[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
RESPONSE OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO THE NATION'S
EMERGENCY CARE CRISIS
=======================================================================
HEARING
before the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
JUNE 22, 2007
__________
Serial No. 110-25
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
http://www.house.gov/reform
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COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts CHRIS CANNON, Utah
WM. LACY CLAY, Missouri JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts DARRELL E. ISSA, California
BRIAN HIGGINS, New York KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of VIRGINIA FOXX, North Carolina
Columbia BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota BILL SALI, Idaho
JIM COOPER, Tennessee JIM JORDAN, Ohio
CHRIS VAN HOLLEN, Maryland
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
Phil Schiliro, Chief of Staff
Phil Barnett, Staff Director
Earley Green, Chief Clerk
David Marin, Minority Staff Director
C O N T E N T S
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Page
Hearing held on June 22, 2007.................................... 1
Statement of:
Schwab, William, M.D., FACS, professor and chief of division
of trauma and surgical critical care, University of
Pennsylvania Medical Center, Philadelphia; Ramon Johnson,
M.D., FACEP, associate director, department of emergency
medicine, Mission Hospital Regional Medical Center,
director of pediatric emergency medicine, Children's
Hospital, Mission Viejo, CA; and Robert O'Connor, M.D.,
MPH, professor and chairman, department of emergency
medicine, University of Virginia, Charlottesville, VA...... 22
Johnson, Ramon........................................... 31
O'Connor, Robert......................................... 52
Schwab, William.......................................... 22
Yeskey, Kevin, M.D., Director, Office of Preparedness and
Emergency Operations, Acting Deputy Assistant Secretary,
Office of the Assistant Secretary for Preparedness and
Response, Department of Health and Human Services; and
Walter Koroshetz, M.D., Deputy Director, National Institute
of Neurological Diseases and Stroke, National Institutes of
Health, Department of Health and Human Services............ 110
Koroshetz, Walter........................................ 119
Yeskey, Kevin............................................ 110
Letters, statements, etc., submitted for the record by:
Cummings, Hon. Elijah E., a Representative in Congress from
the State of Maryland:
Letter dated June 14, 2007............................... 79
Letter dated June 22, 2007............................... 81
Prepared statement of.................................... 5
Davis, Hon. Tom, a Representative in Congress from the State
of Virginia, prepared statement of......................... 15
Johnson, Ramon, M.D., FACEP, associate director, department
of emergency medicine, Mission Hospital Regional Medical
Center, director of pediatric emergency medicine,
Children's Hospital, Mission Viejo, CA, prepared statement
of......................................................... 33
Koroshetz, Walter, M.D., Deputy Director, National Institute
of Neurological Diseases and Stroke, National Institutes of
Health, Department of Health and Human Services, prepared
statement of............................................... 121
O'Connor, Robert, M.D., MPH, professor and chairman,
department of emergency medicine, University of Virginia,
Charlottesville, VA, prepared statement of................. 54
Schwab, William, M.D., FACS, professor and chief of division
of trauma and surgical critical care, University of
Pennsylvania Medical Center, Philadelphia, prepared
statement of............................................... 26
Watson, Hon. Diane E., a Representative in Congress from the
State of California, prepared statement of................. 18
Yeskey, Kevin, M.D., Director, Office of Preparedness and
Emergency Operations, Acting Deputy Assistant Secretary,
Office of the Assistant Secretary for Preparedness and
Response, Department of Health and Human Services, prepared
statement of............................................... 113
RESPONSE OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO THE NATION'S
EMERGENCY CARE CRISIS
----------
FRIDAY, JUNE 22, 2007
House of Representatives,
Committee on Oversight and Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 10:02 a.m., in
room 2154, Rayburn House Office Building, Hon. Elijah E.
Cummings (acting chairman of the committee) presiding.
Present: Representatives Cummings, Davis of Virginia,
Platts, Issa, and Jordan.
Staff present: Phil Barnett, staff director and chief
counsel; Karen Nelson, health policy director; Karen Lightfoot,
communications director and senior policy advisor; Andy
Schneider, chief health counsel; Molly Gulland, assistant
communications director; Steve Cha, professional staff member;
Earley Green, chief clerk; Teresa Coufal, deputy clerk; Caren
Auchman, press assistant; Art Kellermann, fellow; David Marin,
minority staff director; Larry Halloran, minority deputy staff
director; Susie Schulte, minority senior professional staff
member; Brian McNicoll, minority communications director; and
Benjamin Chance, minority clerk.
Mr. Cummings [presiding]. This committee will come to
order. Today's hearing is regarding access to emergency care.
Without objection, the Chair and Ranking Minority Member will
have 5 minutes to make opening statements, followed by opening
statements not to exceed 3 minutes by any other committee
member who seeks recognition.
I will remind the committee members that it is anticipated
that we will be out of here by 12, so we are going to stick
strictly to our rules.
With that, I want to thank all of you for being here. Today
we will examine the response of the Department of Health and
Human Services to the Nation's emergency care crisis. In times
of tragedy Americans rely on our emergency care system. Whether
because of a car wreck, heart attack, stroke or pregnancy
complication, Americans and their families show up at the
doorstep of our Nation's emergency rooms seeking critical care
every day.
Emergency care is the great equalizer. It is the only form
of health care guaranteed to every American, regardless of his
or her ability to pay. But in this way it also provides a
chilling snapshot of what is wrong with our Nation's health
care system.
We all want emergency care to work effectively for
ourselves and for our loved ones. When it does work, and it
usually does, by the way, lives are saved and lifelong
disability is avoided. The many dedicated men and women who
staff our Nation's ERs, trauma centers and ambulance services
deserve our appreciation and our support.
But when the system fails, it can have fatal consequences.
Earlier this week, USA Today carried a front-page story on the
health crisis in Houston, where ERs divert ambulances 20
percent of the time. One doctor described a patient who died
after being diverted from a Houston area hospital to one in
Austin 1,600 miles away. He said, ``diversion kills you.''
In my hometown of Baltimore, a city health department study
documented that between 2002 and 2005 the total hours city
hospitals were on red alert status, meaning that they had no
cardiac-monitored beds for arriving ER patients, increased by
36 percent; the length of time it took ambulances to offload
patients in the ER increased by 45 percent; and the number of
hours ambulances were diverted from over crowded ERs shot up by
165 percent. Unfortunately, the emergency care crisis is not
limited to Houston, and it is certainly not limited to
Baltimore.
Failures in the ER have led to an increase in preventable
deaths from treatable conditions like heart disease. An article
in this morning's edition of USA Today indicates that seven of
our Nation's hospitals have worse heart attack death rates than
the national average, while 35 have higher death rates for
heart failure.
The L.A. Times reported this past May that a 40-year-old
woman collapsed on the waiting room floor of the ER at Martin
Luther King-Harbor Hospital in Los Angeles while janitorial
staff literally mopped the floor around her. Overburdened staff
ignored her pleas for help, and her boyfriend, desperate for
assistance, dialed 911 from the hospital. He was told to find a
nearby nurse. His girlfriend died 45 minutes later.
Last month, Newsweek.com described the critical challenges
facing Grady Memorial Hospital in Atlanta. Grady Hospital
supports one of the busiest ERs in the State and the only Level
I trauma center in a metropolitan area of 5 million people. On
any given day it is not unusual for eight Atlanta hospitals to
be diverting patients at the same time. What will Atlanta do if
Grady closes its ER?
Even here in the District of Columbia it is not unusual for
ambulances to be parked seven deep in front of one or more of
the city's bigger ERs waiting to offload patients. Not to be
too blunt, but these are the same ERs that Members of Congress
and our families would turn to in an emergency.
The fact of the matter is that we have a crisis in
emergency care, and it is nationwide. This begs the question,
with a national emergency and trauma care system as fragile as
ours, how will we manage the real threats of a terrorist
bombing, a natural disaster, or an outbreak of pandemic flu?
Where is the surge capacity?
The emergency room crisis is nothing new. More than 5 years
ago, U.S. News and World Report published a cover story
entitled, ``Crisis in the ER: Turnaways and delays Are a Recipe
For Disaster.'' A copy is displayed on the easel before me.
If you look closely, you will note, ironically, that the
issue was published on September 10, 2001. Five weeks after
September 11th, Chairman Waxman released a report detailing the
national problem of ambulance diversions and the shortage of
emergency care. His report identified over 20 States in which
hospitals were turning away ambulances because of overcrowding
and funding shortfalls. Subsequent reports reached similar
conclusions. A 2003 report by the Centers for Disease Control
and Prevention found that ER rooms in U.S. hospitals diverted
more than 1,300 patients a day--1,300 patients a day--365 days
per year. A 2003 GAO report documented ER crowding throughout
the country.
One year ago, the Institute of Medicine of the National
Academy of Sciences released a three-volume report on the
future of emergency care in the U.S. health system. This
landmark study concluded that our Nation's emergency and trauma
care system is at the breaking point.
Last summer, Congress enacted the Pandemic and All Hazards
Preparedness Act. This act assigned responsibility for leading
all Federal public health and medical responses to public
health emergencies to the Department of Health and Human
Services. But despite this clear responsibility, and despite
the billions of taxpayers' dollars that Congress has
appropriated for biodefense and pandemic preparedness, HHS
appears to be ignoring the mounting emergency care crisis.
The Department has not made a serious effort to identify
the scope of the problem and which communities are most
affected. It has failed to require hospitals that participate
in Medicare to report data on the extent of ER boarding and
ambulance diversion. It has failed to use its purchasing power
through the Medicare program to encourage hospitals to properly
admit ill and injured patients to inpatient units rather than
boarding them in ER hallways and forcing staff to divert
inbound ambulances. It has done nothing to promote the
regionalization of highly specialized trauma and emergency care
services, a key recommendation of the IOM report.
Worse yet, the Department has recently taken some actions
that will make matters worse. It is undisputed that part of the
emergency care crisis is a result of the historic underfunding
of safety net hospitals, many of which serve as cornerstones of
trauma and emergency care systems in their communities.
However, rather than asking Congress for additional resources
to assist these hospitals, the Department has attempted to
bypass Congress by issuing rules that would cut hundreds of
millions of dollars in supplemental Medicaid funding from these
facilities.
Ladies and gentlemen, this simply makes no sense. Last
month the Congress enacted a 1-year moratorium that blocks the
Department from implementing these funding reductions, but HHS
has shown no signs of modifying its position.
Today, we will hear from leading private-sector experts on
emergency care, trauma care, and ambulance services. They will
describe the emergency care crisis from the front lines. We
will also hear from representatives of two agencies within HHS
that have a particularly important role to play in addressing
the crisis: the Office of the Assistant Secretary for
Preparedness and Response, and the National Institutes of
Health.
I hope that the testimony we hear today will help provide
our committee with an understanding of the emergency care
crisis that confronts us all. Nearly 6 years have passed since
the wakeup call of September 11th, and HHS has yet to tackle
this problem. The time for action is long overdue.
With that I yield to the distinguished ranking member of
the full committee, Mr. Davis.
[The prepared statement of Hon. Elijah E. Cummings
follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Davis of Virginia. Thank you very much. I want to thank
Chairman Waxman for initiating this hearing. It is a very
timely issue. We all know the value of a functioning emergency
room. Millions of lives are saved annually only because
emergency care is available.
But across America, it is critical care services that are
in critical condition. Last year, a study by the Institute of
Medicine [IOM], concluded our hospital-based emergency medical
system was at the breaking point. Emergency rooms are finding
it impossible to meet growing and competing demands for trauma
care, mandated safety net care for the uninsured, public health
surveillance, and disaster readiness.
The IOM panel found emergency care capacity suffering from
an epidemic of crowding, with patients parked or boarding in
hallways waiting to be admitted. Ambulances are routinely
diverted to more distant facilities.
