Summary

February 2014 Los Angeles County Lacking a Comprehensive Assessment of Its Trauma System, It Cannot Demonstrate That It Has Used Measure B Funds to Address the Most Pressing Trauma Needs Report 2013-116 COMMITMENT INTEGRITY LEADERSHIP The first five copies of each California State Auditor report are free. Additional copies are $3 each, payable by check or money order. You can obtain reports by contacting the California State Auditor’s Office at the following address: California State Auditor 621 Capitol Mall, Suite 1200 Sacramento, California 95814 916.445.0255 or TTY 916.445.0033 OR This report is also available on our Web site at www.auditor.ca.gov. The California State Auditor is pleased to announce the availability of an online subscription service. For information on how to subscribe, visit our Web site at www.auditor.ca.gov. Alternate format reports available upon request. Permission is granted to reproduce reports. For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255. For complaints of state employee misconduct, contact the California State Auditor’s Whistleblower Hotline: 1.800.952.5665. Elaine M. Howle State Auditor Doug Cordiner Chief Deputy February 20, 2014 2013‑116 The Governor of California President pro Tempore of the Senate Speaker of the Assembly State Capitol Sacramento, California 95814 Dear Governor and Legislative Leaders: As requested by the Joint Legislative Audit Committee, the California State Auditor presents this audit report concerning Los Angeles County’s (Los Angeles) management of Measure B funds. Measure B was approved by voters in November 2002 to maintain and expand Los Angeles’s trauma system, ensure the continued availability of emergency medical services, and respond effectively to biological terrorism. The Board of Supervisors for the County of Los Angeles (board) allocates these funds primarily to reimburse the 14 trauma centers— two county‑operated and 12 non‑county‑operated trauma centers—within Los Angeles’s trauma system for treatment of patients who are unable to pay for their care and who have no third‑party insurance coverage. This report concludes that without a comprehensive assessment of its trauma system, Los Angeles cannot demonstrate that it has used Measure B funds to address the most pressing trauma needs and has fulfilled the intent of the measure by expanding trauma services countywide. Since voters approved the measure in 2002, existing trauma centers remain far removed from some geographical areas of the county (underserved areas), requiring Los Angeles to use helicopters to transport some trauma patients from those areas, including East San Gabriel Valley. Although Los Angeles’s Emergency Medical Services Agency (EMS)—the county entity responsible for overseeing the trauma system—conducts periodic performance evaluations of individual trauma centers, it has not conducted a comprehensive assessment that would allow it to demonstrate whether its trauma system is meeting the needs of all areas and populations in the county. Additionally, the board has not reassessed its approach to allocating Measure B funds in roughly a decade, hindering its ability to demonstrate that it has fulfilled the intent of the measure, which, according to board documents, includes assisting hospitals in underserved areas become trauma centers. After voters approved Measure B, the board established a Measure B Oversight Committee (oversight committee), which has since disbanded. We believe that reinstating the oversight committee could provide the board with a key advisory body to review its allocation approach. Further, although the board initially funded helicopter transport of trauma patients from underserved areas as an interim solution to establishing trauma centers in these areas, it has apparently adopted this as a permanent solution. As a result, we expected EMS to have monitored, assessed, and reported consistently on the adequacy and effectiveness of these helicopter transport services; however, we found that it has not done so. Lastly, shortly after the passage of Measure B, Los Angeles undertook some formalized efforts to designate a hospital as a trauma center in East San Gabriel Valley. Since that time, Los Angeles has made only minimal attempts to do so and if it does not increase and formalize its efforts, it may miss the opportunity to designate a trauma center in this underserved area. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor 621 Capitol Mall, Suite 1200 Sacramento, CA 95814 916.445.0255 916.327.0019 fax www.auditor.ca.gov Blank page inserted for reproduction purposes only. California State Auditor Report 2013-116 v February 2014 Contents Summary 1 Introduction 5 Audit Results Since Measure B Passed in 2002, Los Angeles County Has Not Conducted a Comprehensive Assessment of Its Trauma System 13 Los Angeles Should Reassess Its Allocation Approach to Verify and Demonstrate That the County Is Fulfilling Measure B’s Intent 21 Los Angeles Has Identified and Addressed Some Shortcomings in Its Emergency Medical Services 32 Recommendations 34 Appendix Reimbursements to Hospitals in Los Angeles County From the Measure B Special Tax Revenue Fund for Emergency Medical Services, Trauma Centers, and Bioterrorism Response for Uncompensated Care Costs, Fiscal Years 2008–09 Through 2011–12 37 Response to the Audit Los Angeles County 39 California State Auditor’s Comments on the Response From Los Angeles County 53 vi California State Auditor Report 2013-116 February 2014 Blank page inserted for reproduction purposes only. California State Auditor Report 2013-116 1 February 2014 Summary Results in Brief Audit Highlights . . . Voters in Los Angeles County (Los Angeles) passed Measure B in Our audit of Los Angeles County 2002 to maintain and expand the trauma system countywide, to (Los Angeles) Measure B funds highlighted ensure the continued availability of emergency medical services, the following: and to respond effectively to biological terrorism. The term trauma refers to a critical injury most often caused by a physical force » More than a decade after voters approved that is frequently the consequence of a motor vehicle crash, a the measure, existing trauma centers fall, a drowning, a gunshot, a burn, a stabbing, or a blunt assault. remain far removed from certain areas To better treat these injuries, in 1983 Los Angeles’s trauma within Los Angeles despite Measure B’s system became operational and within two years grew to include stated intent. 22 county‑operated and non‑county‑operated trauma centers. » Although the director of Los Angeles’s However, shortly after Los Angeles’s trauma system reached this Emergency Medical Services Agency peak, trauma centers began to withdraw from the system, citing maintains that the trauma system is the costs of uncompensated care—for patients who are unable to adequate and meeting the needs of all pay for their care and have no third‑party insurance coverage—as areas of the county, it has not conducted the reason for their withdrawal. This left some areas in Los Angeles a comprehensive assessment that would without a trauma center. By 2002 Los Angeles’s Department of allow it to support such a claim. Health Services was facing a significant budget deficit, which was threatening the already weakened trauma system. To, among other » The Board of Supervisors for the County things, address the deficit and preserve and expand the trauma of Los Angeles (board) has not revisited system, the Board of Supervisors for the County of Los Angeles its approach to allocating Measure B (board) submitted a parcel tax measure to the voters in the funds in roughly a decade, hindering its November 2002 general election, referred to as Measure B, which ability to demonstrate to the public that voters ultimately approved. With the passage of the measure, it distributes Measure B funds to address the board implemented a parcel tax of 3 cents per square foot on the most pressing trauma needs. generally all structural improvements, which it has increased over » The board initially funded helicopter time. In fiscal year 2011–12, the measure generated more than services as an interim solution to locating $256 million in revenue. trauma centers in underserved areas, however, it has not regularly monitored, More than a decade after voters approved the measure, existing assessed, and reported on the helicopter trauma centers remain far removed from certain areas within transport services used to transport Los Angeles despite Measure B’s stated intent, which is to provide trauma patients. funding to, in part, maintain and expand Los Angeles’s trauma system countywide. The director of Los Angeles’s Emergency » Although it acknowledges Medical Services Agency (EMS)—the county entity responsible East San Gabriel Valley could support for overseeing the trauma system—maintains that Los Angeles’s a trauma center, Los Angeles has made efforts to expand the trauma system have fulfilled the intent of minimal efforts to persuade a hospital in Measure B. However, although Los Angeles is only required to that area to join the trauma system. implement the actual text of Measure B, certain information within the Official Sample Ballot and Voter Information booklet for the November 2002 general election may have led voters to believe that Measure B’s passage would ensure a trauma center would be located within each of the county’s areas that lack a trauma center in close proximity (underserved areas). Los Angeles’s trauma system currently comprises two county‑operated and 2 California State Auditor Report 2013-116 February 2014 12 non‑county‑operated trauma centers. Nevertheless, the areas of Malibu and East San Gabriel Valley, which includes the city of Pomona, lack a trauma center located within their geographic boundaries, and only one trauma center is located in the expansive Antelope Valley. Although the director of EMS maintains that the trauma system is adequate and meeting the needs of all areas of the county, it has not conducted a comprehensive assessment that would allow it to support such a claim. Rather, EMS in conjunction with the American College of Surgeons (College of Surgeons)—a scientific and educational association of surgeons that operates a Trauma Systems Consultation Program—conducts periodic performance evaluations of individual trauma centers to ensure that they are complying with applicable requirements. We believe a comprehensive evaluation is needed to determine whether the trauma system Los Angeles developed is adequately meeting the needs of all geographic areas and populations in the county. The College of Surgeons is equipped to and has experience in conducting comprehensive on‑site trauma system reviews that, if performed, could provide guidance on best practices in trauma center distribution and system design, as well as assist Los Angeles in identifying at‑risk population groups. For example, according to Los Angeles’s first Emergency Medical Services System Report from 2012, black males experienced more than double the number of traumas than did Hispanic males, who had the next highest incidence of trauma in the report’s consideration of race and gender. A key step in the College of Surgeons’ approach is a form of risk‑factor assessment that analyzes the pattern of injury across different demographic groups. Such an evaluation could inform the public about the needs and challenges of Los Angeles’s current trauma system. However, EMS has expressed reservations about engaging the College of Surgeons to conduct a comprehensive assessment of Los Angeles’s trauma system. Nevertheless, we believe that a comprehensive assessment by the College of Surgeons would likely result in recommendations that could improve and enhance the county’s trauma system or identify areas requiring more focused attention. Additionally, the board has not revisited its approach to allocating Measure B funds in roughly a decade. Following the passage of Measure B, the board created the Measure B Oversight Committee (oversight committee) to, in part, help ensure proper use of the funds, but the committee disbanded