IN THE SENATE OF THE UNITED STATES
March 26, 2009
Mrs. Murray (for herself and Mr. Isakson) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions
To ensure the continued and future availability of life saving trauma health care in the United States and to prevent further trauma center closures and downgrades by assisting trauma centers with uncompensated care costs, core mission services, and emergency needs.
This Act may be cited as
National Trauma Center
Stabilization Act of 2009.
Congress makes the following findings:
Victims of traumatic injury should have
access to lifesaving care regardless of their geographic location or ability to
pay. Major multi-system trauma victims receiving care within the first
Golden Hour following their injury are substantially more likely
Maintaining a strong and effective trauma care system for all victims of traumatic injury requires the availability of a sufficient number of trauma centers at appropriate levels of trauma care capability in all geographic regions of the United States.
Regional trauma centers annually treat 678,000 patients, regardless of their ability to pay. When a trauma victim cannot afford treatment, the trauma center pays for care that may save their life.
The cost of delivering trauma care has steadily increased in the last decade. Trauma centers collectively have incurred $230,000,000 per year in losses for treating victims who are either uninsured or whose care is reimbursed well below the cost of providing care.
Substantial uncompensated care costs are distressing trauma centers and threatening the availability of life-saving trauma services in numerous areas across the United States. Since 2000, 20 hospitals have closed their trauma centers, and 13 others have downgraded their trauma service.
At a time when the threat of mass emergencies are high, financial pressures are placing trauma centers at serious risk. Trauma centers are required to respond to mass emergencies including natural disasters, large scale accidents and terrorist attacks. By their very nature, trauma centers maintain a constant state of readiness, extra capacity, and strong healthcare facility connections with the local and regional emergency care community.
Medical liability exposure and its related costs have contributed to the closing of trauma centers and downgrading of trauma levels. It is important to find ways to minimize risk to those who provide lifesaving care in those initial critical hours following a trauma event.
The supply of trauma surgeons in the United States is rapidly declining. Trauma fellowships are only 60 percent full.
There is a limited pipeline to replace retiring trauma surgeons and surgical specialists. The average age of an American College of Surgeons Fellow is 58 years and most hospitals do not require trauma surgeons to take calls after the age of 60.
A national survey of surgeons conducted by the Robert Wood Johnson Foundation revealed that 50 percent of respondents would abandon emergency calls if it were not mandated to maintain staff privileges.
Increasing numbers of trauma centers are closing their emergency departments or downgrading their trauma center designation level due to factors that include a lack of access to on-call specialists.
The lack of surgical availability is concentrating trauma care in regional trauma centers as the only source of surgical specialty care for hundreds of miles for patients historically cared for in community trauma centers. This causes a lack of surge capacity and results in an inability to accept severely injured patients at the regional trauma center level.
Trauma care centers
Grants for trauma care centers
Section 1241 of the Public Health Service Act (42 U.S.C. 300d–41) is amended by striking subsections (a) and (b) and inserting the following:
The Secretary shall establish 3 programs to award grants to qualified public, non-profit, Indian Health Service, Indian tribal, and urban Indian trauma centers—
to assist in defraying substantial uncompensated care costs as defined in section 1246;
to further their core missions, including by addressing costs associated with patient stabilization and transfer, trauma education and outreach, coordination with local and regional trauma systems, and essential personnel and other fixed costs; and
to provide emergency relief to ensure the continued and future availability of trauma services by trauma centers at risk of closing or centers operating in an area where a closing has occurred within their primary service area.
Minimum qualifications of trauma centers
Participation in trauma care system operating under certain professional guidelines
Subject to paragraph (2), the Secretary may not award a grant to a trauma center under subsection (a) unless the trauma center involved is a participant in a trauma system that substantially complies with section 1213.
Paragraph (1) shall not apply to trauma centers that are located in States with no existing trauma care system.
Qualification for substantial uncompensated care costs
The Secretary shall only award substantial uncompensated care grants under subsection (a)(1) to trauma centers meeting at least 1 of the criteria in 1 of the following 3 categories:
The criteria for category A are as follows:
At least 50 percent of the visits in the emergency department of the hospital in which the trauma center is located were charity or self-pay patients.