While demand for EMS facilities grows, the number of
facilities shrinks, and they find it increasingly difficult to
retain on-call specialists to meet standards for timely care.
The inevitable tragic result: preventable deaths as critically
ill patients literally die from neglect in hallways and in
ambulance spaces waiting for the lifesaving help that never
comes.
The simple truth is emergency care can and should be
better, but it is the legal, financial and demographic trends
that have converged to punish the success of hospital emergency
departments transformed by Federal law into a de facto primary
care provider for millions of under- and uninsured Americans.
That unfunded mandate creates powerful incentives to close
emergency rooms or limit admissions so that capacity to perform
elective, fully reimbursed procedures will not be reduced.
Low reimbursement rates and high malpractice premiums also
work to keep needed specialists, neurosurgeons, orthopedic
surgeons, and pediatricians, among others, from accepting
emergency and trauma patients.
The anemic state of emergency medical services means most
hospital centers are already operating at or near capacity
every day. A highway crash involving multiple casualties can
overwhelm not just one, but all nearby hospitals because no one
has information about the real-time availability of emergency
beds in the region.
Such a fragile, fragmented system holds virtually no surge
capacity in the event of a natural disaster or terrorist
attack. This committee has held several hearings on pandemic
planning and preparedness. A constant concern that emerged from
those hearings was the lack of surge capacity in our Nation's
hospitals.
We have made great strides in homeland security since 9/11,
but our public health infrastructure, particularly emergency
medical response capacity, is still not ready for prime time.
When the influenza pandemic erupts, as many predict it will,
more than half a million Americans could die, and over 2
million could need to be hospitalized.
How do we plan to move from the current inadequate
emergency care structure to the coordinated, regionalized,
scalable, and transparent system that we know that we need?
What is the Federal role in building and sustaining affordable
and efficient medical services? How can we link emergency care
capacity into a national response network to meet the full
range of critical care demands from the predictable to a
pandemic?
I look forward to a discussion with our witnesses today on
these difficult questions. I am especially pleased to welcome
Dr. Robert O'Connor, professor and chairman of the department
of emergency medicine at the University of Virginia. He is
widely regarded as one of our Nation's leading EMS physicians,
and we are very grateful for his time and insights as we
explore these urgent issues. Thank you.
Mr. Cummings. Thank you, Mr. Davis.
[The prepared statement of Hon. Tom Davis follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. It is my understanding that Ms. Watson has an
opening statement. Ms. Watson, you are recognized for 3
minutes.
Ms. Watson. Thank you, Mr. Chairman, for holding today's
hearing. It is so relevant to constituents in my district in
Los Angeles, the 33rd District.
We are going through a very serious crisis in our emergency
care system. A functional emergency and trauma care system is
important for all communities to deal with and respond to
disasters, and we must remember that these emergency care
centers are not only for those patients who use them on a day-
to-day basis, but they are what our Nation will rely on if a
natural disaster or a terrorist attack occurs.
This sector of the health care system is one of the most
important aspects of our homeland security. As pointed out in
the majority memo on May 19, 2007, you heard about the 40-year-
old woman who collapsed on the waiting room floor at Martin
Luther King Hospital, and her pleas for help were ignored, and
she died 45 minutes later.
This hospital serves a major portion of my constituency who
has no insurance and who does not have access to any other
means of health care. This incident was not the only one
reported at the former King/Drew Hospital, and definitely not
the only occurrence in many emergency rooms across the Nation.
What are we showing the world by letting our citizens die in
emergency rooms in the wealthiest Nation in the world?
The three Federal departments, DOT, DHS and HHS, that are
responsible for the oversight of emergency and trauma care must
start working together to make the system work better. I am
sure there is along list of oversight errors and omissions that
point to the core of many of the problems we are discussing
today. I hope that by addressing this issue, it is not too
little and not too late.
Hospitals in our Nation's urban areas have been plagued for
years. They have been underfunded for so long that they cannot
attract the type of doctors and nurses they need to run a high-
quality hospital, and, in turn, due to a poor reputation, you
limit the number of talented health care professionals you
attract, creating a downward spiral.
Mr. Chairman, having hospitals such as King-Harbor in my
community, even in the condition it is in, is better than not
having a hospital at all. The risk of getting inadequate health
care is outweighed by the potential loss from having to drive
an extra 20 minutes to get care at any other hospital, leading
to overcrowding at those other hospitals.
So I am looking forward to hearing from the witnesses, and
I hope that we can get some answers so that we can remove the
many risks that accrue to our public.
Thank you so much, Mr. Chairman.
Mr. Cummings. Thank you, Ms. Watson.
[The prepared statement of Hon. Diane E. Watson follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. What we will do now, without objections, we
will recess because we have two votes. We have about 5 minutes
left for the first vote, and then another vote will come
immediately thereafter. I anticipate that we should be back
here at quarter of the hour. Until then, we will recess.
Thank you, witnesses, for being patient with us. We will
move this along as fast as we can. Thank you.
[Recess.]
Mr. Cummings. Thank you all for waiting. We will resume the
hearing now.
The committee will now receive testimony from the witnesses
before us today. Our first panel consists of three
distinguished experts in emergency and trauma care. Dr. William
Schwab is professor and chief, division of traumatology and
surgical critical care at the University of Pennsylvania
Medical Center in Philadelphia. Dr. Ray Johnson is associate
director of the department of emergency medicine, Mission
Hospital Regional Medical Center, and director of pediatric
emergency medicine, Children's Hospital, Mission Viejo. And Dr.
Bob O'Connor is professor and chairman, department of emergency
medicine, University of Virginia, Charlottesville.
Gentlemen, would you please stand to be sworn in.
[Witnesses sworn.]
Mr. Cummings. I just remind you that we have your
statements, your written statements, and we would just ask you
to summarize within 5 minutes if you can. Then we will have
questions.
Dr. Schwab.
STATEMENTS OF WILLIAM SCHWAB, M.D., FACS, PROFESSOR AND CHIEF
OF DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE, UNIVERSITY OF
PENNSYLVANIA MEDICAL CENTER, PHILADELPHIA; RAMON JOHNSON, M.D.,
FACEP, ASSOCIATE DIRECTOR, DEPARTMENT OF EMERGENCY MEDICINE,
MISSION HOSPITAL REGIONAL MEDICAL CENTER, DIRECTOR OF PEDIATRIC
EMERGENCY MEDICINE, CHILDREN'S HOSPITAL, MISSION VIEJO, CA; AND
ROBERT O'CONNOR, M.D., MPH, PROFESSOR AND CHAIRMAN, DEPARTMENT
OF EMERGENCY MEDICINE, UNIVERSITY OF VIRGINIA, CHARLOTTESVILLE,
VA
STATEMENT OF WILLIAM SCHWAB
Dr. Schwab. Thank you, Congressman. I think rather than try
to summarize, what I might do is start with a bit of a story,
since it is a relatively recent story and something that is
very pertinent to the IOM report.
I sat for 2\1/2\ years as one of the 40 members of the IOM
Commission and spent a considerable amount of time actually
deliberating, analyzing, and trying to come up with solutions,
both tactical and strategic, to look at this crisis in
emergency care. But perhaps this story, more than anything,
will make it real for you.
Just 2 days ago I was not on call for emergencies. There is
a group of nine of us at the University of Pennsylvania,
surgeons that do all the emergency surgery and all the trauma
care. We are a Level I trauma center, we are one of the city's
safety net hospitals, and we are one of the hospitals that in a
disaster for the greater Philadelphia area--a population of
about 15 million people--would go into action.
2:30 in the afternoon, just a normal day, I had a call from
my fourth partner, also not on call, to go to the emergency
department to run a fifth room. I walked down to the emergency
department and walked through our unit, and in that emergency
department there were people everywhere on stretchers. There
were patients in chairs. The emergency physicians, our
strongest colleagues and friends, were administering to people.
And this wasn't a mass disaster, this was a fairly typical
day with the exception that we had just been notified that, in
fact, on Route 95 there was a significant crash, probably a few
mortally wounded, and other people being brought in by
helicopter and by ambulance.
I went into our trauma bay, very similar to that in
Nashville or that in Baltimore, and this three-bed unit had
five people in it, two people on stretchers who were side by
side with three other people. And as we started to take care of
the patients coming in from this terrible wreck and this
collision, we had 30 seconds' warning that the Philadelphia
Fire Department was bringing in yet another person, and that
was a trauma code. It was a young man who had received a
gunshot wound. And in the middle of that mayhem, I opened his
chest, and I started to pump his heart. I tried to resuscitate
him.
Now that is all part of our life in this business, but what
is interesting is I looked up and I recognized that as I was
doing that, about 40 feet away from me, watching me, were
people brought in for routine care and other emergencies.
What was most interesting about this is you might say that
is just Philadelphia, it is a big city, and it is like any
other city, Los Angeles, Washington, or Atlanta. But that
morning I had been on the phone thanking someone at Strong
Memorial Hospital in Rochester, NY, because last week my
brother-in-law, 63-year-old retired teacher, an All-American
football player in his prime who had lost his kidneys a few
years ago to a terrible infection, and a renal dialysis patient
for years, had just been transplanted. He was home, became ill,
and went back to Strong Memorial. But he could not be admitted,
because the emergency department had 40 or 50 people waiting to
be admitted in Upstate New York, where I grew up, in beautiful
downtown Rochester.
I couldn't believe it. But having spent 2\1/2\ years on the
IOM trying to find solutions for the government and for us to
take on the emergency care crisis, you have to believe it. It
is universal, it is a terrible problem, and it is a hidden
problem. It has been swept underneath the rug continuously, and
it may be being swept under the rug because people believe
there is no good way to solve it, and the only way to solve it
is throw money at it. I will tell you the IOM did not conclude
that, and our recommendations came after some thousands of
hours of deliberation and looking at things.
I have to also tell you that as I walked through the
emergency department, I saw teams of specialists down there,
cardiology, neurology, but the one that really frightened me
was an infectious disease specialist. This friend of mine in
the infectious disease department is a virologist, a virus
expert. And after I finished with the emergency thoracotomy,
and I was walking out to do my paperwork, I thought of all the
things I am afraid of. What I am afraid of the most is that
virologist was seeing something, and it was a virus, and that
it was sitting in the middle of our emergency department with
all those hundreds of people.
There is no way that simple solutions will fix this. This
is going to take a concerted effort.
I would like to end by saying that I am absolutely shocked
that there hasn't been more done in the past year, even just
simple communication about how we could help our government
agencies and how we can partner as health care, medicine, and
nursing to help fix this.
We do need to look at better coordination from the
government. We truly believe at the Institute of Medicine and
in our committee, that it is spread out to too many agencies.
There is no one agency that is responsible, there is no
champion for emergency care. We believe that the whole system
has to be looked at, and we believe that there has to be
substantial thought, redesign, and reengineering--not of the
system, but of things like why patients wind up in the
emergency department when they could go to primary care.
We felt that we needed to look at making hospitals and EMS
systems accountable. We just weren't going to make
recommendations to you from the Institute of Medicine that
said, do this for us. We want to make the system accountable.
And we looked for one of the best successes in medicine to fix
it, and that is the trauma system.
Trauma systems have been around for about 30 years. They
actually come from the experience we had during Vietnam, and
that military system was transformed and translated into
civilian trauma care systems. Trauma systems are regionalized,
they are accredited, they are credentialed, and they are
accountable, because they report their results to the public
and to the government. The Institute of Medicine in its
interdisciplinary committee put this at the center of the
committee report, to redesign emergency care based on regional
systems that are accountable, and they report their outcomes. I
think that is an important thing.