shortly thereafter, leaving the board without a key advisory body. Before disbanding, the oversight committee recommended that the board distribute most of the funds to pay for uncompensated trauma and emergency care at county hospitals and for uncompensated trauma care at non‑county‑operated trauma centers. Since that time, the board California State Auditor Report 2013-116 3 February 2014 has not revisited its allocation approach because it believes that the current approach addresses a primary concern of trauma centers. However, it has not conducted a review of its allocation approach in roughly 10 years, hindering its ability to demonstrate to taxpayers that it distributes Measure B funds to address the most pressing trauma care needs. The board initially funded helicopter services as an interim solution to locating trauma centers in underserved areas by allocating $2.4 million in 2003 for this purpose. However, it has not regularly monitored, assessed, and reported on the helicopter transport services that Los Angeles uses to transport trauma patients from underserved areas. As a result, the board cannot demonstrate the adequacy and effectiveness of these services as a substitute for establishing trauma centers in those areas. By 2005 the board was allocating $4.4 million to fund helicopter services 24 hours a day, seven days a week, in all underserved areas and appears to have permanently adopted this as a means of providing trauma care access to these areas. However, although EMS collects data related to helicopter transports, we have doubts about its quality and usefulness because it does not relate specifically to trauma transports, it does not capture which areas patients are transported from, and it is not consistently reviewed by EMS. In fact, we would expect EMS to collect and analyze helicopter transport data, including the number, cause, and patient outcome for cancelled transports, to gauge the effectiveness of these helicopter services in each underserved area. Such an analysis would allow it to better understand where trauma is occurring and verify whether helicopters are transporting trauma patients from underserved areas effectively. Lastly, although it acknowledges that the underserved area of East San Gabriel Valley could support a trauma center, Los Angeles has made minimal efforts to persuade a hospital in that area to join the trauma system. Currently, residents that suffer a trauma injury in this area are transported to LAC+USC Medical Center or Huntington Memorial Hospital, both of which are more than 20 miles away from some areas of East San Gabriel Valley. EMS asserts that it has approached Pomona Valley Hospital Medical Center (Pomona) in the past year, which was a trauma center in the 1980s, about reentering the system, but could provide minimal documentation supporting its communications. Through our discussions with Pomona, we found that it is not opposed to having formal discussions about becoming a trauma center. By undertaking formalized efforts to understand Pomona’s concerns, particularly as they relate to funding, the board could revisit its Measure B allocations and use that money, or funds in its reserve, to provide financial support that would enable a hospital to become designated as a trauma center in East San Gabriel Valley. Thus, to the extent 4 California State Auditor Report 2013-116 February 2014 the board chooses not to revisit its allocations and potentially identify ways in which to entice a hospital to join the system, East San Gabriel Valley may remain without a trauma center. Recommendations To evaluate whether its trauma system is appropriately designed and serving the needs of residents in underserved areas and the needs of the most at‑risk populations, the board should use Measure B funds to engage the College of Surgeons by July 2014 to perform a comprehensive assessment and make the results available to the public. If the assessment identifies weaknesses in the trauma system, the board should undertake strategies to address those weaknesses where feasible. To ensure that it allocates Measure B funds to address the most significant needs of Los Angeles residents, the board should reinstate a Measure B oversight committee. As part of its responsibilities, the oversight committee should reevaluate the Measure B allocation approach, taking into consideration the results of Los Angeles’s comprehensive assessment, and should issue a report on its findings no later than December 2015. To determine the adequacy and effectiveness of the helicopter services it provides to residents of underserved areas who suffer a trauma injury, EMS should collect, assess, and report helicopter transport data for these trauma victims. Los Angeles should undertake formal discussions with Pomona’s management regarding the feasibility of the hospital becoming a trauma center. In doing so, Los Angeles should analyze its current Measure B revenues and allocations to determine whether financial opportunities exist that would meet the needs of Pomona and present the resulting analysis to Pomona. Further, it should document its efforts and the resulting outcome so that both voters and taxpayers are aware of the diligence Los Angeles has undertaken in fulfilling the intent of Measure B. Agency Comments Although Los Angeles agreed with some of our recommendations and indicated it would consider implementing others, it disagreed with the conclusion we reached related to its ability to demonstrate that it has used Measure B funds to meet the most pressing trauma needs. California State Auditor Report 2013-116 5 February 2014 Introduction Background A July 2002 motion to the Board of Supervisors for the County of Los Angeles (board) asserted that the Key Terms Related to Los Angeles County Department of Health Services Los Angeles County’s 2002 Measure B (County Health Services) would face a budget Trauma: A critical injury most often caused by a physical deficit of $710 million in fiscal year 2005–06. The force and frequently the consequence of a motor vehicle motion further stated that the projected decline crash, a fall, a drowning, gunshots, a fire, burns, a stabbing, in health funding would hurt county residents in or a blunt assault. Trauma is the leading cause of death many ways, but none so widespread as the impact during an individual’s first four decades of life. on trauma centers, emergency medical services, Trauma Center: A hospital that maintains specialized and the county’s bioterrorism response. Following equipment and a panel of physician specialists that that motion, the board adopted a resolution to includes a trauma surgeon who is available 24 hours a day, hold a special tax election on November 5, 2002, seven days a week, to treat trauma patients. that would include a special parcel tax measure Countywide System of Trauma Centers: A trauma (Measure B). This parcel tax was to provide funding care system coordinated by the Los Angeles County to maintain all aspects of the countywide system of Department of Health Services (County Health Services) and trauma centers and expand the system to cover all consisting of both public and privately operated resources. areas of the county. Some key terms related to this This system seeks to build and sustain a countywide special tax measure appear in the text box. system of prehospital and hospital trauma care, including care provided in, en route to, from, or between acute care Although the board’s resolution was not codified hospitals, trauma centers, or other health care facilities. as an ordinance, the resolution remains the law Emergency Medical Services: Prehospital and hospital governing the collection and expenditure of critical and urgent emergency care, including care provided the funds that Measure B generates. In passing in, en route to, from, or between acute care hospitals or Measure B, voters approved, in particular, an annual other health care facilities. special parcel tax of 3 cents per square foot on Bioterrorism Response: Activities undertaken directly, structural improvements, excluding square footage managed through contracts, or coordinated by County of improvements used for parking. The measure Health Services to address the medical needs of persons was approved by 1.18 million voters, or 73 percent exposed to a bioterrorist or chemical attack. of those who voted. The text box on the following page shows the specific language of Measure B as it Sources: Resolution adopted by the Board of Supervisors for the County of Los Angeles on July 30, 2002, regarding Measure appeared in the November 5, 2002, Official Sample B and the November 5, 2002, general election. Ballot and Voter Information booklet. Administration and Allowable Uses of Measure B Funds The Measure B resolution establishes certain responsibilities for the entities involved in administering Measure B, and it sets forth the purposes for which the board may spend the funds. Specifically, for each fiscal year after 2003–04, the Measure B resolution requires the board by majority vote to set the tax rate, which may be from zero cents to no higher than 3 cents per square foot. However, according to the Measure B resolution, the tax rate may exceed 3 cents because the board may adjust the rate for any cumulative increases to the medical component of the Western Urban Consumer Price Index, 6 California State Auditor Report 2013-116 February 2014 as established by the United States Bureau of Ballot Language for Los Angeles County’s Labor Statistics. Since fiscal year 2003–04, when Measure B of the November 5, 2002, Measure B became effective, the board has voted Consolidated Statewide General Election to increase the tax rate three times: from 3 cents per square foot on structural improvements in PRESERVATION OF TRAUMA CENTERS AND EMERGENCY 2003 to 3.72 cents in 2008; to 3.99 cents in 2010; MEDICAL SERVICES; BIOTERRORISM RESPONSE. To avoid the life‑threatening shutdown of Los Angeles County’s and, most recently, to 4.24 cents in 2012. In its trauma network, maintain and expand the trauma network resolution, the board also defined the purposes, or countywide, ensure more timely response to critical and allowable expenditure categories, for which urgent medical emergencies and respond effectively Measure B funds must be spent, as Table 1 shows. to biological or chemical terrorism, shall all property In fiscal year 2011–12, the most recent fiscal year owners pay an annual tax of three cents per square foot of within our audit period, the measure generated improvements (buildings) on developed property? more than $256 million in revenue. Source: County of Los Angeles Official Sample Ballot and Voter Information booklet for the November 5, 2002, general election. The board did not, however, indicate in the Measure B resolution an allocation methodology for distributing Measure B funds or explain its process for determining the proportions of the funds it would designate for the various allowable expenditure categories. The absence of such specifics allows the board broad discretion in allocating Measure B funds. Rather than specifying an allocation methodology in the board’s resolution, it has allocated Measure B funds through Los Angeles County’s (Los Angeles) overall budget process—an annual process consisting of review and revisions by various county entities, followed by a public hearing to review the county’s budget before its final adoption. The board allocates Measure B funds to several county entities and others to provide trauma services, emergency medical services, and bioterrorism preparedness activities. In its Measure B resolution, the board assigned County Health Services the operational responsibility of authorizing the disbursement of Measure B funds for the purposes identified in the resolution. County Health Services develops and submits to the board annually its recommended budget for Measure B, and this budget specifies financing uses, sources, and revenue information for the upcoming fiscal year. Once the board approves allocations, County Health Services disburses Measure B funds to authorized service