alongside our professional 
societies and fellow health care providers, look forward to working 
with Congress to achieve the important goal of regionalization.
Coordination of Emergency Services
    The Emergency Medical Services report discussed the current 
emergency medical care system's lack of coordination among the 
different components of care, including 911 dispatch, pre-hospital EMS, 
air ambulance providers, hospitals, and trauma centers. In addressing 
this need, the report states that these elements, along with public 
safety and public health departments, ``should be fully interconnected 
and united in an effort to ensure that each patient receives the most 
appropriate care, at the optimum level, with the minimum delay.'' 
(Emergency Medical Services: At the Crossroads at p. 7.) EMSC fully 
agrees with and shares this goal for the future of emergency care.
    Coordination of services and emergency care is not just a goal for 
EMSC, but is important for all emergency care providers to ensure that 
patients receive the highest quality care. The efficiency and 
effectiveness of our emergency care delivery depends on how well our 
professionals can coordinate their response to an incident, the care 
provided to a patient in distress, and the communication with other 
providers along the service delivery chain to provide a continuum of 
care that achieves the optimum patient outcome.
    To date, EMSC has invested several years in our continuing search 
for solutions to deliver the best possible emergency care services. 
This includes advanced technology to provide the most clinically 
appropriate and cost effective level of care to all patients, state of 
the art medical transportation software for high performance medical 
transportation management, and advanced technology to match physicians 
to hospitals' needs.
    For example, many hospitals currently utilize software programs to 
assist them with bed management issues. When a bed is available, a 
nurse will use the software to notify housekeeping that a bed has 
become available so they can get the room ready for a new patient. We 
have learned, however, for a variety of reasons, nurses do not always 
adequately use the software, so empty beds are not filled timely. EMSC 
has formed partnerships with software developers, which allows us to 
become a part in the process of identifying empty beds. When an EMSC 
ambulance arrives to transport a discharged patient in these 
facilities, the dispatchers use the software to notify the hospital 
that there is an available bed to be filled. This helps hospitals that 
use EMSC's ambulances to more timely fill their empty beds, thus 
alleviating some of the bed shortage problems faced by these hospitals.
    In developing these partnerships, we have gained a number of 
insights and new information that we believe will be useful as Congress 
explores ways to improve coordination and communications in emergency 
care. We stand willing and ready to work with the Subcommittee and 
other interested individuals and organizations to provide our expertise 
and experience to this very important effort.
Patient Care Issues
Patient ``Boarding'' and ``Parking''
    One important area of continuing concern is the practice of 
``boarding'' where emergency departments are unable to timely admit 
patients into the hospital and must hold the patient in an emergency 
department bed or in a non-clinical space, such as an office or 
hallway. This practice reduces care capacity and contributes to an 
already overcrowded emergency room. The IOM Emergency Medical Services 
report urges elimination of the practice of boarding except in extreme 
cases, such as a mass casualty event. (Emergency Medical Services: At 
the Crossroads at p. 201; Recommendation 4.5.) Similarly, the American 
College of Emergency Physicians has cited the negative aspects of this 
practice and suggested solutions in testimony before this Subcommittee. 
EMSC echoes these concerns and joins our fellow emergency care 
professionals in calling for an end to the improper practice of 
boarding.
    An additional practice that negatively impacts patient care is 
``patient parking.'' Some hospitals have significant issues with bed 
turnaround and availability and emergency department overcrowding. When 
an ambulance arrives at the hospital, the hospital will refuse to 
formerly ``accept'' the patient and instead tells the ambulance that 
there is inadequate emergency department staff to handle the patient. 
If there is not, which occurs in many cases, or the patient needs to be 
seen at that specific facility, because of a physician on staff or the 
appropriate level of care available at that facility, then the 
ambulance is often asked to wait in the parking lot until the patient 
can be brought into the facility. This practice not only negatively 
impacts the patient care for the individual in the ambulance, but it 
also prevents the ambulance from responding to another request for help 
since the EMS professionals cannot respond until the first patient is 
admitted into the emergency department.