Last, there were two things that came about during the 2\1/
2\ years that I served in the Institute of Medicine that I
think you are aware of. One you are very aware of, and that is
the inability of the health care system and specifically the
emergency care system to respond with surge capacity for mass
casualties and disasters. If on Wednesday afternoon we had
another van or school bus crash, only the dedication and
commitment of the nurses and physicians would have taken care
of those patients, because we had no room.
You know about that. You know about that because of some of
the hearings that have taken place, that emergency care cannot
respond. We don't have the capability to do it, we don't have
the capacity to do it.
The other one that I think is quite frightening, that the
Institute of Medicine discovered, is the work force issues. If
you look beyond the emergency department, there is a tremendous
crisis developing on the surgical side to staff the in-house
care that must take place after the emergency department care
ends.
One of the biggest things that we revealed is, in fact,
after the emergency physicians resuscitate--many specialists
including cardiologists, and surgeons, are called to render
care and complete care within the hospital. The shortage of
physicians and specifically surgeons that are responding to
emergencies is concerning. And in the future, as we try to cope
with caring for about 80 million boomers, the shortage of
surgeons is a profound thing in this report that needs to be
addressed.
Thank you, Mr. Cummings.
Mr. Cummings. Thank you very much.
[The prepared statement of Dr. Schwab follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. Dr. Johnson.
STATEMENT OF RAMON W. JOHNSON
Dr. Johnson. Mr. Chairman, members of the committee. I want
to first start by giving you an idea of my practice environment
because I don't work in an inner city or a highly urbanized
area. I work in a suburban emergency department that sees
approximately 45,000 to 50,000 visits a year. We also function
as a satellite children's facility, so approximately 40 percent
of our volume are children.
I want to tell you that even in our sleepy suburban
community, which I believe is typical of almost every community
of America outside of the urban setting, I am in an environment
that continues to be understaffed. We are underfunded. We are
overworked, overwhelmed, and overcrowded.
I want to address each one of those things for you. First
of all, let me give you a story. It was interesting listening
to Dr. Schwab talk about his experience. My experience is a
little bit more profound than that, because 1 day when I was
working in the emergency department, a frantic mother brought
in a child who was choking to death and was blue, and I did not
have even a single bed available in my emergency department.
I debated for a few seconds, should I just put the child on
the floor in order to try and open the airway? I did not have a
bed. Fortunately, because of the dedicated staff we work with
in our emergency department, the nurses were able to scramble a
patient out of a bed and pull the bed over to the middle of the
emergency department hallway, where I pulled an apricot pit out
of this child's trachea.
It struck me then and there when I looked up, and you are
kind of ``adrenalinized'' at that point--you look up and see
about 30 people looking at you, most of them are patients, some
of them sitting with their gowns that are kind of open in the
back, so it makes for an interesting sight as well.
I am here to tell you that even in my sleepy community of
Mission Viejo, CA, a suburban area, there are days when I don't
have adequate resources to take care of my patients.
One of the big problems that we are facing, I think, in
this country is an explosion in the volume of patients we are
seeing. In my area, for example, we have had a tremendous
growth in population because of construction, and I understand
that we are not the only area of the country that is seeing
that kind of explosion. But one of the problems that we are
seeing is the lack of infrastructure to help support that
explosion in population growth. So as a result, we are
confronted with the issue of overwhelmed, overcrowded emergency
departments every day.
We also have a situation where we also have patients that
are literally living in our emergency department for more than
a day at a time. We have psychiatric patients sitting in our
emergency department because we cannot get resources to them or
there aren't beds in my immediate area to send those patients
to.
Most people have this misunderstanding about overcrowding
in emergency departments. I would like to dispel that myth once
and for all, here in this committee. Overcrowding in emergency
departments is not due to patients who have minor problems
coming into the emergency department. It is due to patients who
are sick, sitting in beds in my emergency department, when
there are no inpatient beds, no capacity in the hospital, to
get them upstairs. So I can't get new, incoming patients back
into my emergency department.
That means that I have to contact my charge nurse and let
her know when I don't have any beds any longer because they are
full of inpatients in my department. I have to let her know
that ambulances cannot come here. So that means, although we
are a cardiac receiving center, we have a cath lab available 24
hours a day to take the sickest cardiac patients in my
community, I cannot get them into my hospital emergency
department because I don't have a bed for them. So I have a
hospital with tremendous capabilities, tremendous talent,
tremendous dedication, and I cannot get these patients to my
facility to take care of them.
All I ask of you, all I ask of this committee and of the
Federal Government, is to help me do what I do best, and that
is save lives and take care of patients. I cannot do that
unless we have the resources.
I think the Institute of Medicine report laid it out very
clearly. We are underfunded, we don't have adequate resources.
We are talking about a surge capacity; there is no surge
capacity left within our hospital environment. By the way, my
hospital is located approximately 30 minutes north of a nuclear
power plant, and I can guarantee you if there is anyplace that
needs surge capacity, it is my facility. It just does not
exist.
Let me summarize by saying the American College of
Emergency Physicians has over the last few years brought this
to the attention of everyone we could possibly bring it to. We
have had a rally on the lawn of the Capitol, had surveys that
have been put together, and we have even introduced a bill, the
Access to Emergency Medical Services Act of 2007.
I know this is an oversight committee, but the fact of the
matter is that we are making every effort to try and come to
solutions that will help solve this problem. But, once again,
my sleepy community town is, I think, average America. And if
we are seeing the same problems that urban and suburban
environments are seeing all over this country. We should all be
very, very afraid of what is happening. We really need to do
something, and do something quickly. Thank you.
Mr. Cummings. Thank you very much, Dr. Johnson.
[The prepared statement of Dr. Johnson follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. Dr. O'Connor.
STATEMENT OF ROBERT E. O'CONNOR
Dr. O'Connor. Thank you very much, Mr. Chairman. I was
struck by the opening comments that I heard several of you
make, Congressman Davis, Congresswoman Watson, and Congressman
Cummings. I agree with everything you said, and I am struck by
the uniformity of recognition that our health care system, our
emergency health care system, is in a state of disarray.
I look back at my own career. I have been in practice for
over 20 years. I have been involved in the medical direction of
prehospital care for just about as long; the instruction of
prehospital care providers perhaps longer. I wanted to try to
tell what my views were about how we have gotten to the place
we are at today.
What I have seen throughout my career are tremendous
strides in care. We take care of patients with myocardial
infarction, heart attack right now, when we used to have no
other treatment options other than to provide comfort measures
only and not truly offer definitive care. We have made
tremendous strides in trauma care, in stroke care, and the list
goes on.
However, we are hampered by our ability to provide that
care. We have state-of-the-art technology, and yet we are
practicing in a non-state-of-the-art environment where patients
who are just hapless bystanders witness things that perhaps
they should not see in a crowded emergency department
environment.
The conditions in an emergency department, we have the
tools to provide the best care that we can. The environment is
so crowded that it sometimes creates a major obstacle to that.
I look back on my career with EMS and prehospital care, it was
sparked by funding that goes back really into the 1970's,
prompted by the National Academy of Sciences report, ``Trauma:
The Neglected Disease of Modern Society.'' Over that time, the
initial funding was at quite a high level. In 2007 dollars, it
is about $1.5 billion. It was $300 million at the time. That
has since dwindled. While a solution to the problem is not to
throw money at it, I do think increased funding for EMS would
be one possible solution.
The second part is to look at some of the funding agencies
that provide care for EMS and to see how best to spend that
money. If you look at certain EMS programs, the rural EMS grant
program exists to support training and equipment for smaller
communities. That has since been eliminated. If you look at the
Trauma Systems Planning grant, that has also been eliminated.
The EMS for Children [EMS-C] program has to continually fight
for funding year in and year out, and it is only through the
focused effort of Members of Congress that this program has
sustained funding from year to year.
Regarding one of the recommendations from the Institute of
Medicine report, it was to establish a lead Federal agency, I
have some comments in my written testimony regarding that.
There currently exists the Federal Interagency Committee for
EMS, which is the ideal body, really, to look at how to
establish a lead agency. I think it is essential that we have a
lead agency in the Federal Government, one to champion EMS
causes.
If you go back to the fall of 2001, September 11th
specifically, the public concern over our preparedness for
terrorism, mass casualty events resulted in funding for police
and fire and other agencies. EMS was notably absent from that
funding pool. While I strongly believe that we need to have
public safety--strong public safety resources such as police
and fire--I also think that EMS is in a unique position where
they work at the intersection of public safety plus public
health. In fact, EMS is the integration of public safety with
emergency health care.
So in closing, I would like to thank everyone for your
efforts. We in emergency care take pride in what we do. We, I
believe, provide excellent care to patients. We are somewhat
hampered by the resources we are given and the demands on our
time and effort. If we are given the opportunity to and the
resources to improve that care, we will welcome that
opportunity. So thank you.
[The prepared statement of Dr. O'Connor follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. I want to thank all of you for your
testimony. We will go into questioning now, and we will stick
by the strict 5-minute rule.
I would like to ask a question of all three witnesses.
Since back in 2002 the Congress has appropriated some $2.7
billion to the Department of Health and Human Services to
improve the ability of communities to respond to emergencies
that cause mass casualties. According to an analysis prepared
for this committee by the Congressional Research Service,
critics have charged the program over the years with lacking
sufficient focus to adequately direct funds in meaningful
directions, and with failing to assure that emergency health
care services will be available consistently across
jurisdictions.
Have the billions of dollars spent by the Department to
enhance--that's HHS--to enhance surge capacity for bioterror
attacks and other mass casualty events made any difference in
your daily practice? Dr. Schwab, we will start with you.
Dr. Schwab. Thank you, Mr. Chairman.
It's an interesting thing, if you look at the IOM report
and some of the data we looked at, of all those billions and
billions of dollars. If I can track this back, only 4 percent
ever went actually into the States to look at EMS or look at
preparedness.
In response to your question has any of this money affected
myself or our trauma center or the emergency department, the
answer is categorically no. I don't think we could track a dime
into the actual practice at the bedside for making our
patient's lives better.
Dr. Johnson. I would have to also say no, Mr. Chairman. I
sit on our advisory committee for HRSA funding for trauma
preparedness in California, and I can tell you that while my
hospital bought a tent, it doesn't help my day-to-day ability
to take care of patients in the emergency department who are
sitting there waiting for a bed upstairs.
Mr. Cummings. Dr. O'Connor.
Dr. O'Connor. Of the money you cited of the bioterrorism
program, less than 5 percent has gone to EMS during that time
period.
Mr. Cummings. Dr. Schwab, you describe the situation has
steadily worsened over many years. The crisis has been
extensively documented in academic studies, the news media and
even the Department's own reports. From your perspective what,
if anything, has HHS done to address the problem?
Dr. Schwab. I think one of the most important things that I
think they have done is they have listened. I wish I could say
they have reacted. On the other hand, I have been in this
business now for 30 years. Twice during that 30 years I have
seen Federal legislation that was directed specifically at
emergency, EMS and trauma, and then within a few years I have
seen actually that appropriation go away, which means that we
had money, we used it effectively, it went away, and we can't
make the sustained type of efforts.
I was very heavily involved in the late 1980's and 1990's
with HHS in designing the model trauma plan. That was 3 years'
funding that was subsequently taken away through
appropriations, and that whole effort failed, and honestly, all
of our work really went up in smoke at that time.
So I think there is a complexity here that in order for the
government agencies to respond, they have to have money in
order to do it.
Mr. Cummings. A lot of people say that money is not
necessarily always the answer. You hear that a lot up here. I
have often argued that the most important thing is the
effective and efficient use of money. And so I think that all
of you have talked about money, and I am just wondering, what
do you all see? If you could wave your magic wand and you had
the money, what would be the most effective and efficient use
of it? I will start with you, Dr. Johnson, then go back.