providers. Measure B funds are accounted for using Los Angeles’s countywide electronic accounting and purchasing system, in which board‑approved allocations are established and expenditures are recorded. According to Los Angeles’s fiscal manual, the system is used to ensure that the available balance of an allocation is not exceeded. Additionally, as the resolution requires, the Los Angeles County Department of Auditor Controller files annual reports with the board regarding the amount of Measure B funds collected and spent, as well as the status of required projects. California State Auditor Report 2013-116 7 February 2014 Table 1 Purposes for Which Los Angeles May Spend Measure B Funds Trauma • Maintain all aspects of countywide system of trauma centers. centers • Expand system of trauma centers to cover all areas of the county. • Provide financial incentives to keep existing trauma centers within the system. • Pay for the costs of trauma centers, including physician and other personnel costs. Emergency • Coordinate and maintain a countywide system of emergency medical services. medical • Pay for the costs of emergency medical services, including physician and services other personnel costs. Bioterrorism • Enable stockpiling of safe and appropriate medicines to treat persons response affected by a bioterrorist or chemical attack. • Train health care workers and other emergency personnel to deal with the medical needs of those exposed to a bioterrorist or chemical attack. • Provide medical screenings and treatment for exposure to biological or chemical agents in the event of a bioterrorist or chemical attack. • Ensure the availability of mental health services in the event of terrorist attacks. Administration • Defray administrative expenses, including the payment of salaries and benefits for personnel in the Los Angeles County Department of Health Services and other incidental expenses. • Recover the costs of the special election in 2002. • Recover the reasonable costs incurred by the county in spreading, billing, and collecting the special tax. Source: Resolution adopted by the Board of Supervisors for the County of Los Angeles on July 30, 2002, regarding Measure B and the November 5, 2002, general election. Voluntary Implementation of Trauma Systems in California State law allows, but does not require, local agencies that provide emergency medical services (local agencies) to establish trauma systems. For those local agencies that elect to establish trauma systems, state law requires that the agencies submit their trauma system plans to the California Emergency Medical Services Authority (Authority)—the state entity charged with developing the planning and implementation guidelines for emergency medical services systems and with reviewing and approving trauma system plans. Although local agencies must describe in these plans the rationale used to arrive at the number and location of trauma centers, the State provides little guidance on the design of trauma systems. Specifically, the only requirement related to the design of trauma systems is in state regulations and specifies that no more than one trauma center shall be designated for each area comprising 350,000 residents. Essentially, the American College of Surgeons (College of Surgeons) has indicated that admitting a minimum number of injured patients helps ensure that trauma surgeons maintain adequate experience. Additionally, state law recognizes that it is essential for individuals 8 California State Auditor Report 2013-116 February 2014 who need trauma care to receive that care within 60 minutes immediately following their injuries. According to state law, it is during this period, referred to as the “golden hour,” when the potential for survival is greatest, and the need for treatment for shock or injury is most critical. Nevertheless, state law does not require that trauma systems be designed in a certain manner to achieve this goal. Additionally, local agencies may designate as trauma centers only those hospitals that meet minimum standards established in state regulations promulgated by the Authority. These state regulations place various requirements on Summary of Selected Requirements hospitals designated as trauma centers to maintain for Trauma Centers in California personnel, services, and service capabilities Personnel: Includes numerous personnel requirements, necessary to provide around‑the‑clock trauma such as a trauma program medical director, a trauma nurse services. The text box summarizes some of these coordinator/manager, a multidisciplinary trauma team of requirements for trauma centers. Although a surgical and nonsurgical specialists that are on call and trauma center designation may afford a hospital a promptly available, and an emergency department staffed certain level of visibility and prestige, as indicated with qualified specialists in emergency medicine who are in a report by the Authority, maintaining this level immediately available. of readiness requires considerable investment by Services or Programs: Includes intensive care service, the hospital regardless of the number of trauma a burn center, physical therapy, a rehabilitation center, patients or the patients’ ability to pay for services respiratory care, and pediatric service. received. As such, trauma centers that serve low‑income populations of residents who may Service Capabilities: Includes immediately available lack health insurance or other means to pay for radiological service, clinical laboratory service, and surgical service. their care likely endure a greater financial burden than trauma centers that serve a higher‑income Source: Title 22 of the California Code of Regulations. population that is more likely to have health insurance. History of Los Angeles County’s Trauma System According to County Health Services’ documents, Los Angeles’s trauma system began operating in 1983 after years of planning. The system became operational shortly after the State established the Authority and approximately three years before the Authority developed regulations governing trauma systems. Los Angeles’s 2001 trauma plan indicates that the implementation of its trauma system included specific criteria for hospital designation, such as the ability to maintain services at a required level, and a recommended maximum time within which patients would be transported to a trauma center. County Health Services initially designated eight hospitals as trauma centers. Around each trauma center, County Health Services delineated a geographical service area in which all residents could reach the trauma center within a maximum ground‑transport time of 20 minutes. A letter from County Health Services to the board indicates that County Health California State Auditor Report 2013-116 9 February 2014 Services instituted the 20‑minute transport time to limit the maximum time a mobile intensive care unit would be occupied transporting a trauma patient. Following the initial designation of eight hospitals, County Health Services repeated the process to designate additional hospitals as trauma centers to serve areas outside the 20‑minute ground‑transport service of existing trauma centers. Los Angeles’s trauma system included 22 trauma centers during the trauma system’s peak in 1985. By 1990, however, 10 hospitals had withdrawn from the trauma system. Hospitals that withdrew cited unacceptable levels of uncompensated care for trauma patients. Further, as hospitals withdrew from the trauma system, remaining trauma centers treated growing numbers of uncompensated care patients, resulting in additional facilities withdrawing from the trauma system for financial reasons. Consequently, some areas within the county—East San Gabriel Valley, Antelope Valley, and Malibu—lacked a designated trauma center entirely. This situation resulted in Los Angeles’s use of air transportation from these areas for patients who needed access to trauma centers. Effective August 1999 Los Angeles expanded trauma centers’ service areas by increasing the maximum allowable time for patient transport from 20 minutes to 30 minutes. Additionally, in 2010 a trauma center was designated in Antelope Valley. Today, the 14 trauma centers’ service areas include every geographical area of Los Angeles, yet some areas remain underserved because they lack a trauma center within close proximity. Recent Developments in Approaches to Evaluating Trauma Systems As the approach to providing trauma care has evolved in the United States, so have methods for evaluating trauma systems. The College of Surgeons—an association of surgeons that assesses and evaluates trauma systems—states that since 2002, both the federal Health Resources and Services Administration and the College of Surgeons have endorsed an approach to developing trauma systems that includes an evaluation of the frequency, rates, and pattern of injury in a population, an approach referred to as injury epidemiology. For instance, according to the College of Surgeons, knowledge of a region’s injury epidemiology enables the identification of priorities for the allocation of resources, the nature and distribution of injury prevention activities, the financing of the system, and health policy initiatives. Essentially, according to the College of Surgeons, the approach focuses on analyzing data and assessing the burden of injury across specific population groups, such as children, elderly people, and various ethnic groups, to ensure that specific needs or risk factors are identified. 10 California State Auditor Report 2013-116 February 2014 Scope and Methodology The Joint Legislative Audit Committee (audit committee) directed the California State Auditor to conduct an audit of Los Angeles’s management of Measure B funds for 2008 through 2012, which we defined as fiscal years 2008–09 through 2011–12. The audit committee specifically asked us to review and assess Los Angeles’s policies and procedures regarding how it determines the allocation of Measure B funds and to review any plans that Los Angeles may have to mitigate the differences in Measure B funds spent in underserved areas without trauma centers and the rationale for those plans. Table 2 lists the audit committee’s objectives and the methods we used to address those objectives. Table 2 Audit Objectives and the Methods Used to Address Them AUDIT OBJECTIVE METHOD 1 Review and evaluate the laws, rules, With the assistance of legal counsel, we reviewed relevant laws, regulations, and other background and regulations significant to the materials applicable to county trauma systems and Los Angeles County (Los Angeles) Measure B of audit objectives. the November 5, 2002, Consolidated Statewide General Election (Measure B). 2 Determine the roles, responsibilities, • We reviewed the Los Angeles County Board of Supervisors’ (board) Measure B resolution; relevant and organizational structure of the laws; and organization charts of the board, the Los Angeles County Department of Health Services entities involved in managing and (County Health Services), which includes the Emergency Medical Services Agency (EMS), and administering Measure B funds and the Los Angeles County Department of Auditor Controller (auditor‑controller) to determine the ensure that they are consistent with organizational structure of entities involved in managing and administering Measure B funds. applicable laws and policies and • We interviewed key staff at County Health Services, EMS, and the auditor‑controller to determine are effective. the roles and responsibilities of the entities involved in managing and administering Measure B funds. In doing so, we learned that the board had established a Measure B Oversight Committee (oversight committee) shortly after the measure passed, in part, to monitor the collection and expenditure of the tax revenues under Measure B. We describe this oversight committee, which no longer exists, and our concerns with its disbandment further in the Audit Results. • In evaluating the effectiveness of the roles, responsibilities, and organizational structure of the entities involved in managing and administering Measure B funds, we did not identify any reportable issues, other than our concerns with the absence of the oversight committee. 