At least 70 percent of the visits in such emergency department were Medicaid (title XIX of the Social Security Act) and charity and self-pay patients combined.
The criteria for category B are as follows:
At least 35 percent of the visits in such emergency department were charity or self-pay patients.
At least 50 percent of the visits in such emergency department were Medicaid (title XIX of the Social Security Act) and charity and self-pay patients combined.
The criteria for category C are as follows:
At least 20 percent of the visits in such emergency department were charity or self-pay patients.
At least 30 percent of the visits in such emergency department were Medicaid (title XIX of the Social Security Act) and charity and self pay patients combined.
Trauma centers in 1115 waiver States
Notwithstanding paragraph (3), the Secretary may award a substantial uncompensated care grant to a trauma center under subsection (a)(1) if the trauma center qualifies for funds under a Low Income Pool or Safety Net Care Pool established through a waiver approved under section 1115 of the Social Security Act.
The Secretary may not award a grant to a trauma center unless such trauma center is verified or designated by the American College of Surgeons or an equivalent State or local agency.
The Secretary may not award a grant to a trauma center under subsection (a)(1) unless the trauma center involved—
submits to the Secretary a plan satisfactory to the Secretary that—
is developed on the assumption that the center will continue to incur substantial uncompensated costs in providing trauma care; and
provides for the long-term continued operation of the center at similar or greater levels of medical care than in prior years notwithstanding such substantial uncompensated costs;
agrees to implement the plan according to a schedule approved by the Secretary; and
has policies in place to assist patients who cannot pay for part or all of the care they receive, including a sliding fee scale, and to ensure fair billing and collection practices.
Considerations in making grants
Section 1242 of the Public Health Service Act (42 U.S.C. 300d–42) is amended by striking subsections (a) and (b) and inserting the following:
Substantial Uncompensated Care Awards
The Secretary shall establish an award basis for each eligible trauma center for grants under section 1241(a)(1) according to the percentage described in paragraph (2), subject to the requirements of section 1241(b)(3).
The applicable percentages are as follows:
With respect to a category A trauma center, 100 percent of the uncompensated care costs.
With respect to a category B trauma center, not to exceed 75 percent of the uncompensated care costs.
With respect to a category C trauma center, not to exceed 50 percent of the uncompensated care costs.
Core mission awards
In awarding grants under section 1241(a)(2), the Secretary shall—
reserve 25 percent of the amount allocated for core mission awards for Level III and Level IV trauma centers, and reallocate such amount to Level I and Level II trauma centers if there are not sufficient qualifying Level III and IV centers to which such funds may be obligated;
reserve 25 percent of the amount allocated for core mission awards for large urban Level 1 trauma centers that—
have at least 1 graduate medical education fellowship in trauma or trauma related specialties, including neurological surgery, surgical critical care, vascular surgery, and spinal cord injury for which demand is exceeding supply;
have either annual uncompensated care costs exceeding $10,000,000 or where at least 20 percent of emergency department visits are charity or self-pay or Medicaid patients; and
are not eligible for substantial uncompensated care awards under section 1241(a)(1); and
give preference to any application made by a trauma center—
in a geographic area where growth in demand for trauma services exceeds capacity; or
that demonstrates the financial support of the State or political subdivision involved.
For purposes of paragraph (1)(C)(ii), for any of the purposes specified in section 1241 for each fiscal year during which payments are made to the trauma center involved from the grant, such financial support may be demonstrated by State or political subdivision funding for the trauma center's capital or operating expenses (including through State trauma regional advisory coordination activities or Medicaid funding designated for trauma services, or other governmental funding). State funding derived from Federal support provided through the Trauma Systems Planning Grants awarded to States or political subdivisions shall not constitute State or local financial support for purposes of preferential treatment under this subsection.