Dr. Johnson. First, Mr. Chairman, I would like to say for
at least my situation, unless my hospital wants to build more
beds with that money, it doesn't really help my situation. More
money doesn't help me personally in the emergency department.
What it may do, though, is allow me to get my orthopedic
surgeon to come in, because they won't come in to take care of
patients who are underfunded. So it may entice them to come in
and get my patients out of the emergency department a lot
faster.
So unless my hospital wants to build more beds, it doesn't
really help me. I will say there is no question in my mind that
there are many nurses, for example, who I can't hire for my
institution because the cost of living where I live is too
high, and the salaries are too low. So if I had that pot of
money, the first thing I would do is buy myself about 10 more
nurses to be on staff every day because that would certainly
help me take care of my patients in a more efficient way.
So, given that money, I would take care of that.
Mr. Cummings. Dr. O'Conner.
Dr. O'Conner. I think the best way to answer your question,
the best way to spend money is to use it in a way where it is
leveraged, where it amplifies the amount of money that we are
spending. I think if you look at emergency care, systems of
regionalization, a demonstration project in that area might be
one such means to do that, to look at research so that findings
in efficiency and effectiveness of care can be translated
across the entire U.S. population, to look at a means of
establishing best practices, whether it is through a
demonstration program as well.
But I would encourage, in terms of spending money--I mean,
money, if there isn't enough, I think in terms of efficiently
using it and safeguarding the taxpayers or the fiduciary
responsibility--I think to look at the way to leverage the
amount of money that is spent in terms of benefits to
healthcare would be the way to go.
Mr. Cummings. Dr. Schwab, I just want to go back to
something earlier. You talked about the trauma system and how
that might be helpful to what we are dealing with. Can you
elaborate a little bit more on that?
Dr. Schwab. Yes, thank you.
Let me go back again, because I think it is important,
because the staff has supplied you all with these references
and our written comments constantly refer to the IOM report.
The IOM Committee on the Future of Emergency Care worked for a
year trying to find something that worked for a tactical
solution, not a strategic solution. And my colleagues to my
left actually have already given you some of the successes, but
the real success in organizing regional care and delivering one
form of emergency care to life-threatened patients was trauma,
trauma systems. This has been a three-decade effort led by the
American College of Surgeons but endorsed by enabling
legislation in some 40 States to create regional centers in
which all patients whose life and limbs are threatened are
brought to those centers where emergency physicians and trauma
surgeons are waiting. They are effective, they are efficacious,
and they are cost-effective.
And that is not me saying that or the IOM, but, in fact,
the peer review literature. The most recent literature on that
topic is in the New England Journal of Medicine. It was a
national study. Some of the States were included in this study;
some were not.
In the entire national study population it asked the
question, ``what advantage to the patient whose life is
threatened does a trauma system give?'' And it was a 25 percent
reduction in mortality.
Now, we thought in the IOM that if we could use the trauma
system model as a blueprint and apply those components,
efficient and effective regionalized--not fragmented--care that
is accountable, and apply it to the emergency care system
overall, it would be a wonderful tactic to do. And going back
to Dr. O'Conner's comments, there is a strong recommendation in
the IOM to provide money immediately to set up pilot projects
to study the impact of a regionalized emergency care system.
So I think the tactical solution is there in print. It is
proven in the field of emergency care, and I think it is
doable. And if you asked me what I would do with the money, Mr.
Chairman, I would take it and I would fund those projects,
those pilot projects, but I would make them accountable for
what they are doing; and I would require them to report what
they've done--not just to our government agencies, but to you.
Mr. Cummings. Let me ask one more question, and you all may
answer this, too.
CMS has proposed a rule that would cut hundreds of millions
of Federal Medicaid dollars from securing supplemental payment
to hospitals and provide significant amounts of uncompensated
emergency and trauma care. The purpose of these payments is to
help these hospitals offset the financial losses they incur by
providing those services.
Last month, Congress enacted a 1-year moratorium
prohibiting CMS from implementing this rule. In this public
notice about the rule, CMS officials say, ``we anticipate the
rule's effect on actual patient services to be minimal.'' Do
you agree with that?
Dr. Schwab. I don't agree with that; and I have to tell
you, this was a real shocker to all of us. This was a shocker
to me; 40 to 50 percent of all the patients that my emergency
medical colleagues and I touch have their reimbursement
essentially administered under CMS. To in any way give those
patients less ability to pay us to cover our costs, many times
not even cover our costs, to me is absurd.
What is interesting about this is that CMS should be
standing up for the consumer, the patient. And this month in
Consumer Reports the back page is entirely dedicated to the
consumer in what it calls the greatest crisis in the most
threatening part of healthcare, emergency care, and it tells a
consumer how to get through an emergency department visit. For
us to think that we are going to lose more funding is
absolutely absurd at this time.
Mr. Cummings. Dr. Johnson.
Dr. Johnson. From what I understand, Mr. Chairman, it has
been reported that hospitals lose more money on Medicare
patients that come through the emergency department than some
other groups of patients. Fifty percent of hospitals report
being in the red when they admit patients through the ED that
are covered by Medicare. So I do think that CMS, if it can
increase funding for those patients, it would actually assist
in getting those patients into the hospital more effectively.
Mr. Cummings. Dr. O'Conner.
Dr. O'Conner. In terms of speaking to the hospital impact
of those cuts, as it stands now Medicare's share of transports
is greater than the share of payments. Medicare patients
represent 40 percent of the total transports, while comprising
only 31 percent of the revenue; and to have that money further
cut would increase that gap accordingly. Providers pay
substantially below their average costs even to provide routine
transport. In fact, one other aspect of this is that in
general, pre-hospital care providers are reimbursed for
transport only, not for the care or specific care that is
provided. So I think those cuts would have a dramatic and
deleterious impact.
Mr. Cummings. Thank you.
Mr. Davis.
Mr. Davis of Virginia. Thank you. And thank you very much
for what you do.
My son had a broken jaw in a Swarthmore-Haverford game. He
broke his jaw in a baseball game; and, of course, he had to
wait to get a physician that would do it because of tort costs.
But we took him to an emergency department, and I had my first
experience with Pennsylvania's rules.
Let me ask you, in terms of magnitude, I am going to get an
order of magnitude here in terms of the problems and how we can
solve it here. Tort laws play a role, there is no question
about that, in emergency rooms, mandated emergency care. We are
serving people in many cases who are either here illegally or
are uninsured and can reimburse nothing who play a role in this
and are squeezing out other people who can appropriately pay.
We have certificates of need, limited beds, and try to
allocate them in an appropriate fashion; and yet one of the
problems I hear is that we don't have enough beds in some
areas. But if they could get to appropriate certifications you
could create more beds which would be able to alleviate moving
people from emergency rooms to hospital beds.
Federal reimbursability, which of course the private sector
also pegs reimbursability now in some cases to Medicare, being
very, very low, so even if you get a patient, the
reimbursability of that doesn't always cover the cost. And when
you add in the uninsured and everything else, it creates a huge
problem; and the ability to attract and retain good people,
whether doctors, where we still have a shortage, or nurses.
As you rank all of these, all of them have a Federal
component. What do we do? How important is each one or are some
of them really red herrings or are they all important in terms
of trying to get an understanding or our arms around this
problem?
I'll start with you, Dr. Schwab.
Dr. Schwab. You are just picking on me because your son was
playing in Pennsylvania. [Laughter.]
Let me say this. They are excellent questions. Each on its
own we could spend a fair amount of time, and I think you have
to dissect and drill down and look at how it affects emergency
care. I want to start with the first one you mentioned, if I
could, sir, and that is tort reform.
One of the things in the last 10 years, including the major
crisis in Pennsylvania trauma centers just a few years ago that
Governor Rendell handled beautifully for us, was blamed on
malpractice. If one tries to ascribe that tort reform will
solve the crisis in emergency care, I would say that it is not
fair. That is a much bigger issue. However, where it affects us
is that there is no consideration of our malpractice risk, our
malpractice premiums, for delivering care to an emergency
patient versus that patient in which you have established a
doctor-patient relationship.
And what is interesting about that, again, in the report,
if you look at it, the majority of the patients are life
threatened, many of which cannot speak for themselves, comas,
hit in the head, having a heart attack or stroke. We can't get
information about them. We have no information about them, yet
we are required to treat within a matter of seconds.
I knew nothing about this man whose chest I had to open. I
didn't know his allergies. I didn't know his medicines. I
didn't know anything. I didn't know if he had diabetes. I
didn't know anything. But I had to do something, as do my
colleagues sitting next to me.
But what is interesting is my malpractice is exactly the
same. I get no benefit for doing that. I get no recourse from
that, and I am at extremely high risk if one goes ahead and
tracks malpractice complaints into emergency care. They are
very high.
So I haven't answered your question comprehensively, but at
least your first topic, what we say in the IOM report is that
there needs to be a study done immediately to look at some way
of relieving the physicians and nurses that are applying or
giving emergency care. And by that, we defined and said we
should define what an emergency episode is and in that episode
we should go ahead and look at how the government may excuse us
from some of the malpractice burden we carry if we truly are
delivering life-saving care.
Mr. Davis of Virginia. Everybody thinks reimbursements are
low, and that drives a lot of this as well, the uninsured. I
appreciate your answer.
Dr. Johnson.
Dr. Johnson. Some things CMS can do to help alleviate some
of the problems. They are a very powerful organization because
they hold the purse strings, and hospitals do whatever they can
to try to get ahold of those funds. I think CMS can use its
purchasing power to get hospitals to probably move patients
upstairs by creating financial incentives to reduce crowding.
If hospitals achieve high efficiency and get patients out of
the ED in an efficient way, CMS can be rewarded by CMS for
doing that; and if they are not, they can also raise a big
stink, so to speak, to be penalized for not moving patients out
of the ED.
For example, we have observation codes that CMS could
expand upon to provide additional funding. We can now put
patients into areas of the hospital where we can observe them
and not require full hospital admission. That actually might
save money in the long run for the system.
Finally, I do think you probably are aware that there are
many different types of patients that hospitals can put into
beds upstairs. Some of those are nice elective surgeries where
it is certainly predictable how long they will be in the
hospital and how much it is going to cost them, and it seems
CMS is more than happy to pay a certain fee for those patients.
But when you have an emergency department patient who is very
ill, the hospital cannot collect enough money to cover their
costs. So if CMS were to expand and prioritize emergency
department patients over those nice elective, predictable
patients, that actually might get patients into beds a lot more
efficiently and open up emergency department beds.
Mr. Davis of Virginia. Let me talk to you on the tort side,
because Dr. Schwab makes a case. You probably know less about
your patients than anybody else when they come in. You have to
make life-saving decisions based on limited information, and if
it is the wrong decision you are going to see it in court and
you are going to have to revisit that decision. Is the standard
pretty tough for emergency room? What has been your experience?
Dr. Johnson. To be perfectly honest, there is a tremendous
amount of defensive type of medicine that is practiced in the
emergency department. There are many things that we do knowing
full well that we are just covering the bases, so to speak, and
probably not as important in the care of the patient. If I had
some relief, some liability protection, I think that I could
also practice in a more efficient way, absolutely.
Mr. Davis of Virginia. Thank you.
Dr. O'Conner.
Dr. O'Conner. In terms of liability protection, many of the
services are protected to the level of gross negligence. Maybe
one such model is to look at emergency care in its total as a
means to overcome this problem.
In terms of your question, there are staffing issues; there
are hospital issues.
Mr. Davis of Virginia. Gross negligence is a much higher
standard of negligence to show. It would give you some relief
in not having to do some of these defensive mechanisms. Is
there a consensus on that? That is an easier standard for you
to operate under, at least.
Dr. O'Conner. It is, yes. Also, I never would have thought
that EMS pre-hospital work would be impacted by things such as
nursing home placement, things on the other end of healthcare.