3 Review and assess Los Angeles’s • We interviewed key staff at County Health Services and the auditor‑controller and reviewed policies and procedures regarding documentary evidence provided by Los Angeles, including accounting information related to how it determines the allocation of its budget procedures, budget documents, and the most current fiscal manual, to determine Measure B funds, how funds are spent, Los Angeles’s process for allocating, spending, and accounting for Measure B funds. In doing so, and how funds are accounted for. we learned Los Angeles performs these functions through its regular county budget process. Determine how the county projects the As we describe in the Audit Results, this process appears to be appropriate and efficient. special tax revenue and prepares its • We reviewed documentary evidence related to the oversight committee, including board budget or spending plan. motions and letters, to determine the role of this committee in implementing the measure and determining Measure B allocations. • We reviewed the board’s Measure B resolution to determine what types of expenditures are allowable. • We reviewed annual reports from the auditor‑controller regarding Measure B to analyze the county’s Measure B allocations each fiscal year from 2003–04 through 2011–12. California State Auditor Report 2013-116 11 February 2014 AUDIT OBJECTIVE METHOD • We judgmentally selected 20 claims for reimbursement from two non‑county‑operated trauma centers from our audit period. We also obtained County Health Services’ loss statements for the three county hospitals from our audit period. We reviewed the selected documents to verify whether Los Angeles followed its policies and procedures for spending Measure B funds. In reviewing contracts Los Angeles has with county‑operated hospitals, we identified that Los Angeles needs to revise them to more accurately reflect how Los Angeles reimburses county‑operated hospitals for uncompensated care costs. Following our fieldwork, we discussed this issue with County Health Services and recommended they revise their contracts. County Health Services agreed with our recommendation. • We interviewed key staff at County Health Services and the auditor‑controller to determine how Los Angeles projects special tax revenue and prepares the county budget. We found the auditor‑controller lacks formal policies and procedures regarding how it projects the Measure B revenue Los Angeles will collect each year. Although we did not believe this issue rose to the level of reporting in our Audit Results, following the end of our fieldwork we discussed this issue with Los Angeles and recommended to the auditor‑controller that they formalize their procedures for projecting Measure B revenues. The auditor‑controller agreed with our recommendation. 4 For the past four years, perform We defined our audit period as fiscal years 2008–09 through 2011–12. the following: a. Determine the total Measure B funds We reviewed Los Angeles’s financial statements and transfer schedules for our audit period to allocated to medical service providers determine how funds were allocated and spent. In the Appendix, we present the amounts of by area or other relevant allocation Measure B funds each of the county‑operated hospitals received for uncompensated trauma factors, such as demographics, as and emergency care and the amounts the non‑county‑operated trauma centers received for needed. Determine, to the extent uncompensated trauma care for fiscal years 2008–09 through 2011–12. possible, how much of the allocations to underserved areas without trauma centers have been spent. b. Review and assess any analyses or We completed this work as part of Objectives 3 and 6 and describe Los Angeles’s approach to justification used by Los Angeles allocating Measure B funds in the Audit Results. in making decisions on funding allocations. Determine what factors, such as serving underserved areas or expanding services, Los Angeles considers in making its decisions. c. To the extent possible, determine We reviewed helicopter transport data provided by EMS to determine the number of helicopter why and how often helicopters transports, the locations where they occurred, as well as the number of helicopter transports that and air paramedic services have were cancelled or aborted between 2009 and 2012. We describe our concerns with this data in the been used and in what areas, such Audit Results. as in underserved areas without trauma services. d. Determine the total revenues, • We reviewed the county’s Comprehensive Annual Financial Reports to determine the total expenditures, and fund balances for Measure B revenues, expenditures, and fund balances for our audit period. We present this each year and determine the reasons information in Table 3 on page 25 of the Audit Results. for any significant fluctuations • We interviewed key staff at County Health Services to determine the reasons for any fluctuations from year‑to‑year or for significant or large ending balances in the Measure B fund balance from year‑to‑year. amounts in fund balances. 5 Review any plans Los Angeles may • We interviewed key staff at EMS and reviewed documents provided by Los Angeles to have to mitigate the differences in determine the steps, if any, the county has taken to expand services funded by Measure B. Measure B funds spent in underserved • We reviewed the board’s Measure B resolution and relevant materials provided to voters to areas without trauma centers and the determine what expectations voters may have had regarding the expansion of trauma services rationale for those plans. Determine if to underserved areas if Measure B passed. those plans include proposals to expand • To determine Los Angeles’s efforts in designating a trauma center in the East San Gabriel Valley, the services funded by Measure B. we reviewed documentation related to board meetings and spoke to key staff at County Health Services, EMS, and the Pomona Valley Hospital Medical Center. continued on next page . . . 12 California State Auditor Report 2013-116 February 2014 AUDIT OBJECTIVE METHOD • We interviewed key staff at EMS to determine how Los Angeles has expanded helicopter services and how it monitors and reports on the adequacy of these services. • We interviewed key staff at EMS to determine whether the agency reviews and analyzes helicopter transport data. In the Audit Results we describe our concerns with the quality and usefulness of its data. 6 Determine whether Los Angeles • We reviewed Los Angeles’s process for allocating and spending Measure B funds, as described analyzes its spending and funding in the Method column for Objective 3, and interviewed key staff at County Health Services plans and reassesses its past and future and EMS to determine whether Los Angeles analyzes its spending plans. We found the county decisions to ensure it is equitably has generally allocated Measure B funds in the same proportions year after year, but does not allocating funds in the areas of greatest analyze how Measure B expenditures address the population’s trauma care needs and fulfill the need and that decisions are consistent intent of Measure B, as described in the Audit Results. with the intent of Measure B. • We reviewed the board’s Measure B resolution and other relevant county documentary evidence to determine the intent of Measure B. • After determining through interviews with key County Health Services staff that Los Angeles does not analyze or reassess its spending decisions, including its allocation decisions, based on areas of greatest need, we interviewed key EMS staff and reviewed documentation provided by EMS to determine whether EMS evaluates the Los Angeles trauma system. • We reviewed measures passed by four other counties to fund emergency medical services to determine, among other things, how those counties allocate the funds and have communicated these allocation approaches to voters. • We interviewed key officials from the American College of Surgeons (College of Surgeons) Trauma Systems and Trauma Center Verification Programs and reviewed materials produced by the College of Surgeons to determine what a comprehensive trauma system evaluation conducted by the College of Surgeons entails. We also interviewed key staff from EMS to determine whether Los Angeles has considered such a review. We report this information in the Audit Results. 7 Review and assess any other issues Based on interviews with key staff at County Health Services, we describe in the Audit Results that are significant to Los Angeles’ Los Angeles’s perspective on how changes in insurance coverage resulting from the Patient management of Measure B funds. Protection and Affordable Care Act might affect funding for its trauma system. Sources: California State Auditor’s analysis of Joint Legislative Audit Committee’s audit request number 2013‑116, planning documents, and analysis of information and documentation identified in the column titled Method. California State Auditor Report 2013-116 13 February 2014 Audit Results Since Measure B Passed in 2002, Los Angeles County Has Not Conducted a Comprehensive Assessment of Its Trauma System More than a decade after voters of Los Angeles County (Los Angeles) approved Measure B to, among other things, maintain and expand the trauma network countywide, certain geographical areas within Los Angeles remain far removed from existing trauma centers, thus requiring helicopter transport for some of those areas’ trauma patients. Because of this situation, inequities may exist in Los Angeles’s residents’ access to trauma care. Specifically, a resident who lives in an area without a trauma center may have to travel a greater distance to access trauma services than would a person who lives near a trauma center. The absence of a nearby trauma center potentially lengthens the time before the trauma victim receives care and may therefore affect the patient’s health outcome. The Los Angeles Emergency Medical Services Agency (EMS)—the county entity responsible for overseeing the trauma system—nonetheless asserts that the trauma system is adequate. However, EMS’s current evaluation efforts focus on the performance of individual trauma centers rather than on the system as a whole and whether it is meeting the needs of at‑risk population groups. A comprehensive evaluation of Los Angeles’s trauma system may provide greater transparency regarding the system’s needs and challenges, and it may allow the Board of Supervisors for the County of Los Angeles (board) to demonstrate to voters whether Los Angeles has fulfilled the intent of Measure B. According to a resolution adopted by the board in July 2002, funds raised by the measure are to be used, in part, to maintain all aspects of Los Angeles’s system of trauma centers and to expand the system to cover all areas of the county. That resolution remains the legal source document describing the specifics of Measure B (Measure B resolution). A board supervisor’s motion urging the board to approve the Measure B resolution acknowledges that Los Angeles’s system of trauma centers at that time did not cover every corner of the county and that an optimal trauma system would include three additional trauma centers in certain areas of the county that lacked such centers. The director of EMS, which is the agency responsible for designating trauma centers, maintains that Los Angeles’s efforts to expand the trauma system have fulfilled the intent of Measure B by stabilizing the system and ensuring that adequate care is provided to all areas of the county. As support for this position, the director stated that since the measure passed more than 10 years ago, no trauma centers have left the trauma system because of financial problems and two additional trauma centers have joined. 