In awarding grants under section 1241(a)(3), the Secretary shall—
give preference to any application submitted by a trauma center that demonstrates the financial support (in accordance with subsection (b)(2)) of the State or political subdivision involved for any of the purposes specified in section 1241 for each fiscal year during which payments are made to the center under the grant;
give preference to any application submitted by a trauma center that—
is providing trauma care in a geographic area in which the availability of trauma care has either significantly decreased as a result of a trauma center in the area permanently ceasing participation in such system as of a date occurring during the 2-year period preceding the fiscal year for which the trauma center is applying to receive a grant under section 1241(a)(3), or in geographic areas where growth in demand for trauma services exceeds capacity;
will, in providing trauma care during the 1-year period beginning on the date on which the application for the grant is submitted, incur substantial uncompensated costs in an amount that renders the center unable to continue participation in such system and results in a significant decrease in the availability of trauma care in the geographic area; or
operates in rural areas where trauma care availability will significantly decrease if the center is forced to close or downgrade service and substantial uncompensated costs are contributing to a likelihood of such closure or downgradation; and
reallocate any emergency awards funds not obligated due to insufficient, or a lack of qualified, applications to the significant uncompensated care award program.
Section 1243 of the Public Health Service Act (42 U.S.C. 300d–43) is amended by striking subsections (a), (b), and (c) and inserting the following:
Commitment regarding continued participation in trauma care system
The Secretary may not award a grant to a trauma center under section 1241(a) unless the trauma center involved agrees that—
the center will continue participation in the system described in section 1241(b), except as provided in subsection (b)(2) of such section, throughout the grant period beginning on the date that the center first receives payments under the grant; and
if the agreement made pursuant to paragraph (1) is violated by the center, the center will be liable to the United States for an amount equal to the sum of—
the amount of assistance provided to the center under section 1241(a); and
an amount representing interest on the amount specified in subparagraph (A).
Maintenance of financial support
With respect to activities for which a grant awarded under section 1241 are authorized to be expended, the Secretary may not award such a grant unless the trauma center involved agrees that, during the period in which the center is receiving payments under the grant, the center will maintain access to trauma services at levels not less than the levels for the prior year, taking into account reasonable volume fluctuation that is not caused by intentional trauma boundary reduction, downgrading of the level of services, or diversion of services in excess of 5 percent.
Trauma care registry
The Secretary may not award a grant under section 1241(a) unless the trauma center involved agrees that—
not later than 6 months after the date on which the center submits a grant application to the Secretary, the center will establish and operate a registry of trauma cases in accordance with guidelines developed by the American College of Surgeons; and
in carrying out paragraph (1), the center will maintain information on the number of trauma cases treated by the center and, for each such case, the extent to which the center incurs substantial uncompensated costs in providing trauma care.
Section 1244 of the Public Health Service Act (42 U.S.C. 300d–44) is amended by striking subsections (a), (b), and (c) and inserting the following:
The Secretary may not award a grant to a trauma center under section 1241(a) unless an application for the grant is submitted by the center to the Secretary and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this part.
Limitation on duration of support
The period during which a trauma center receives payments under a grant under section 1241(a)(3) shall be for 3 fiscal years, except that the Secretary may waive such requirement for the center and authorize the center to receive such payments for 1 additional fiscal year.
Limitation on amount of grant
Notwithstanding section 1242(a), a grant under section 1241 may not be made in an amount exceeding $2,000,000.
Except as provided in section 1242(b)(1)(B)(iii), acquisition of, or eligibility for, a grant under section 1241(a) shall not preclude a trauma center's eligibility for the other grants described in such section.
Of the total amount appropriated for a fiscal year under section 1245, 70 percent shall be used for substantial uncompensated care awards under section 1241(a)(1), 20 percent shall be used for core mission awards under section 1241(a)(2), and 10 percent shall be used for emergency awards under section 1241(a)(3).
Notwithstanding subsection (e), if the amount appropriated for a fiscal year under section 1245 is less than $25,000,000, all available funding for such fiscal year shall be utilized for substantial uncompensated care awards under section 1241(a)(1).
Substantial uncompensated care award distribution and proportional share
Notwithstanding section 1242(a), of the amount appropriated for substantial uncompensated care grants for a fiscal year, the Secretary shall—
50 percent of such funds for category A trauma center grantees;
35 percent of such funds for category B trauma center grantees; and
15 percent of such funds for category C trauma center grantees; and
provide available funds within each category in a manner proportional to the award basis specified in section 1242(a)(2) to each eligible trauma center.
Beginning 2 years after the date of enactment of the National Trauma Center Stabilization Act of 2009, and every two years thereafter, the Secretary shall biennially—
report to Congress on the status of the grants made pursuant to section 1241; and
evaluate and report to Congress on the overall financial stability of trauma centers in the United States.