In looking at the magazine cover that is now 6 years old,
Crisis in the ER, and it really is a crisis in the healthcare
system. I think our current admission and discharge process
from the in-patient setting is broken. And it is reflected by
the overcrowding stories that we have heard, it is reflected by
ambulances that have to be diverted, thereby creating a problem
in a second hospital that they divert to. Ambulance diversions
are particularly problematic because they tend to cause a rapid
downward spiral of the entire system in the region.
So I think, in answer to your question, it is not a simple
thing to answer. I think that, as a first step, we may want to
try to understand the problem a little bit better.
Mr. Cummings. Mr. Yarmuth.
Mr. Yarmuth. Thank you, Mr. Chairman.
I want to get at that topic a little more extensively. I am
trying to get my arms around--and I know it is hard to
generalize across the entire country in all sorts of different
communities--to what extent this is a total patient capacity
problem and, therefore, more of a method of dispersion problem,
as opposed to just an emergency room capacity problem. Dr.
Schwab, do you want to start?
Dr. Schwab. Thank you.
Let me just say the difficulty here is--if I can just have
you think about a large geopolitical area. So you have a
metropolitan service area, suburban area and a rural area.
There are a certain number of hospital EMS units, emergency
departments that render care for their citizens. There is no
doubt that there is a disbursement or a fragmentation problem.
And again in the report, we identified that and said one of the
things that could really help deficiencies is if we design this
regional emergency care system that includes all components of
that care system, from the rural ambulance care up in the
mountains versus the ones in the city, all talking
electronically and in real time so that we can take people to
where there are open beds. Thus the term regionalization.
But then there is also a problem in that we have to look at
how those hospitals that are getting patients--and especially
if the patient needs specialized care, cardiac, neurologic,
trauma obstetrical or pediatric--that those centers that
function as the regional emergency care centers are in fact
enabled through proper funding and proper resources to maximize
their efficiency and be able to move patients through.
Dr. O'Conner just mentioned he never thought that the
nursing home would affect the EMS. I can tell you every day we
have now continuously dedicated very high-level nursing and
administrators who are helping to get people out to skilled
nursing facilities, rehabilitation so we can take more people
in. It is all connected, Congressman.
But I think what you have to look at is, again, how you
might design this regionalized system which would help us
disperse people better, but not lose sight that not all
hospitals can deliver all types of care.
Mr. Yarmuth. To what extent--and maybe Dr. O'Conner can
address this--to what extent do you believe that the
competitive aspect of institutions exacerbates this problem?
I know in my community we have several very highly
competitive hospital entities who most not-for-profit now, but
we know that means in the healthcare business mostly
nontaxpaying don't make profits. I am curious as to whether you
have done an analysis of how big a problem that is in this
context.
Dr. O'Conner. I can give you some examples.
Locally, we established a--again I won't name the locale--
pre-hospital, 12-lead program to identify patients with heart
attack, with acute myocardial infarction in the pre-hospital
setting, so they can go to a place where they can receive
angioplasty if necessary. But we found tremendous resistance
from some of the smaller hospitals which perceived a potential
competitive disadvantage of taking care of all patients,
including heart attack patients.
I went back to them with data that showed how many patients
this involved. It was a small number and I pointed out they
were the type of patients that were being transferred out
anyway. And the hospitals understood this, so they were more
accepting.
We started the program, and it has been very successful. I
say this because if you can educate the administration of these
other hospitals, they will realize that it is not really a
competitive disadvantage. In fact, what you are doing is saving
a secondary transfer or taking patients who are too sick for
that hospital or require services that cannot be rendered by
that hospital to a more appropriate facility.
Mr. Yarmuth. One quick question, and anybody can answer.
We talked about this regional approach, and I understand
that would be very important here. To your knowledge, is any
region or any community in the country doing a good job at
this? Are there any models we can look at to try to roll out
across the country?
Dr. Schwab. Well, I don't want to play to your chairman,
but the model that occurs in the State of Maryland is an
excellent model to look at. As far as trauma systems go, the
model in San Diego. And as far as models in emergency medical
services [EMS] coordination, the greater Pittsburgh regional
area is well-known.
To go back to the question, how would you use your money,
what we need to do is formally study those systems and see what
the best practices are, again, for efficacy, efficiency, and
effectiveness, and make sure that that is not just our feeling
but in fact we can prove that to the country and to our
citizens.
Mr. Cummings. Thank you very much.
Mr. Issa.
Mr. Issa. Thank you, Mr. Chairman.
Dr. Johnson, welcome. I apologize that I no longer
represent Mission Viejo, but redistricting was not kind to me
in my loss of Orange County.
Governor Schwarzenegger has proposed in your home State, in
our home State, a broad, sweeping universal coverage initiative
that requires that employers either take fiscal responsibility
for their employees or pay a 4 percent fee that would go into a
pool to help fund those activities which are necessary as a
result of their failure. And emergency rooms, obviously, become
the first choice of people who have no formal health coverage.
In Orange County if, in fact, we were able to accomplish
that through private means to ensure that every individual had
either State coverage, if they were unemployed or indigent in
some other way, or company coverage, back door, front door,
depending whether or not an employer provided that care or paid
the 4 percent, how much would that change what you see at the
emergency room in yours and neighboring hospitals?
Dr. Johnson. That is an excellent question. Let me answer
that by saying, since 1993, the number of patients visiting the
emergency department has arisen to 115 million visits a year,
and most of those visits are patients who are insured. They are
insured. So it is not a question of not having funding and
going to the emergency department because it is a place of last
resort. It is a question of not having access to primary care
capabilities within the community; and, as a result, the
emergency department becomes the facility where they are forced
to go because they can't get in to see their physician. Or,
worse, they go to see their physician who decides you must go
to the emergency department. In that regard, whether there is a
universal coverage in California or not, it probably would not
change the situtation in our particular environment of Mission
Viejo.
Mr. Issa. So how do we reverse that? I realize it is a
wealthy community in the center of the greater LA, Orange
County, San Diego megalopolis. So if it can be fixed, and a
suburban well-to-do neighborhood would seem to be the easiest
place to fix it, how do we make those changes to get people to
the front door of an urgent care center or to the front door of
routine medical treatment through a normal relationship and not
at your emergency room door?
Dr. Johnson. Well, once again, given the reality that most
of the patients who actually come to the emergency department
are absolutely sick and actually need to be there, we actually
see a very small volume of patients who have minor problems
that really do not need to be in the emergency department.
Unless we are willing to build another hospital in Mission
Viejo, CA, we are not going to solve the problem.
Mr. Issa. When you say ``sick,'' do you mean life-
threatening, immediate injury, or----
Dr. Johnson. Life-threatening admission.
Mr. Issa. And what percentage did you say that was?
Dr. Johnson. Between 20 and 30 percent of the patients who
present to the emergency department there of Mission Viejo
require admission.
Mr. Issa. Twenty percent.
Dr. Johnson. Twenty to thirty percent.
Mr. Issa. What about the 80 percent?
Dr. Johnson. I would say the remaining 70 percent, at least
half of those patients require being seen in the emergency
department and probably receive care within 2 hours.
Mr. Issa. What did we do in our society that created this
huge rise?
Dr. Johnson. Lack of primary care access is driving a lot
of it. I think patients are waiting until they are sick before
they seek healthcare.
Mr. Issa. So they are insured, well-to-do, in a suburban
neighborhood; and they are not going to primary care because
there is no access.
Dr. Johnson. Correct. If you call your physician and say
you need an appointment to be seen because I have a cough and
they say I will see you 3 weeks from now, that doesn't work.
Then you wait a week until you have pneumonia and then go to
the emergency department.
Mr. Issa. I guess I will ask one more time, because this is
an area I want to shed light on. It is your neighborhood that I
missed. Because if anything can be fixed, it can be fixed in
southern Orange County because means are there. You are saying
we need more doctors so doctors don't say come in 3 weeks. What
really will change that? Do we need urgent care? Do we need
community clinics? Tell me what we need in one of the richest
geographic areas in the country that we don't have and why.
Dr. Johnson. There is no doubt the entire healthcare system
is broken. I think all those things are possible solutions. I
do think we can expand our emergency department capabilities to
add more observation capability, for example, and keep patients
out of the inpatient service but require some prolonged level
of care, perhaps in between the inpatient service and the ER.
Mr. Issa. The day before yesterday I was with Michael
Moore, the maker of ``Sicko;'' and the group I was with, I was
the only person that wanted to preserve the private care
system. Everybody else in that room, from Mr. Conyers on down,
they wanted to have a single-payer, government-driven system.
And I have to ask you, do you know of a single-payer,
government-led system that would fix this? And what is that
model, if one exists?
Dr. Johnson. I think any model that we create in the United
States of America will be unique to this particular country. I
don't think we can look to other models to be the only model
that is available. I think we will have to try to find our own
model that will work for most of our citizens.
Mr. Issa. Anybody else want to weigh in on that?
Dr. Schwab. If you'll think of Philadelphia as Orange
County.
Mr. Issa. I love Philadelphia. You had a great convention
for us there, and I was there just a few weeks ago. Except for
the heat, the humidity, if you are on the 19th floor and you
look out, it does look like San Diego.
Dr. Schwab. In short, I don't think one solution fits all.
I will go back again to the IOM report. We looked at this.
And specifically what we said with no doubt, including one of
our recommendations, is we have to increase access to primary
care in all aspects of the population. Because, according to
the analysis, if you look at those 114 million ED visits, a
huge percentage of those, maybe not where Dr. Johnson
practices, are for non-life-threatening emergency chronic care
conditions for people who can find care in no other area. And
in Philadelphia, in our hospital, that is a huge part of our
emergency medical faculties' burden.
Mr. Issa. Thank you, Mr. Chairman, for the indulgence.
Mr. Cummings. No problem.
Let me just say this. As I listen to the testimony, it is
frightening. When you think about an area like, for example,
where you operate Dr. Johnson, to have the kind of problems
that you just stated is amazing. Then I guess it quadruples in
an area where you are from, Dr. Schwab. Is that a fair
statement?
Dr. Schwab. Yes, it is.
Mr. Cummings. Mr. Cooper.
Mr. Cooper. Thank you, Mr. Chairman.
John Maynard Keynes once said that we are all the slaves of
some defunct economist. I would like to suggest that we may be
somewhat the slaves of the major Federal intervention in this
area in the last several decades, the EMTALA law. When you see
graphs like the ones we have been presented with where patient
demand is going up, up, up and the number of emergency rooms
and emergency capacity is going down, down, down, there is a
fundamental problem. Because any regular economic system when
demand goes up, supply goes up. So, thinking strategically for
a moment, I think that what we really need here is a
recognition of the role that money plays.
Mr. Issa questioned why in a rich community there is a
shortage of primary care. Well, it is pretty well-known, at
least at the elite medical schools, no one wants to be a
primary care doctor, because being a primary care doctor pays
much less than being a specialist and the work is often more
difficult and carries other risks.
You get what you pay for, and you don't get what you don't
pay for. You also don't get what you mandate without funding.
And if we had a third panel of hospital administrators, the
people who actually allocate resources between the grass roots
and 60,000 feet, I think most of them will tell you, whether a
nonprofit or for-profit hospital, that the ER business is a
very bad business to be in.
That is why new-fangled hospitals, specialty hospitals
oftentimes don't even include an ER. And that is why, in a
celebrated case that I am surprised hasn't been mentioned, in a
Texas specialty hospital they had to call 911 from the hospital
because they had no emergency capacity within the hospital.
So it seems to me that if you look at programs like
Medicare or Medicaid, the truth is they really don't pay enough
for the services received, and they haven't for years. And
everybody knows that, but we don't do anything about it. And a
couple billion dollars here or there isn't going to solve the
problem because the problem is so immense, you know, these
specialty problems, because bioterrorism or things like that
are fashionable at the moment, they are little more than Band-
Aids for the needs that you have.