14 California State Auditor Report 2013-116 February 2014 However, although Los Angeles is only required to implement the actual text of Measure B, certain information within Los Angeles’s Official Sample Ballot and Voter Information booklet (voter information booklet) for the November 2002 general election may have led voters to believe that the passage of the measure would ensure that certain areas of the county would have local trauma centers. In particular, included in the voter information booklet was a rebuttal to arguments against Measure B that stated, “Measure B will make it possible to provide trauma service in three areas where none currently exists: Pomona, East San Gabriel Valley and the Antelope Valley.” It further stated, “Antelope Valley residents would have either a Trauma Hospital or a fully‑equipped trauma helicopter that is dedicated full‑time to that area.” As of January 2014 the Los Angeles trauma system consisted of 14 trauma centers: two county‑operated and 12 non‑county‑operated hospitals. As Figure 1 shows, the areas of Malibu and East San Gabriel Valley, which includes the city of Pomona, lack a trauma center located within their geographic boundaries. Although one trauma center is located in the expansive Antelope Valley, some patients must be transported more than 30 miles to reach a trauma center. To better understand the county’s current perspective about whether it believes these areas continue to be underserved, we interviewed the director of EMS. According to the director, Malibu is an area in which the population density, about 12,500, does not support a hospital that could be designated as a trauma center. Additionally, in 2010, Antelope Valley Hospital was designated a trauma center, a change that decreased the travel time to the nearest trauma center The director explained that East and the use of air transport in the Antelope Valley. Further, the San Gabriel Valley is the only director explained that East San Gabriel Valley is the only underserved underserved area in Los Angeles area in Los Angeles with a population density that would support with a population density that a trauma center. Nevertheless, for purposes of our report, we refer would support a trauma center. to all three areas as “underserved” because the distances to existing trauma centers from these areas may require that Los Angeles employ helicopters to transport patients from these areas to a trauma center. We believe that Los Angeles should better define the areas it considers underserved so that it can focus its efforts on those areas. Although Figure 1 shows that the service area of a trauma center encompasses each underserved area, for some residents of Malibu, Antelope Valley, and East San Gabriel Valley those trauma centers may be several miles away. For instance, residents in the city of Pomona are roughly 28 miles from their designated trauma center, LAC+USC Medical Center, while residents in Malibu are roughly 20 miles from their designated trauma center, Ronald Reagan UCLA Medical Center. To serve residents of these underserved areas, Los Angeles employs helicopters to transport trauma patients to these areas’ designated trauma centers when the estimated ground transport times exceed 30 minutes. California State Auditor Report 2013-116 15 February 2014 Figure 1 Trauma Centers in Los Angeles County and Their Respective Service Areas as of January 2014 KERN COUNTY Lancaster 5 AVH Antelope Valley VENTURA COUNTY HMN HCH NRH 5 Los Angeles 405 East HMH San Gabriel CHH CSM Malibu UCL Valley USC Pomona Malibu CAL 10 605 PACIFIC OCEAN SFM Legend ORANGE COUNTY HGH Freeways LBM Trauma center Long Beach SMM Trauma center service areas N 0 10 mi Underserved area boundaries Trauma Centers in Los Angeles County AVH: Antelope Valley Hospital HMN: Henry Mayo Newhall Memorial Hospital CAL: California Hospital Medical Center LBM: Long Beach Memorial Medical Center CHH: Children’s Hospital of Los Angeles NRH: Northridge Hospital Medical Center CSM: Cedars-Sinai Medical Center SFM: St. Francis Medical Center HCH: Providence Holy Cross Medical Center SMM: St. Mary Medical Center HGH: Harbor-UCLA Medical Center* UCL: Ronald Reagan UCLA Medical Center HMH: Huntington Memorial Hospital USC: LAC+USC Medical Center* Sources: California State Auditor’s adaptation of information provided by Los Angeles County’s Emergency Medical Services Agency and information obtained from www.randmcnally.com regarding the approximate location of selected cities. * Harbor‑UCLA Medical Center and LAC+USC Medical Center are the two county‑operated trauma centers. 16 California State Auditor Report 2013-116 February 2014 Although the director of EMS maintains that the trauma system is adequate and that it is meeting the needs of all areas in Los Angeles, including those areas that are underserved, she acknowledged that Los Angeles has not conducted an evaluation of its trauma system to demonstrate that it has fulfilled the intent of Measure B. Rather, EMS’s evaluation efforts include obtaining trauma data and monitoring individual trauma centers periodically. In conjunction with the American College of Surgeons (College of Surgeons)—a scientific and educational association of surgeons that has established a committee on trauma to, in part, assess and evaluate trauma systems—EMS conducts periodic performance evaluations of individual trauma centers to verify compliance with accepted College of Surgeons’ standards of care for trauma patients and compliance with applicable state regulations. Additionally, the director explained that EMS monitors the trauma system by reviewing trauma data submitted quarterly by each individual trauma center, such as the number of trauma patients served and the severity of patient injuries, which EMS recently began summarizing in an annual report. These monitoring efforts, however, do not enable EMS or Los Angeles to examine whether the system as a whole serves Los Angeles’s residents equitably or to identify any gaps in service by population group or geographic area. Although EMS collects data for each Although EMS collects data for each trauma patient—including trauma patient, current monitoring information on each patient’s gender, age, race or ethnicity, and activities do not include analyzing place of residence—current monitoring activities do not include this data to assess how the trauma analyzing this data to assess how the trauma system is serving those system is serving those population population groups most at risk of having a trauma injury. Further, groups most at risk of having a EMS’s current data‑monitoring activities also do not allow for the trauma injury. county to assess the burden of injury across specific demographic groups to ensure that specific needs or risk factors are identified— an approach explained in the Introduction and referred to by the College of Surgeons in its Regional Trauma Systems: Optimal Elements, Integration, and Assessment Systems Consultation Guide (consultation guide) as injury epidemiology. By understanding where injuries occur, what type of injuries occur most often, and to whom they occur, the College of Surgeons suggests that decision makers could be better informed when deciding where to spend trauma resources or in considering whether trauma policy should be revised. For example, according to EMS’s first Emergency Medical Services System Report, which was published in July 2012 and based on Los Angeles’s data, males between the ages of 20 and 24 experienced the highest incidence of trauma of any age group in Los Angeles, and they experienced nearly four times the incidence of trauma as did females in the same age group. Additionally, black males experienced more than double the trauma incidence of Hispanic males, who had the next highest reported incidence of trauma if one considers race and ethnicity. California State Auditor Report 2013-116 17 February 2014 As Figure 2 on page 18 and 19 indicates, the majority of trauma The majority of trauma centers centers appear to be generally located in Los Angeles’s most appear to be generally located populated areas—the areas containing a higher concentration of in Los Angeles’s most populated individuals ages 20 to 24 and the areas with a higher concentration areas—the areas containing a of black males. However, EMS does not use demographic data to higher concentration of individuals assess the trauma system in terms of how the number and location ages 20 to 24 and the areas of trauma centers are meeting the needs of these at‑risk populations. with a higher concentration of Although we believe that EMS’s publishing of its annual Emergency black males. Medical Services System Report is a good first step toward providing the public with greater information about the occurrence of trauma across specific population groups, EMS should take further steps to use the demographic data to ensure that it identifies specific needs within its trauma system. Without a comprehensive assessment of its trauma system as a whole, Los Angeles cannot demonstrate that its current system is meeting the needs of those in its population at the greatest risk of experiencing trauma. A comprehensive assessment would provide greater transparency to the public regarding Los Angeles’s existing trauma system’s needs and challenges. In fact, according to the manager of the College of Surgeons’ trauma systems and trauma center verification programs (trauma programs manager), the College of Surgeons is the only independent, nonprofit organization that conducts assessments of trauma systems. It operates a trauma systems consultation program that conducts a comprehensive on‑site review of trauma systems at all levels of maturity, and the review can be tailored to address specific trauma system concerns. According to the College of Surgeons, a hand‑chosen multidisciplinary team of national trauma system experts provides an independent, comprehensive assessment of the system. The review includes a critical analysis of the current system’s status, including its challenges and opportunities. Additionally, the process allows trauma system participants to request that the College of Surgeons focus on questions specific to the system’s critical issues. The College of Surgeons states that the report prepared following the consultation provides a current assessment of the trauma system and recommendations for future trauma system development. 18 California State Auditor Report 2013-116 February 2014 Figure 2 Location of Trauma Centers in Los Angeles County and Selected Demographics KERN COUNTY KERN COUNTY Total Population AVH Total Population of Black Males AVH Antelope Valley Antelope Valley 64,524 - 206,920 598 - 2,316 254,201 - 369,012 3,397 - 6,012 414,533 - 570,853 10,977 - 16,619 942,452 V C E O N U T N U T R Y A 32,840 - 50,968 V C E O N U T N U T R Y A 1,776,852 - 2,512,536 HMN 148,058 HMN HCH HCH NRH NRH HMH HMH Malibu UCL CSM CH C H AL USC San V E a G a l a l s e b t y riel Malibu UCL CSM CH C H AL USC San V E a G a l a l s e b t y riel PACIFIC OCEAN SFM PACIFIC OCEAN SFM HGH ORANGE COUNTY HGH ORANGE COUNTY LBM LBM SMM SMM KERN COUNTY Total Population Ages 20-24 AVH Antelope Valley 3,570 - 13,389 16,029 - 31,094 43,521 - 78,927 126,521 VENTURA COUNTY 214, 905 HMN HCH NRH LEGEND HMH CSM CHH Trauma center UCL Malibu USC East Census County Divisions* San Gabriel CAL Valley Underserved area boundaries SFM PACIFIC OCEAN HGH ORANGE COUNTY LBM SMM California State Auditor Report 2013-116 19 February 2014 Figure 2 Location of Trauma Centers in Los Angeles County and Selected Demographics KERN COUNTY KERN COUNTY Total Population AVH Total Population of Black Males AVH Antelope Valley Antelope Valley 64,524 - 206,920 598 - 2,316 254,201 - 369,012 3,397 - 6,012 414,533 - 570,853 10,977 - 16,619 942,452 V C E O N U T N U T R Y A 32,840 - 50,968 V C E O N U T N U T R Y A 1,776,852 - 2,512,536 HMN 148,058 HMN HCH HCH NRH NRH HMH HMH Malibu UCL CSM CH C H AL USC San V E a G a l a l s e b t y riel Malibu UCL CSM CH C H AL USC San V E a G a l a l s e b t y riel PACIFIC OCEAN SFM PACIFIC OCEAN SFM HGH ORANGE COUNTY HGH ORANGE COUNTY LBM LBM SMM SMM KERN COUNTY Total Population Ages 20-24 AVH Antelope Valley 3,570 - 13,389 16,029 - 31,094 43,521 - 78,927 126,521 VENTURA COUNTY 214, 905 HMN HCH NRH LEGEND HMH CSM CHH Trauma center UCL Malibu USC East Census County Divisions* San Gabriel CAL Valley Underserved area boundaries Sources: California State Auditor’s adaptation of information provided by Los Angeles County’s Emergency Medical Services Agency and SFM information obtained from the United States Census Bureau (Census Bureau) Web site based on the 2008–2012 American Community PACIFIC OCEAN HGH ORANGE COUNTY S N u o r t v e e : y T fi h v e e t ‑ r y a e u a m r e a s c ti e m n a te te rs s ’ . full names appear in Figure 1 on page 15. LBM * A Census County Division is a subdivision of a county that is a relatively permanent statistical area established by the Census Bureau SMM and state and local government authorities. 