    EMSC has proactively acted to address this practice and to improve 
patient care by using extra rooms that hospitals make available, 
purchasing additional gurneys, and staffing the rooms with 
administrative and clinical personnel. For example, when an ambulance 
arrives at a hospital that would normally have told the crew to remain 
with the patient in the ambulance in the parking lot until adequate 
emergency room staff was available to provide care, EMSC personnel have 
brought the patient into a room in the hospital set aside for this 
purpose and our clinical personnel have monitored the patient until the 
hospital could formerly accept the patient. While this innovative 
strategy allows EMSC to keep our ambulances in service without having 
to call in additional crews to staff units to maintain response time 
requirements and provide clinically acceptable care in these areas, it 
is a costly procedure and currently, there exists no government or 
private payer reimbursement for this practice. We believe that Congress 
should work to establish standards on both patient boarding and patient 
parking to improve patient flow throughout the emergency medical care 
system.
    In the IOM report, the committee calls for a panel to develop 
evidence-based model pre-hospital protocols for treatment, triage, and 
transport of patients. (Emergency Medical Services: At the Crossroads 
at p. 60) We believe that the issues of patient boarding and patient 
parking should be included in this discussion. Our widespread 
experience in treatment, triage, and transport would be useful in the 
national debate about how to improve and revamp this aspect of the 
emergency care system, and we offer our expertise and experience to 
those individuals and organizations committed to this undertaking.
Discharge Resource Rooms at Hospitals
    Another area where we have been active in finding new solutions to 
overcrowding and congestion in emergency departments is in the 
discharge of patients from the emergency department. Many hospitals use 
``discharge resource rooms,'' which are essentially ``holding rooms'' 
for patients who are ready to be discharged, but the mechanics of the 
actual discharge still need to occur, such as finding an available bed 
for the patient in a skilled nursing facility or rehabilitation 
facility, completing the discharge paperwork, and arranging for the 
correct level of transportation. These are all things that occur after 
the patient has been taken to the discharge resource room. We assist 
hospitals with staffing a coordinator that manages the conditions of 
patient travel and, in some cases, also help with clinical staffing of 
these rooms. This allows a hospital bed to become available for the 
next patient.
    This is another way in which EMSC has helped develop innovative 
solutions to the overcrowding and patient flow issues faced by 
emergency departments across the country. We believe that our efforts 
in addressing emergency care patient flow issues would be useful in 
identifying ways find solutions to these problems.
Summary
    To conclude: we believe that EMSC's unique position in the 
emergency care healthcare sectors and our familiarity with the wide 
range of complexities and challenges facing the many elements involved 
in the delivery of emergency medical services make us a valuable 
resource in the continuing efforts to improve the delivery of emergency 
medical services. EMSC urges Congress and emergency medical health care 
organizations to consider and address the issues of regionalization of 
care, coordination of care, the practices of ``patient boarding'' and 
``patient parking'' of emergency care patients, and other improvements 
to overall patient flow management. It is critical that we as a nation 
develop permanent solutions to address these problems to improve 
patient care and maximize the efficiency of emergency department 
operations, so that all patients receive the best quality emergency 
care. While EMSC has been innovative in working with hospitals and 
other emergency care providers to arrive at temporary solutions to 
these problems, it falls far short of the solutions needed to address 
the very significant problems facing the delivery of emergency care 
across the country.
    We believe that the private sector companies in this field should 
be included in the working groups and task forces engaged in the next 
phase of the IOM's work. EMSC stands ready and willing to assist in any 
way we can to offer perspectives, insights, and experience from the 
private sector in the range of issues confronting all of us who toil in 
the emergency medical services field.
    We thank the Subcommittee for its attention to this crisis and for 
their actions to chart a course to find solutions and new ideas that 
will benefit emergency medical care providers, and most importantly, 
patients and our communities.