When the government wants to tackle the problem, it can.
None of you are old enough to remember the old Hill-Burton
hospitals that were built pretty much nationwide after World
War II because we needed more hospital capacity.
Well, today, we need more ER capacity. And especially that
surge capacity that many of you have alluded to is extremely
expensive. Because, by definition, surge capacity is not used a
good bit of the time; and you have to pay for all these
resources to be on hand when they are not used.
But think of this analogy. With fire protection, it costs
you more the farther you live from a good fire department. We
may be reaching the time where health insurance will cost you
more the farther you live, the less able your local ER is.
Because I think Dr. Schwab mentioned a 25 percent risk or
increase in mortality if you don't receive proper emergency
care.
Dr. Schwab. Proper trauma care.
Mr. Cooper. So these are serious issues that will take far
more than this committee's resources to deal with.
I would like to suggest that fundamentally it is an
economic problem; and yet physicians, others who are not
trained to think in those terms--but solving them I think will
take an economic solution.
So I have used up my time, Mr. Chairman, but it is more of
a statement than a question, anyway.
Mr. Cummings. You actually have about a minute, because the
timer malfunctioned.
Mr. Cooper. Timer malfunction. Well, I would welcome any
response that you all have. I just say it is more of a
statement than a question.
Dr. O'Conner. If I may very briefly, I think your comments
are right on target. We are in many ways--I am very comfortable
with EMTALA, because I treat any patient who comes in. I have
to say that is the way I like it. I look at the curves in the
reports.
Mr. Cooper. EMTALA has two parts, the requirement that you
see everyone and then also no pay for some.
Dr. O'Conner. Yes. I was going to say when EMTALA was first
enacted, I was talking to a leader in the health insurance
field who said I am not paying for a medical exam. There is no
reason I have to. That has, of course, softened somewhat. I was
struck by that stance.
I think if you look at the number of visits in emergency
care, in many ways, we are victims of our own success. A
patient can get a very elaborate work-up in a very brief period
of time. A similar work-up as an outpatient would take days to
weeks. So I think that is part of the explanation for demand.
Even if we had something along the lines of universal health
coverage, demand would still be quite high. That would be my
opinion.
Mr. Cummings. Mr. Murphy.
Mr. Murphy. Thank you very much, Mr. Chairman.
Thank you all for being here today.
I spent 4 years as the chairman of the Public Health
Committee in the State of Connecticut; and part of the reason
that I sought a seat here in Congress was that it was pretty
apparent that this wasn't going to be a 50-State strategy, that
there needed to be a central solution to the issue of
overcrowding in the ER.
I want to ask the three of you sort of an unfairly simple
question. It strikes me, as we are talking about potential
solutions here, that there are sort of three areas in which you
can focus your efforts.
First, you can focus your efforts on trying to prevent
people from getting to the ER in the first place, either
through greater access to primary care or through trying to
broaden those who have insurance.
Second, you can focus on the ER itself, greater resources
there, greater coordination between sites.
And, third, as Dr. Johnson noted, you can expand the
ability to move patients out of the ER. You can broaden and
expand the capability of hospital inpatient services, i.e.,
sort of open up the potential to move patients out more
quickly.
I guess it would be helpful for me at the very least to get
a sense of how you might prioritize those three approaches. If
we had to focus in one place first, second and third,
preventing people from getting there, making the process itself
in the ER more efficient or, third, trying to open up capacity
to get people out of the ER, how might you recommend us
approaching that? Or is there a fourth that I am missing?
Dr. Johnson. I would certainly recommend the final
recommendation which would be to open the capacity by ending
the boarding of admitted patients in the emergency department.
By ending boarding and opening beds in the emergency room, all
of a sudden you solve the problem of ambulance diversion. You
basically allow patients to be seen in the ED. If they have no
access to primary care, we are more than happy to take care of
them there. Most emergency departments have figured out that if
patients have minor problems they can wait in the waiting room
for who knows how long or be seen in another area where minor
care cases can be seen efficiently. But once you at least have
bed capacity in the emergency department you can do what you
are there to do, which is to save lives; and getting those
boarded patients out should be the No. 1 priority, I believe.
Dr. O'Conner. I would agree that the third priority is the
key of increased capacity. Because, without it, it doesn't
allow for improved efficiencies within the department.
I think a lot of the inefficiencies that occur in the
emergency department now are directly attributable to patient
boarding hours, where staff will take care of patients who are
normally in the inpatient setting.
As far as keeping patients who don't belong there out, I
think just by waiting times and the crowding issue, we sort of
do that already. We have looked locally at some of our EMS
transports, and patients with seemingly minor complaints such
as a headache ``self-triage'' with higher acuity if they call
EMS. Or if they come to the emergency department, as opposed to
an urgent outpatient clinic, they tend to be sicker, tend to
have a more serious illness than if not.
Mr. Murphy. Let me ask one last question, and that is the
issue of psych patients. One of the greatest capacity issues
for inpatient beds in Connecticut is our lack of inpatient
psych beds, adult psych beds in particular. How much of a
problem right now is the lack of capacity on the back end to
get psych patients, both juvenile and adult, out of the ER and
into a more community based system of care or an inpatient
system of care?
Dr. Johnson. A single word: Huge. In my department, for
example, one to two patients a day that come into my department
are psychiatric patients. Even after we have done all the
medical screening, they can potentially sit in my emergency
department for a period of time from hours to literally up to
24 hours and supposedly get admitted into my hospital if there
is bed capacity. But they have actually lived in my emergency
department for a couple of days before we can get psychiatric
personnel to come out and evaluate them to find a bed to place
them in.
Sometimes there may not be a bed to place them; and, as a
result, they will have to stay in the emergency room if they
are a true high risk before we can actually stabilize them or
have an evaluation of them to be seen or to be sent home or to
another institution.
So psych patients are a huge problem. I would love to talk
to you after the hearing on ways we might be able to solve
that, but this is a huge problem confronting emergency rooms
all over the country now.
Mr. Cummings. Thank you.
Let me ask a question quick. If you had to relate our
emergency systems using hospital terms like ``intensive care''
or ``a critical condition''--you know the various terms you all
use--how would you all describe it?
Dr. Schwab. I would say it is life-threatening or
resuscitating on a day-to-day basis, and it is going to die if
we don't fix it. I don't know if that is hospital terms or not.
Mr. Cummings. It sounds pretty hospital terms to me, but it
sounds almost like funeral home terms, too.
Dr. Schwab. Let me just go on and say I meant what I said
before. If it wasn't for the dedication of the nurses, the
paramedics and the physicians that struggle with this on a day-
to-day basis, this system would have broken already; and that
was the conclusion the Institute of Medicine's report.
Mr. Cummings. Dr. Johnson.
Dr. Johnson. Mr. Chairman, I believe that you are looking
at the proverbial canary in the mine right now. You are looking
at him face to face. Because I am here to tell you that when I
take my last breath in that emergency department it will be
when the system completely falls apart, and I am on my last
breath right now. So we are the canaries, the emergency
physicians and the nurses and the personnel. I have had some of
my best nurses leave my department, which is I believe one of
the best departments in California, to go to other areas of the
hospital like the cath lab where they can get paid the same
salary for half the work.
Dr. O'Conner. In terms of what is acceptable to the staff,
situations that used to be considered bad days, tough days at
work are now routine; and the threshold to which some of the
days rise is appalling.
Mr. Cummings. Mr. Sarbanes.
Mr. Sarbanes. Thank you, Mr. Chairman.
I had the privilege for almost 20 years to represent as my
prime clientele community hospitals in Maryland and the region,
probably 25, 30 hospitals over the course of that time. So this
problem is one that I am very familiar with from all sides, and
it is almost impossible to overstate it. You are trying your
best here to do it in ways that will get our attention, which I
think you have, but hopefully a broader attention.
Dr. Schwab, you said ``the patient may die'' when asked to
assess this system using those kinds of terms; and, Dr.
Johnson, you said that the system--you are holding on before
the system completely falls apart. What does that look like?
What does this system look like when it dies, when it
completely falls apart? What is the prospect down the road that
we can look back later to the testimony in this hearing and
say, well, this is not a surprise to anybody. I mean, we
predicted this would happen.
This is the fundamental human problem of if A, then B, and
if B, then C, but for some reason we can't get it together to
have a minimal amount of foresight. So what does it look like
when the system dies?
Dr. Schwab. Let me tell you about my Wednesday afternoon,
which is a pretty typical day. What you probably don't know is
that we are the most frequently closed trauma center in the
State of Pennsylvania. We are closed nine times more than any
other trauma center in the State because of volume. So I see
this doomsday picture you are asking me to give. I see it
momentarily.
Because what happens is we close, ambulances are diverted,
ambulances go to other centers, some are not trauma centers,
there are no surgeons waiting. And ultimately what happens, I
think, if we can ever prove it and would dare to prove it, is
patients die. If the emergency system falls apart, rather than
that being episodic throughout a day, it is going to be
continuous; and it will be some kind of terrible movie that I
don't want to ever think about.
But it is happening now in our largest cities and even some
of our suburban areas. It happens. People are diverted. And
there is now an excellent study to show that people, other
patients don't do well with diversion. They die while they are
being diverted.
There are also now studies, one of which is now coming out
of the University of Pennsylvania, which shows that if
simultaneously on an overload condition everybody is busy, you
are doing major trauma cases and yet another cardiac code comes
in, there is data to show that those patients don't do as well
either. Why? Because everybody is busy.
Think of O'Hare International Airport on Friday afternoon,
a terrible thunderstorm and all flights are canceled, what it
is like. It is mayhem.
Mr. Sarbanes. You conjure up an image in my mind where,
ultimately, diversion is straight to the morgue. That you are
going from one hospital to one hospital to one hospital and you
can't get in; and eventually, you know, you just pass it by and
you go straight to the morgue. That is what I am hearing here.
Dr. Johnson. In your scenario, what would probably happen
is that a patient would stay in the ambulance until they
reached a point where they would die, and then the ambulance
would have the ability to upgrade the patient to a ``code''
status and go to the nearest facility, regardless what the
status would be, whether they are open or closed. So patients
eventually do have a finite period of time which they can ride
around in the ambulance.
I will tell you what will happen in your scenario. It will
be a very slow, incremental collapse of the system, beginning
with the loss of subspecialty capability. So neurosurgeons,
orthopedic surgeons, hand specialists, they will eventually be
gone from those facilities. And what would happen is you would
lose them in your rural areas, for those who have that
specialty backup already, and then you will lose them from your
suburban areas and consolidate them in fewer and fewer
facilities, leaving more and more facilities without any
subspecialty backup. Which means if you come in with something
other than what I can handle as an emergency physician, if you
require plastic surgery or if you need a hole drilled into your
skull to relieve pressure from blood building inside your head,
that would not happen and you would, of course, then die in my
facility because I would not be able to transfer you anywhere
and I would not have the specialty backup in order to take care
of you.
So that is how it would happen. The lack of subspecialty
services would mean that patients would die at the institutions
they were at.
We would foresee increasing ambulance diversion to the
point where you would have some facilities that would have
ambulance diversions continually. I know in my area there is a
rule in the Los Angeles area that if you are on diversion for
so many hours you have to be off an hour before you can go back
on. So it would be on diversion, off diversion, on diversion,
off division.
Mr. Sarbanes. You are describing an emergency diversion
system, not an emergency care system. I appreciate you being
candid about this. Let's talk about a solution.
I am out of time. Thank you, Mr. Chairman.
Mr. Cummings. Thank you, Mr. Sarbanes.
There are a lot of people dying, aren't there? I am basing
it on what you all just said. There are people dying that don't
have to die.
Dr. Schwab. That's correct.