20 California State Auditor Report 2013-116 February 2014 According to its client manual regarding a trauma Selected Areas of Review Included in the consultative visit, the College of Surgeons American College of Surgeons’ Trauma System assembles a team of five reviewers to conduct the Consultation Process consultation. The team typically includes a trauma surgeon; an emergency physician; a trauma nurse; Injury Epidemiology—The frequency, rates, and pattern a state, regional, or local EMS director; and a team of injury events in a population. Injury pattern refers to the occurrence of injury‑related events caused by leader, usually a surgeon. The review team, various factors, including time, place, and such personal according to the trauma programs manager, meets characteristics as age, race, and sex. on site with the lead agency and stakeholders to review various elements described within the Trauma System Plan—A clearly articulated planning College of Surgeons’ consultation guide. The team process resulting in a written trauma system plan. This is also supported on site by College of Surgeons process builds on a completed inventory of trauma system resources that identifies gaps in services or resources and staff. The text box describes examples of areas of the location of assets. In addition, the process relies on an review included in the consultation process and assessment of demographics, topography, or other access discussed in the consultation guide. A enhancements or barriers to access by patients. consultation, for instance, may include a needs assessment to review the optimal placement, level, Financing—A sufficient amount of funding to plan, and number of trauma centers within a system to implement, and evaluate a statewide or regional system of trauma care. help trauma system leaders determine whether the existing system’s design is meeting population Definitive Care Facilities—The acute‑care facilities needs. According to the trauma programs operating within an inclusive trauma system that provide manager, a trauma system consultative visit by the definitive care to the entire spectrum of patients with College of Surgeons typically requires less than a traumatic injuries. year to complete and costs $65,000. In California Systemwide Evaluation and Quality Assurance—The the College of Surgeons has already conducted processes for evaluating the performance of all aspects formal evaluations of regional trauma systems in of the trauma system, including the outcomes of three counties—Marin in 2002, Ventura in 2010, population‑based injury prevention initiatives and access and Solano in 2013. to care. Trauma Management Information Systems—The Although EMS employs the College of Surgeons information systems designed to provide data from to assess regularly the services provided by throughout the trauma care system that allow and facilitate individual trauma centers, EMS has expressed evaluation of the structure, process, and outcomes of the reservations about requesting the College entire trauma care system. Decision makers use these of Surgeons to conduct a trauma system information systems to develop, implement, and influence consultation of Los Angeles’s system. According public policy. to the director of EMS, the agency believes that Source: American College of Surgeons’ Regional Trauma such a review would not add value because Systems: Optimal Elements, Integration, and Assessment Systems Consultation Guide. Los Angeles’s trauma system is well established, and it would likely not be feasible to implement any recommendations to add or remove trauma centers. For example, the director of EMS suggested that such a review may find that some areas of the county have too many or too few trauma centers, and she believes the board would not direct a hospital to withdraw. Furthermore, state law does not authorize either the State or a local health department to require a hospital to join a trauma system. California State Auditor Report 2013-116 21 February 2014 On the other hand, we believe a comprehensive assessment by the College of Surgeons would likely result in recommendations that could improve and enhance the county’s trauma system or identify areas requiring more focused attention. Specifically, using Measure B funds, Los Angeles could request that the College of Surgeons focus on questions related to assessing its allocation of Measure B funds and analyzing how EMS might better use the data it collects to continuously evaluate, improve, and report on its trauma system. Although Los Angeles does recognize that the geographic locations of existing trauma centers within its trauma system are not optimal, without a comprehensive assessment like one conducted by the College of Surgeons, Los Angeles is precluding itself from identifying weaknesses in its trauma system and from ensuring that it is adequately serving all areas and population groups of the county. Thus, county residents, particularly those residing in underserved areas or belonging to population groups at the greatest risk of experiencing trauma, may lack assurance that Los Angeles is using Measure B funds effectively and that it is being transparent in terms of the successes and challenges of its trauma system. Los Angeles Should Reassess Its Allocation Approach to Verify and Demonstrate That the County Is Fulfilling Measure B’s Intent Not since 2003 has the board revisited its approach for allocating funds to maintain and expand the trauma system countywide, and the dissolution of its Measure B Oversight Committee (oversight committee) in 2004 left it without a key advisory body that could help ensure that the allocation approach is sound. Further, although the board originally intended to provide helicopter services as an interim solution for trauma patients residing in underserved areas, more than 10 years later the board has continued to fund helicopter services using Measure B revenue. Given the length of time Los Angeles has provided helicopter services to trauma patients in underserved areas, we expected EMS to monitor, assess, and report consistently on the effectiveness and adequacy of these services; however, we found that it has not done so. As a result, the board lacks the ability to demonstrate to the public that the funds it has provided for these purposes are fulfilling the intent of Measure B. Additionally, although EMS made some attempts several years ago Although EMS made some attempts to designate a trauma center in East San Gabriel Valley, it has made several years ago to designate a minimal attempts since that time. Interestingly, when we contacted trauma center in East San Gabriel one of the eligible hospitals in the area to gauge its interest in Valley, it has made minimal becoming a trauma center, we learned that an opportunity may attempts since that time. exist to do so. 22 California State Auditor Report 2013-116 February 2014 Los Angeles Cannot Demonstrate Adequately to Taxpayers That It Distributes Funds in a Manner That Fulfills Measure B’s Intent The board has not revisited its allocation approach in nearly a decade and cannot provide assurance to residents of Los Angeles that it directs Measure B funds toward the areas and population Its approach to allocating groups with the greatest needs. In fact, its approach to allocating Measure B funds has resulted in Measure B funds has resulted in significant fund balances over significant fund balances over at at least the four fiscal years within our audit period—fiscal least the four fiscal years within our years 2008–09 through 2011–12. Because the ballot language for audit period—fiscal years 2008–09 Measure B did not specify the manner in which funds should through 2011–12. be allocated or identify the proportion of funds that should be designated for each of the expenditure categories, such as trauma or emergency medical services, the board has broad discretion in determining how to allocate Measure B funds. With this discretion, almost immediately following the passage of Measure B, the board created an oversight committee to monitor and report back annually on the collection and expenditure of the tax revenues under Measure B to ensure proper use of these funds. The oversight committee was chaired by the County of Los Angeles Department of Auditor Controller (auditor‑controller) and was made up of representatives from Los Angeles’s chief executive office, Los Angeles County Department of Health Services (County Health Services), county counsel, the assessor, the treasurer, and the tax collector. Based on a letter from the auditor‑controller to the board, the oversight committee appears to have been formed in February 2003 and reported to the board on its actions in both 2003 and 2004. In its June 2003 letter to the board, the oversight committee proposed that the board allocate Measure B funds in certain proportions among the various allowable expenditure categories. The oversight committee recommended distributing most of the projected revenues to pay for trauma and emergency care at county‑operated hospitals and for trauma care at non‑county‑operated trauma centers. Specifically, Los Angeles reimburses the hospitals and trauma centers for treatment of patients who are unable to pay for their care and who have no third‑party insurance coverage, which we refer to as uncompensated care. According to available documentation, the oversight committee’s last report to the board appears to have been in May 2004, after which, according to the assistant auditor‑controller, it effectively dissolved. The assistant auditor‑controller explained that the oversight committee was not intended to provide permanent oversight of Measure B. Rather, he stated that the oversight committee’s purpose was to ensure that the major implementation and startup activities were well coordinated among the involved county departments and that processes and procedures California State Auditor Report 2013-116 23 February 2014 would be carefully planned and instituted. Once the processes and procedures were in place, the assistant auditor‑controller indicated that the ongoing attention of a permanent oversight committee was no longer required. However, the board‑approved motion to create the oversight committee specified the importance of having proper safeguards in place to ensure that Measure B funds were spent on their intended goals and having county departments with proper expertise involved in reviewing the use of these funds. In fact, according to a letter written by the Office of the Pasadena City Manager the day before the 2002 general election, one Los Angeles supervisor had expressed his opposition to Measure B and cited various concerns, including the potential for misappropriation of Measure B funds and the possibility that the funds would not provide for equal access to trauma services for residents of portions of the county. Not surprisingly, this same supervisor presented the motion to the board regarding the creation of the oversight committee, and in his motion he specifically stated that the committee was to ensure proper use of the funds and to report back annually to the board. Thus, the motion did not indicate that the oversight committee was to be temporary. While we acknowledge that the board’s initial intentions to establish the oversight committee were prudent and addressed interests of transparency, we question