Authorization of appropriations
Section 1245 of the Public Health Service Act (42 U.S.C. 300d–45) is amended to read as follows:
Authorization of appropriations
For the purpose of carrying out this part, there are authorized to be appropriated $100,000,000 for fiscal year 2009, and such sums as may be necessary for each of fiscal years 2010 through 2015. Such authorization of appropriations is in addition to any other authorization of appropriations or amounts that are available for such purpose.
Part D of title XII of the Public Health Service Act (42 U.S.C. 300d–41 et seq.) is amended by adding at the end the following:
In this part, the term uncompensated care costs means unreimbursed costs from serving self-pay, charity, or Medicaid patients, without regard to payment under section 1923 of the Social Security Act, all of which are attributable to emergency care and trauma care, including costs related to subsequent inpatient admissions to the hospital.
Trauma service availability
Establishment of grant program
Title XII of the Public Health Service Act (42 U.S.C. 300d et seq.) is amended by adding at the end the following:
Trauma service availability
Grants to States
To ensure universal access to trauma care services provided by trauma centers and trauma-related physician specialties, the Secretary shall provide funding to States to enable such States to award grants to eligible entities for the purposes contained in this section.
Awarding of grants by States
Each State may award grants to eligible entities within the State to—
improve the availability of trauma services in underserved areas;
address trauma center over-crowding;
enhance trauma surge capacity;
address shortages of trauma surgeons and certain other trauma related physician subspecialties, including providing reimbursement for the unreimbursed costs to trauma centers for trauma-related physician compensation to ensure the availability of such physicians to protect against trauma center closures or downgrades; and
improve trauma service coordination and the appropriate transport of trauma patients to trauma centers.
To be eligible to receive a grant under subsection (b) an entity shall—
a public or non-profit trauma center that meets that requirements of paragraphs (1), (2), and (5) of section 1241(b);
a safety net public or nonprofit trauma center that meets the requirements of paragraphs (1) through (5) of section 1241(b) for the purposes of grants to carry out activities described in paragraphs (1) and (2) of subsection (d);
a consortium of public or non-profit trauma centers; or
a hospital that seeks to establish new trauma services in underserved areas (as defined by the State); and
submit to the State an application at such time, in such manner, and containing such information as the State may require.
A State shall utilize at least 40 percent of the amount available to the State under this part for a fiscal year to award grants to entities described in paragraph (1)(A)(ii).
Use of funds
The recipient of a grant under subsection (b) shall carry out one or more of the following activities consistent with subsection (b):
Providing safety net trauma centers with funding to support physician compensation in trauma-related physician specialties where shortages exist in the region involved.
Providing for individual safety net trauma center fiscal stability and costs related to 24-hour a day, 7 days a week, service availability with priority provided to safety net trauma centers located in urban, border, and isolated rural areas.
Activities to reduce trauma center overcrowding.
Establishing new trauma services in underserved areas.
Enhancing regional systemic coordination of trauma service availability.
Making capital improvements to enhance access and expedite trauma care, including providing helipads and associated safety infrastructure.
Enhancing regional trauma surge capacity.
Ensuring expedient transport by ground or air to the appropriate trauma center.
A State may use not to exceed 20 percent of the amount available to the State under this part for a fiscal year for administrative and systemic costs of the State in awarding grants, including coordination with other States to recognize existing or otherwise appropriate patient transfer patterns that may exist beyond State boundaries while remaining consistent with the State trauma and emergency medical service systems of each State.
Distribution of funds
Except as provided in paragraph (2), from the amount appropriated for each fiscal year to carry out this part, the Secretary shall distribute to each State an amount that bears the same ratio to such appropriated amount as the population of the State involved (as reported in the most recent decennial census) bears to the total population of the United State (as reported in the most recent decennial census).
Notwithstanding paragraph (1), a State shall at a minimum receive an amount for a fiscal year that is not less than 1 percent of the amount appropriated for such fiscal year.
Authorization of appropriations
For the purpose of carrying out this part, there is authorized to be appropriated $100,000,000 for each of fiscal years 2010 through 2015.