Dr. Johnson. Yes.
Mr. Cummings. Ms. Norton.
Ms. Norton. Thank you, Mr. Chairman.
This is an important hearing. I am here not only as a
member of this committee but as a member of Homeland Security
Committee. I am here also as a representative of a big city in
the post-9/11 period, one might say of a big city in the post-
9/11 period where you have to think about EMS. And there is a
lot of thinking about it, but I don't think enough thinking
about what the Federal Government's responsibility is to EMS
ambulance services.
Taking a point you make, Dr. O'Conner, in your testimony
about the funding of EMS ambulance services. Looking to more
than 30 years ago, 1973, this was a clear priority because we
funded $300 million to advance EMS services nationwide, is that
correct?
Dr. O'Conner. Yes. That was in 1973.
Ms. Norton. Now, in real terms, you show a kind of
priority. In real terms 1973, that amount of money would be
$1.5 billion today.
Now, let's look at what you are coping with now. The block
grant program, the whole thing has been block granted. That
happened in 1981. What we are seeing is the devolution of this
whole mission. As I understand it, the block grant program
provides these EMS services to only 16 States and only $8
million. We are talking now the equivalent of $1.5 billion 30
years ago. $8 million out of $9 million that we appropriated,
but only $8 million of it for EMS services.
Now, as I understand it, the Bush administration wants to
eliminate the block grant altogether. Now that would mean the
$8 million would be gone, would it not?
Dr. O'Conner. Yes, it would.
Ms. Norton. In 2006, the committee notes that the Bush
administration zeroed out the small community ambulance
development and trauma EMS programs that was once run by HHS.
We are awfully concerned here about isolated rural communities,
and without community ambulance service I don't need to tell
experts like yourselves what the effect of that would be. Now
the only HHS program that I could find that still supports EMS
services at the Federal level is the EMS for children, called
the EMSC program, is that not correct?
Dr. Johnson. That is correct.
Ms. Norton. Now the signature issue for this administration
is homeland security. We are talking about emergency services.
This gets to be very serious. In the last three budgets, we
could not find--what we did find was the administration had
proposed to zero out even EMSC programs, is that not correct?
Dr. Johnson. That's correct.
Ms. Norton. We talk about a nonexistent program. Can you
explain how over 30 years we have gone from a priority for EMS
services through the Federal Government to essentially the
decline and fall of such services? I mean, how could that
happen? Have States been clear about the importance of these
services?
In post-9/11, Dr. O'Conner, you are from Virginia, close to
where we had the worse trauma, second only, of course, to New
York, how could this disconnect continue to get to this point?
Dr. O'Conner. There has been a slow decline over 30 years.
The initial money started up what we now know as pre-hospital
care and EMS. That was largely successful. In fact, it was
money that most would argue was extremely well spent. It
allowed the establishment of State EMS offices and really
created the medical care that we know today as pre-hospital EMS
care.
What has happened since then is there has been a transition
of funding to different areas that has resulted in it becoming
a very easy target to zero out EMS programs. I would just hope
that the administration would reconsider some of these
decisions.
Ms. Norton. So if it wanted to eliminate something and you
were receiving the money, was this considered more a State
issue and not a Federal issue, do you think, so the money could
be stolen from here as opposed to other places?
Dr. O'Conner. I think some of it has to do with the
fragmentation of EMS. There is not a single go-to lead agency
that can oversee where the money goes.
Ms. Norton. Would folding it into the block grant--was that
the beginning of the end of the program?
Dr. O'Conner. In retrospect, yes. I didn't know that at the
time.
Ms. Norton. Do you think that this program should be a
stand-alone program?
Dr. O'Conner. I think that all of emergency care would fair
better as a stand-alone program. This is not just about EMS. It
is about everything we do in unscheduled care for emergency
problems. I think if the sum total of emergency care were a
stand-alone agency, it would help for sure.
Dr. Schwab. If you are asking me about EMS alone, I think,
once again, my comments have always been to look at the
emergency care system comprehensively, a lead agency or a
coordinating body with the authority of responsibility and
continuous appropriations to help us solve these problems.
Ms. Norton. And you think EMS would receive the proper
priority within emergency care?
Dr. Schwab. I absolutely do. In the IOM report, we actually
call for that. One of the three reports is about emergency
medical services, and we need to fund them adequately to do
their job.
Mr. Cummings. The gentlelady's time is up.
Let me say as we summarize and we move onto our next panel,
the gentlelady, when she opened her questioning, she talked
about homeland security. And I was just curious, if we had a
Madrid-level bombing today in D.C., for example, what would
happen? Would we be able to take care of folks?
Dr. Schwab. America has always been good, Congressman, at
rising to the occasion, no matter what it was. So would we be
able to take care of them? The answer would be, we would. The
question is, who would suffer? Because we have to put all of
our resources taking care of those that are involved with that
type of bombing. Where would we divert our ambulances, where
would the children go, and where would the routine myocardial
infarction, heart attack, stroke victim go while we were
overwhelmed with that?
Mr. Cummings. So there is no capacity, really, no extra
capacity.
Dr. Schwab. There is no extra capacity. That is very clear.
It is frightening because, because of our emergency departments
being overloaded with routine patients and trauma patients and
whatnot, it occurs on a day-to-day basis already. So adding on
a disaster like that would just overwhelm the system.
Mr. Cummings. Dr. Johnson.
Dr. Johnson. I would echo that as well, Mr. Chairman. I
think that in the beginning when the Federal Government created
moneys to be used for bioterrorism protection, what it didn't
do was figure out if we would be much more at risk of a routine
bombing. As we started down the road of buying tents and
preparing for pandemic flu, we have yet to deal with the day-
to-day environment of not having enough trauma surgeons, not
having enough resources in our everyday emergency department
that is already overwhelmed.
Dr. O'Conner. At this time of day in every emergency
department in the United States there is no capacity, so a
Madrid-level bombing would completely overwhelm the system.
Mr. Cummings. Thank you all very much. Your testimony has
been chilling. It is very, very helpful. Thank you very much.
We'll call our next set of witnesses: Dr. Kevin Yeskey and
Dr. Walter Koroshetz.
As you all come forward, I just want the committee to know
the committee also invited Dr. Leslie Norwalk, the Acting
Administrator of the Center for Medicare and Medicaid Services
for EMS to testify on behalf of her agency. She has declined to
appear citing schedule conflicts. She also has declined to send
any other CMS official to represent her agency.
This is highly unfortunate and, frankly, inexplicable and
inexcusable. The programs administered by CMS play a major role
in the financing of our healthcare system, including medical
care and emergency care. Indeed, all patients admitted to a
hospital through the ER, over three-fifths are covered by
Medicare or Medicaid. Because lack of adequate financing is one
of the factors contributing to the Nation's emergency care
prices, the testimony of CMS is critical to a full assessment
of the Department of Human Health and Human Services' response
to the emergency care crisis.
Our staff was informed that Ms. Norwalk's schedule did not
permit her to attend. However, CMS has 4,328 full-time
employees. It is difficult for us to understand why she could
not be with us today. So the Office of the Assistant Secretary
for Preparedness and Response, which is represented here today,
has only 222 full-time equivalent employees. This is just 5
percent of CMS's staff capacity.
Chairman Waxman shared these concerns with Ms. Norwalk in a
letter sent earlier this week. I ask unanimous consent a copy
of that letter be included in the record at this point. Without
objection, so ordered.
[The information referred to follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. This afternoon the committee will send a
letter to Ms. Norwalk posing a set of questions regarding her
agency's response to the emergency care crisis. We look forward
to complete and truthful responses to these questions by the
close of business on Friday, June 29th. I ask unanimous consent
that those responses be included in the record as well. No
objection, so ordered.
[The information referred to follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. Thank you very much, doctors. Would you
please stand.
[Witnesses sworn.]
Mr. Cummings. We will first hear from Dr. Kevin Yeskey, the
Director of the Office of Preparedness and Emergency Operations
and Acting Deputy Assistant Secretary in the Office of the
Assistant Secretary for Preparedness and Response at HHS.
STATEMENTS OF KEVIN YESKEY, M.D., DIRECTOR, OFFICE OF
PREPAREDNESS AND EMERGENCY OPERATIONS, ACTING DEPUTY ASSISTANT
SECRETARY, OFFICE OF THE ASSISTANT SECRETARY FOR PREPAREDNESS
AND RESPONSE, DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND
WALTER KOROSHETZ, M.D., DEPUTY DIRECTOR, NATIONAL INSTITUTE OF
NEUROLOGICAL DISEASES AND STROKE, NATIONAL INSTITUTES OF
HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES
STATEMENT OF KEVIN YESKEY
Dr. Yeskey. Thank you, Mr. Chairman, members of the
committee, for the invitation to speak to you today on such an
important topic, one in which the Office of the Assistant
Secretary of Preparedness and Response is extremely interested
and engaged.
I am Kevin Yeskey, a Board-certified emergency medicine
physician, a former U.S. Public Health Service Officer and the
Director of the Office of Preparedness and Emergency Operations
within the Office of the Assistant Secretary for Preparedness
and Response at the Department of Health and Human Services.
The Office of the Assistant Secretary for Preparedness and
Response is relatively new, being created by the Pandemic and
All-Hazards Preparedness Act passed in December 2006
establishing a lead Federal official for public health and
medical preparedness and response within HHS. The Assistant
Secretary for Preparedness and Response [ASPR], serves as the
principal advisor to the Secretary of Health and Human Services
on matters related to Federal public health and medical
preparedness and response activities to national disasters.
Additionally, the responsibility of the ASPR include: one,
leading the Federal public health and medical response to acts
of terrorism, natural disasters, and other public health and
medical emergencies; two, developing and implementing national
policies and plans related to public health and medical
preparedness and response; three, overseeing the advanced
research and development and procurement of qualified medical
countermeasures; four, providing leadership in international
programs, initiatives and policies that deal with public health
and medical emergency preparedness and response.
In short, the ASPR is responsible for ensuring a one-
department approach to public health and medical preparedness
and response, and leading and coordinating the relevant
activities of the HHS operating divisions. As a result of many
changes, including the passage of the Pandemic and All-Hazards
Preparedness Act, the Office of the Assistant Secretary for
Preparedness and Response is forward-leaning and results-
driven. In just a short time since the enactment of the
Pandemic Act, it has created the Biomedical Advanced Research
and Development Authority; has completed the transfer of two
programs, the National Disaster Medical System from the
Department of Homeland Security and the Hospital Preparedness
Program from the Health Resources and Services Administration;
and has announced a National Biodefense Science Board. Again,
all this has been completed since January 2007.
We are also committed to the use of evidence-based
processes and scientifically founded benchmarks and objective
standards called for in the law under the National Health
Security Strategy. By utilizing this approach, OASPR will
assure consistency in the preparedness efforts across our
Nation, ensure greater accountability of local, State and
Federal entities, and provide for a foundation for improved
coordination.
The IOM ``Future of Emergency Care'' report represents an
objective assessment of the status of our Nation's overall
emergency care, as we have already heard. Recognizing the
importance of these reports, HHS convened an internal work
group to examine the 22 recommendations that were specifically
directed at HHS.
We evaluated the initiatives, and the working group
suggested a strategy to address those concerns. The working
group was comprised of senior-level representatives from the
relevant operating divisions and staff divisions of the
Department, to include the National Institutes of Health, the
Centers for Disease Control and Prevention, the Center for
Medicare and Medicaid Services, the Food and Drug
Administration, the Agency for Health Care Research and
Quality, the Health Resources Services Administration, the
Assistant Secretary for Health, and the ASPR.