why it would abandon such an oversight mechanism. If re‑established with representatives from county departments who have expertise in the county’s trauma and EMS systems, as well as in bioterrorism preparedness programs, the oversight committee could provide assurance to voters that Measure B funds are used appropriately and that the board’s allocation of Measure B funds is sound. For example, annual reports produced by the oversight committee, if made available on the county’s Web site, could describe to the board, voters, community leaders, and others how Measure B expenditures are meeting the county’s trauma needs. Further, such reports could increase transparency about how Measure B funds are spent by describing the ways in which Los Angeles has fulfilled the intent of Measure B, which, according to board documents, includes assisting hospitals in underserved areas to become trauma centers. For more than nine years following the dissolution of the oversight For more than nine years following committee, the board has remained without a key body to oversee the dissolution of the oversight and advise it on the allocation of Measure B funds. Since the committee, the board has remained passage of Measure B, the board has generally allocated Measure B without a key body to oversee funds in the same proportions year after year through the county and advise it on the allocation of budget process. The allocations for fiscal year 2011–12, shown Measure B funds. in Figure 3 on the following page, demonstrate that the board continues to allocate Measure B funds primarily to reimburse non‑county‑operated trauma centers and county‑operated hospitals for uncompensated care costs, as originally recommended by the 24 California State Auditor Report 2013-116 February 2014 oversight committee. In the Appendix, we present the amount of Measure B funds each non‑county‑operated trauma center and each county hospital received during fiscal years 2008–09 through 2011–12. Additionally, the board has generally allocated $4.4 million annually to address the needs of trauma patients residing in underserved areas, an amount that the board has used to fund helicopter transport services. Figure 3 Allocations of Los Angeles County’s Measure B Special Tax Revenue Fund for Emergency Medical Services, Trauma Centers, and Bioterrorism Response Fiscal Year 2011–12 (Dollars in Millions) Administrative costs—$1 (0.4%) Emergency Medical Services Agency—$1.8 (0.7%) Trauma access expansion to underserved areas—$4.4 (1.7%) Physician Services for Indigents program—$4.7 (1.8%) Bioterrorism response—$9.2 (3.6%) Non-county-operated trauma centers— $39.9 (15.7%)* County-operated hospitals—$194.1 (76.1%)* Total amounts allocated—$255.1 Source: Measure B Special Tax Revenue Fund for Emergency Medical Services, Trauma Centers, and Bioterrorism Response Status of Measure B Projects, an unaudited report prepared by the Los Angeles County Department of Health Services, for fiscal year ending June 30, 2012. * The county‑operated hospitals are reimbursed for uncompensated care costs associated with providing trauma and emergency medical services. Non‑county‑operated trauma centers are reimbursed for costs including uncompensated care associated with providing trauma services and for providing medical direction and destination to prehospital care personnel within the Los Angeles County emergency medical services system. By using the initial allocation approach recommended by the oversight committee in 2003, and by making subsequent adjustments pertinent to the needs of the program, county officials believe that they have addressed a primary concern of trauma centers and helped stem their withdrawal from the trauma system. According to the director of EMS, by reimbursing a California State Auditor Report 2013-116 25 February 2014 significant portion—but not the total amount—of trauma centers’ uncompensated care costs, Measure B funds have helped to stabilize the county’s trauma system and expand the number of trauma centers it contains. Nevertheless, underserved areas of the county—such as East San Gabriel Valley—continue to lack trauma centers. Moreover, without ongoing input from an advisory body, such as an oversight committee, to review the allocation approach and advise the board on whether the current funding strategy is best fulfilling the intent of Measure B, the public may lack certainty that the county is investing its resources most effectively toward the allowable purposes set forth in Measure B. Further, the board’s approach to allocating Measure B funds appears overly conservative because it has resulted in significant fund balances at year end. Specifically, as Table 3 shows, our review of Measure B allocations found that the current approach has left anywhere from roughly $6 million to nearly $11 million in unallocated funds at year end from fiscal years 2008–09 through 2011–12. County Health Services’ special funds manager stated that the Measure B fund balances result from surpluses from previous years, and he explained that these funds are not fully allocated in the immediate subsequent year and are accounted for as contingency in Los Angeles’s budgetary process until a new request is received. Nevertheless, an advisory body similar to the oversight committee could recommend whether and how the board should allocate significant fund balances, such as whether to help fund efforts to establish trauma centers in underserved areas, or to consider whether such balances are warranted. Table 3 Ending Fund Balances for Los Angeles County’s Measure B Special Tax Revenue Fund for Emergency Medical Services, Trauma Centers, and Bioterrorism Response Fiscal Years 2008–09 Through 2011–12 (In Thousands) FISCAL YEAR END JUNE 30, 2009 JUNE 30, 2010 JUNE 30, 2011 JUNE 30, 2012 Beginning fund balance $37,437 $9,891 $6,018 $5,935 Revenues 235,124 236,540 254,942 256,098 Expenditures* 262,670 240,413 255,025 251,037 Ending fund balance $9,891 $6,018 $5,935 $10,996 Sources: County of Los Angeles (Los Angeles) Comprehensive Annual Financial Reports and annual statements of financial activity filed by the Los Angeles Department of Auditor Controller with the Los Angeles Board of Supervisors, fiscal years 2008–09 through 2011–12. * Includes transfers to county‑operated hospitals, Los Angeles County Department of Public Health, and the Los Angeles County Emergency Medical Services Agency. 26 California State Auditor Report 2013-116 February 2014 Although administering Measure B funds through the county’s budget process appears appropriate and efficient, Los Angeles cannot demonstrate to voters that it is directing funds to the most pressing needs of its trauma system because it lacks ongoing oversight and analysis of its approach to allocating Measure B funds. According to County Health Services’ associate chief financial officer, the current allocation approach that is based on uncompensated care costs is an objective, verifiable method that is consistent with the Measure B resolution. However, Because it focuses on we are concerned about this approach because it focuses on uncompensated care at existing uncompensated care at existing trauma centers and does not trauma centers and does not consider the trauma care needs of Los Angeles’s population, consider the trauma care needs particularly those population groups at the greatest risk of trauma of Los Angeles’s population, injury. The comprehensive assessment described previously would particularly those population allow Los Angeles to identify at‑risk populations and priority groups at the greatest risk of areas that may need more focused attention and services. For trauma injury, the board cannot example, as we explain later in the report, the underserved area of demonstrate that it is fulfilling the East San Gabriel Valley has long lacked a trauma center. However, intent of Measure B. by not revisiting its allocation of Measure B funds, Los Angeles may have missed opportunities to assist existing hospitals in underserved areas become trauma centers and, therefore, may have fallen short of fulfilling the intent of Measure B. With the information gained from a comprehensive assessment, the oversight committee could revisit its approach to allocating Measure B funds to ensure that the board directs funds in a manner that addresses Los Angeles’s most pressing trauma care needs and fulfills the intent of Measure B. Additionally, the Patient Protection and Affordable Care Act (Act) may influence the manner in which Los Angeles allocates Measure B funds to support its trauma and emergency medical services systems in the future. County Health Services’ officials explained that it is unclear how much reimbursement trauma centers will receive once the Act is fully implemented. To address the uncertainties raised by the Act, Los Angeles officials have begun to hold negotiation meetings with trauma center representatives. Specifically, representatives from County Health Services, EMS, and the Office of County Counsel are meeting with representatives of the Hospital Association of Southern California (hospital association)—which represents non‑county‑operated trauma centers—to discuss ways to address the effects of the Act on trauma centers in Los Angeles. Based on the information from its meetings with the hospital association, the associate chief financial officer at County Health Services stated that it would consider revising how Los Angeles reimburses trauma centers using Measure B funds. We believe the oversight committee, if reinstated, should review Los Angeles’s negotiation efforts and inform the board of any concerns it identifies. California State Auditor Report 2013-116 27 February 2014 Although Los Angeles Has Used Measure B Funds to Provide for Helicopter Transport of Trauma Patients From Underserved Areas, It Does Not Monitor, Assess, or Report Consistently on the Adequacy of These Services In 2003 County Health Services’ director at that time (former director) proposed to the board that it allocate $4.4 million of Measure B funding to provide trauma services for patients in underserved areas—East San Gabriel Valley, Antelope Valley, and Malibu. As explained in the proposal, the original intent of the expansion funds under Measure B was to assist hospitals in these areas to become trauma centers. However, as acknowledged by the former director, none of the hospitals in these areas were prepared to join the trauma system at that time. Further, although the former director stated that County Health Services intended to keep this funding earmarked for potential trauma centers in these areas, he proposed an interim solution to augment the current trauma system transport capability for Los Angeles residents. Specifically, based on his proposal, the board ultimately provided $2 million of Measure B funds for 24‑hour, seven‑days‑a‑week helicopter services in the Antelope Valley and up to $2.4 million to reimburse public entities for, among other things, providing helicopter services to trauma patients in underserved areas. In 2005 the board approved an annual allocation of $450,000 in Measure B funds Although originally an interim to designate a 24‑hour, seven‑days‑a‑week paramedic air squad solution for trauma patients helicopter for East San Gabriel Valley. Although the former director residing in underserved areas, originally indicated that the helicopter services would be an interim more than 10 years later the board solution for trauma patients residing in underserved areas, more has continued to use Measure B than 10 years later the board has continued to use Measure B funds funds to provide helicopter services to provide helicopter services for access to trauma services for for access to trauma services for patients residing in these areas. patients residing in these areas. At the time the former director made his proposal to the board, he acknowledged that although helicopter transport is not the optimal method, as there are inherent safety and weather limitations, it is the best alternative when trauma centers are not available. Given this acknowledgement and the fact