The working group met regularly in 2006 and 2007, and the
ASPR and I were briefed about the working group's progress. In
evaluating the recommendations, the working group concluded
there were three consistent items. One was the creation of a
lead agency for emergency care within HHS to encourage efforts
directed at daily emergency care issues, while also supporting
the Federal Interagency Committee on Emergency Medical
Services. The second was a unity of effort within HHS to
promote clinical and systems-based research; and, finally, to
further promote greater regionalized approaches to delivering
daily emergency care.
The Institute of Medicine also held regional workshops to
discuss these findings and recommendations and to encourage an
open dialog with involved parties. The final capstone workshop
conducted here in the National Capital included the
participation of the ASPR.
As already noted, we have undertaken initial steps to
better understand the IOM report recommendations, and we have
initiated steps within HHS to implement them. ASPR is also
creating an administrative element within the Office of the
Assistant Secretary for Preparedness and Response that will
promote coordination and unity of effort across the
Department's emergency care activities.
In closing, OASPR will continue to provide leadership in
this area, fostering a departmentwide approach to the Nation's
emergency care issues.
Again, thank you for the invitation to speak today.
Mr. Cummings. Thank you very much, doctor.
[The prepared statement of Dr. Yeskey follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. Dr. Koroshetz.
STATEMENT OF WALTER J. KOROSHETZ
Dr. Koroshetz. Thanks very much. It is a pleasure to talk
to you about the NIH efforts in emergency research.
The emergency conditions that threaten patients with risk
of their life and risk of their quality of health are
exceedingly important to the NIH, and much of our effort goes
into trying to find better treatment for these patients, and I
would ask you to think about our efforts in terms of a pyramid
where at the bottom we have the basic research issues that then
go up higher into the translational research issues where what
we discover from the basic can be applied to disease process.
And at the final top of that pyramid is the effort to get this
out to patients and actually try on patients to see if it
really helps them.
I would say that this has been the motive of research at
NIH, and it has actually, I think, led to significant
improvements in the care of emergency patients. I would say
that at the current time the difficulties you heard in the
first panel, they are impediments not only to patient care, but
also to research on this high end of the pyramid where it is
much more difficult now to be able to translate these new
discoveries into better care in that environment where people
are so hard pressed. It's very hard to ask them to do research
on top of taking care of patients.
So I would just emphasize what you heard this morning is
affecting the research in emergency care as well as the patient
care.
In response to the IOM report, the NIH put together a
Trans-NIH Emergency Medicine Task Force comprised of
representatives from over 23 institutes. We are now involved in
doing a targeted internal review of our research portfolios and
trying to get at the key questions that need to be addressed to
improve emergency care of patients, what are the real big
questions that need to be answered.
Doctors also met with leaders of emergency medicine and
asked them to come up with the same type of analysis, what are
the big questions that need to be solved in this area to
improve patient care. Because it is very multidisciplinary,
these problems--some of which are very high-level neurologic
problems, cardiac problems. It requires coordination throughout
the NIH, and after the NIH there has been a much greater
emphasis on doing this kind of coordination through the Office
of Portfolio Analysis and Strategic Initiatives. So I think we
can come up with a trans-NIH approach to these problems that
arise from our internal review and from discussions with the
outside experts. As mentioned before, the NIH has participated
with the major groups at HHS.
In terms of just a couple of examples of what came out of
our institute, the Neurologic Institute, lots of things that
are real emergencies that need to be taken care of quickly like
strokes, head injury, and we have, for instance, set up
networks of emergency physicians to try to do trials and get
new treatments in the emergency scenario out to patients
quickly. We have stroke centers throughout the country where
emergency medicine has to be the lead organization. We are
trying to train emergency physicians in these centers to become
experts in stroke care delivery.
And even in the Washington area, the NIH Intramural Program
has gone into emergency rooms in different hospitals and
offered stroke and imaging expertise in the emergency setting.
The NHLBI has had similar efforts with the Resuscitation
Outcomes Consortium, the Heart Attack Alert Program, and NIGMS
with research and training programs in trauma.
So, in summary, I think that the NIH is very successful at
coming up with new discoveries that will impact the care of
emergency patients. Our bottleneck may be at the point of
testing in the environment, which, as you heard today, is
somewhat chaotic, and we are certainly interested in working
with the Department and the Assistant Secretary of Preparedness
and Response to improve delivery.
Mr. Cummings. Thank you very much.
[The prepared statement of Dr. Koroshetz follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Cummings. Mr. Sarbanes.
Mr. Sarbanes. Thank you, Mr. Chairman.
Dr. Yeskey, I am interested in knowing more about this $2.7
billion of resources that has been committed since 2002 to the
Hospital Preparedness Program, and I guess what is remarkable
is the testimony we heard from the prior panel was pretty
uniform in saying they don't really see much evidence of impact
from expenditures to that program.
That is consistent with my own experience when I worked
with community hospitals post-9/11, and certainly post-2002
when these dollars became available, where, for the most part,
absent the occasional grant opportunity, they were not able to
perceive any kind of coordinated effort to improve disaster
preparedness at their level.
And I understand the program is now within your
jurisdiction or oversight, and I wonder if you could speak to
why it is that so much money has been spent on this, and yet in
the field, the practitioners who are on the front lines don't
have a perception that it has made any kind of a measurable
impact on improvement.
Dr. Yeskey. The program, in its transfer coming over, needs
to be enhanced in its ability to assess the impact that it has
had. We know we can do a better job of assessing both the
weaknesses of the program thus far, as well as some of the
successes, and there have been some successes. The program
initially was set up to provide hospital preparedness for the
bioterrorist scenarios rather than the day-to-day surge
capacity issues that we heard about today.
But there have been successes. Hospitals have developed
command-and-control systems that enable them to integrate
better into a community's response plans with EMS, law
enforcement. They have developed interoperable communications
so they can help in a systems way route patients in an event so
they have a better way of getting the patients to the care they
need. Those are just a few examples of that.
I think we need to look a little bit harder at how we can
improve how moneys are being spent using more effective
performance measures, being able to describe what exactly we
want hospitals to do and to measure that. The money we give in
a hospital preparedness program goes to the States. It doesn't
go directly to the hospitals, it goes to the States, and they
distribute that money to their hospitals and health care
facilities rather than going to the hospitals directly.
We do have this year, in this upcoming grant program, a
competitive piece as directed by the Pandemic and All-Hazards
Preparedness Act where money can go for the development of
regional coalitions of hospitals, and that money will go
directly to those coalitions rather than to the State; however,
those coalitions need to be integrated into an overall state
plan. And we hear that from the States from time to time, that
they want to make sure that they understand what their
coalitions are doing so fits into the overall State
preparedness plan.
Mr. Sarbanes. So it sounds from the get-go they needed more
accountability as the money was being passed down the line,
which ultimately that accountability comes back to those who
are originating the grants and the money that is flowing. So
that is the Federal Government's responsibility, if it is going
to dispense $3 billion, to make sure as it is meted out, it is
being done in a judicious way.
Let me ask you really quickly before time runs out, we
heard a lot of testimony about what some viewed as a tactical
response to the emergency care situation. I view, perhaps, it
as being strategic as well, and that is to set up these
regional networks of response, emergency care, and I was glad
of the mention of what has been accomplished in Maryland, which
I think is a model with the MIEMS model and Maryland Shock
Trauma Institute and so forth.
I assume you see great possibilities in that approach, and
that many of these dollars would be directed toward trying to
facilitate that kind of thinking and modeling.
Dr. Yeskey. We support regional--coalitions. Regional
models of emergency care.
Mr. Sarbanes. Thank you, Mr. Chairman.
Mr. Cummings. Thank you very much, Mr. Sarbanes.
Dr. Koroshetz, in the IOM report on emergency care, the
committee recommended, ``The Secretary of the Department of
Health and Human Services should conduct a study to examine the
gaps in opportunities in emergency and trauma care research and
recommend a strategy for the optimal organization funding of
the research effort.''
I am very glad to learn from your testimony this morning
that the Department has organized a Trans-NIH Emergency
Medicine Task Force. When can we expect the task force's
recommendations?
Dr. Koroshetz. My understanding is that we are currently in
the process of doing the internal review and the fingerprinting
of the research that is going on now, and that should be done
by the end of this year, along with the consultation with the
outside groups about where they see the gaps matching up with
our assessment. And so we think the beginning of next year we
would have the final report.
Mr. Cummings. Now, let me tell you this, that Mr. Waxman
and this committee, we are going to hold you to that, so when
you get back to your shop, and there is something different,
would you let us know that? And I hope staff will make that a
part of our questions, because one of the things that we are
trying to do is that we found a lot of times is we will get
answers, people tell us they are going to do things, and the
next thing you know, time passes by and it is 2 years later, a
whole new group of Congressmen, a whole new committee, and it
sort of slips under the rug. This is something that we cannot
afford to let happen. So we are going to hold you to that.
Dr. Koroshetz. I understand.
Mr. Cummings. Dr. Koroshetz, in your written testimony you
state, ``The structural issues in the U.S. health care system
do not fall within the purview of NIH.''
If that's true, then where should the doctors like those on
the first panel turn for the research they need to help them
improve the organization and delivery of emergency care?
Dr. Koroshetz. Well, I think we would say that the NIH is
going to be most effective at determining what is the best
therapy for a patient and actually improving what that therapy
is. But the issues that you heard about this morning are so
complicated with regard to the finances, the regional
organizations, specialist involvement, that going into those
areas would really detract of our mission of making these
therapies available.
I would caveat that by saying that certainly we will put an
emphasis onto bringing the therapy to market and trying to
break down the bulwarks that prevent therapy from coming to
market, but it is probably something we can't do alone, that we
need to do with people who are interested. The Brain Attack
Coalition is a nice example. So we came up with a new stroke
therapy, but it requires a great deal of new work being done in
emergency departments to deliver that therapy, and you heard
how strained they are.
We started a coalition with emergency physicians, EMS
providers----
Mr. Cummings. Let me ask you this. I just want to make sure
we are able to end this hearing so we don't have to hold you up
for another 2 hours or hour and a half. Let me ask you this:
Would the Agency for Health Care Research and Quality [AHRQ]
have jurisdiction over this, be helpful with this?
Dr. Koroshetz. I think in the past that they have looked at
delivery of health care and outcomes related to how care is
delivered.
Mr. Cummings. So you would recommend that?
Dr. Koroshetz. I think from the standpoint of the questions
about those which relate to what is the best therapy versus how
it is actually proportioned, I think that the AHRQ, it may be
more in their ballpark in terms of how things are delivered.
Mr. Cummings. You realize that AHRQ, their budget is more
than $300 million, or a little more than 1 percent of your
agency's budget. Do you know that?
Dr. Koroshetz. Yeah.
Mr. Cummings. Let me leave you with this. I heard you talk
about getting therapies, I guess, into practice. One of the
things that, if we listen to the testimony today, we heard was
those therapies are nice, they are important, but they are not
getting to people in many instances because people are dying.
Dr. Koroshetz. Because of the overcrowding issue.
Mr. Cummings. Yes. I was just sitting here thinking anybody
in this room could possibly, God forbid, have a heart attack
right now, and although we may have all the research, we have
done all the things we are supposed to do, given money to NIH,
and then because of overcrowding, they will die. Even the
gentleman, Dr. Johnson I think it was, from one of the more
affluent areas, people in his district are dying.
And so it just seems to me that we can do better. And it is
a shame and very upsetting that CMS did not appear here today.
I think that that is one of--when you have close to 4,250
employees, and you can't find 1 person, and it is your
responsibility to address this issue, and you don't show up,
you are a no-show, that is a major, major problem. This
committee is determined to get Dr. Norwalk here and to figure
out what is CMS doing about this problem.
Ladies and gentlemen, I move that the Members have 5 days
to submit questions and comments. With that, the hearing stands
adjourned. Thank you very much.
[Whereupon, at 12:38 p.m., the committee was adjourned.]