that Los Angeles has provided helicopter services to patients from underserved areas for roughly a decade, we expected EMS to monitor, assess, and report consistently on the effectiveness and adequacy of these services; however, we found that EMS has not done so. Specifically, we expected EMS to have a regular process for reviewing and analyzing helicopter service data specific to underserved areas in an effort to ensure that helicopters are adequately serving trauma patients transported from these areas. For example, for each underserved area, EMS could compile and analyze the number of trauma patients transported by helicopter, the location within the underserved area where the trauma incident occurred, the duration of each trauma patient’s transport, the mortality rates of 28 California State Auditor Report 2013-116 February 2014 these transported trauma patients, and any instance of cancelled transports. Such an analysis would allow EMS to gauge the demand for and effectiveness of helicopter services in each underserved area and the ability of helicopter service providers to meet that demand, to better understand where trauma is occurring, and to verify whether helicopters are transporting trauma patients from underserved areas in a manner comparable to trauma patients transported by ambulance from other areas of the county. We believe Los Angeles should ask the College of Surgeons, as part of its comprehensive assessment, to assess the adequacy of helicopter services that Los Angeles provides in underserved areas. The chief of EMS’s prehospital care operations and ambulance programs (operations chief) stated that he receives and reviews helicopter flight data submitted to him by each of the helicopter service providers on a quarterly basis. Helicopter service providers send the data directly to the operations chief in spreadsheets, and he uses the information to identify and further analyze individual flights that are outliers in terms of transport times. The data include helicopter transports throughout Los Angeles and are not limited to transports made in underserved areas. Nevertheless, the operations chief’s review of the helicopter data does not include a compilation of the outliers by each underserved area or a documented trend analysis over time for each of the underserved areas. Such analyses could indicate, for example, whether lengthy transport times were an issue in any particular underserved area. Further, the operations chief explained that the data are not limited to trauma patient transports; rather, the data include a small number of flights flown by providers for medical emergencies, as well as search‑and‑rescue missions that resulted in patient transport. Although these data also include some information on cancelled EMS has not consistently flights, EMS has not consistently collected data on the number collected data on the number of flights cancelled in each of the underserved areas, a situation that of flights cancelled in each of the further hinders its ability to determine accurately the availability underserved areas, a situation of helicopter services. Specifically, only two of the three helicopter that further hinders its ability service providers track and report the number of cancelled flights. to determine accurately the For example, only after we asked the operations chief for data availability of helicopter services. regarding cancelled trauma helicopter transports did he apparently realize that the Los Angeles County Sheriff’s Department did not maintain and report data regarding cancelled flights. Weather conditions and maintenance can affect a helicopter’s ability to fly, which can cause the flight to be cancelled, aborted, or not accepted upon initial dispatch. The operations chief explained that in cases in which a helicopter cannot fly due to weather conditions, the emergency medical service providers use ground transportation as an alternative. He also stated that for cases in which a helicopter is under routine maintenance, the helicopter providers have adequate backup aircraft to conduct patient transports as needed. California State Auditor Report 2013-116 29 February 2014 However, for those data submitted by helicopter service providers to EMS regarding the number of cancelled flights, the data do not include information about how trauma patients were ultimately transported. As a result, EMS cannot assess the data to determine the overall effect of cancelled flights, such as the length of time it took to transport patients using alternate transportation methods and, of even greater concern, what the medical outcomes were for those patients. Without reviewing this type of information regularly and specifically for underserved areas, EMS cannot be certain or demonstrate to residents that helicopter services are effective in fulfilling the intent of Measure B to expand trauma services to underserved areas. In our efforts to determine the total number of transports from each of the underserved areas, we obtained and reviewed helicopter service data submitted by the service providers, as described previously, and compiled by the operations chief. We found that the data the operations chief compiled and provided to us included transports from cities located outside of the respective underserved areas and excluded transports from cities that should have been included in the respective underserved areas. Because of these issues, we had overall concerns about the quality of the data and thus did not present it because it could mislead those attempting to draw conclusions based on the data. Further, although EMS gave us additional data regarding the efficiency of helicopter services it receives separately from the spreadsheets, we also have concerns with this data. As part of its standard operations, EMS collects data submitted by emergency service providers in its trauma system database. The data it collects covers many components of patient care, including patient outcomes and transport times, which describes the number of minutes it takes an ambulance or a helicopter to transport a trauma patient from the scene of an emergency to the hospital. The director of EMS believes that transport times and mortality rates— the ratio of the total number of trauma patient deaths to the total number of trauma patients—for the underserved areas demonstrate the adequacy of the helicopter services. However, EMS could not EMS could not provide us with provide us with evidence that it consistently monitors, assesses, evidence that it consistently or reports this information specific to underserved areas. Rather, monitors, assesses, or reports it provided us with outdated reports it had compiled for another transport times and mortality entity, and subsequently it provided updated data upon our request. rates, which could demonstrate the However, we have doubts about the accuracy and usefulness of adequacy of the helicopter services the data regarding transport times because we identified errors— in underserved areas. which EMS acknowledged—including transports listed as lasting more than a thousand minutes. This indicates that EMS does not review these data for accuracy and perform the follow‑up necessary to correct such errors, which further lessens the data’s reliability and usefulness. 30 California State Auditor Report 2013-116 February 2014 Los Angeles Needs to Better Gauge the Concerns of a Hospital in East San Gabriel Valley About Its Possible Participation in the County’s Trauma System Shortly after the passage of Measure B, Los Angeles undertook some formalized efforts to designate a hospital as a trauma center in East San Gabriel Valley; however, since that time, Los Angeles has made only minimal attempts to do so, and this area continues The voter information booklet to be underserved. As mentioned previously, the voter information provided for the November 2002 booklet provided for the November 2002 general election may have general election may have led led some to believe that the passage of Measure B would ensure some to believe that the passage a designated trauma center would be located in East San Gabriel of Measure B would ensure a Valley. Trauma patients from East San Gabriel Valley are designated trauma center would be transported to LAC+USC Medical Center or Huntington Memorial located in East San Gabriel Valley. Hospital, both of which are more than 20 miles away from some areas of East San Gabriel Valley. Shortly after the election, in August 2003, board documents indicate that none of the hospitals located in underserved areas was prepared to join the trauma system at that time. Subsequently, minutes of a board meeting held in September 2005 reported that for more than a year, the board, in partnership with various local entities, reviewed efforts to have Pomona Valley Hospital Medical Center (Pomona), a private hospital in East San Gabriel Valley, reenter the system as a trauma center. Pomona originally joined Los Angeles’s trauma system in the 1980s but reportedly decided to withdraw using financial viability as a principal determinant. The September 2005 board minutes explain that Pomona conducted a feasibility study to assist political leaders in East San Gabriel Valley to better understand the hospital’s concerns about reentering the trauma system. Pomona reported that it was not feasible to reenter the county’s trauma system for various reasons, including the lack of physicians necessary for trauma center designation, the hospital’s insufficient capacity and infrastructure, and the high cost of reentering the system and sustaining a trauma center. Further, in its feasibility study, Pomona stated that despite the lack of a trauma center in the geographic region, area trauma victims were being acceptably managed by the existing county trauma system. Given that this study was completed more than eight years ago, and Pomona’s concerns about entering the trauma system could have changed or lessened over time, we interviewed EMS officials to determine whether the county has undertaken any subsequent efforts to discuss with the hospital its interests in reentering the trauma system. The director of EMS explained that the agency has continued to communicate with Pomona informally to engage hospital leadership in discussions about reentering the trauma system. The evidence the officials provided consisted of two brief, informal e‑mail exchanges between EMS officials California State Auditor Report 2013-116 31 February 2014 and Pomona in April and June 2013. One e‑mail was roughly a half‑page response by Pomona’s vice president of administration to a phone call made by the director of EMS, which, according to the director, was made to determine whether the hospital’s intentions of entering the trauma system had changed. EMS could provide no documentation indicating that there was any further discussion as to how the county might potentially address the hospital’s previous concerns. Not surprisingly, in the e‑mail response to the director of EMS, Pomona’s vice president of administration cited some of the same concerns as stated in Pomona’s 2005 feasibility study. When we asked hospital officials from Pomona about Los Angeles’s efforts to engage the hospital in discussions about becoming a trauma center, they confirmed that since 2005 EMS has not formally reached out to the hospital, with the exception of the informal exchanges regarding Pomona’s interest in becoming a trauma center. To better gauge Pomona’s current position on entering Los Angeles’s trauma system and to more fully understand its concerns, we interviewed hospital officials in December 2013. Although we learned that Pomona continues to have some of the same reservations as those reported in its 2005 feasibility study, we also found that it is not opposed to having formal discussions with Los Angeles leadership about becoming a trauma center. Pomona officials explained that the hospital is currently in the process of expanding its facilities by adding an outpatient center that will also allow for the expansion of the emergency department, and the concerns it cited in 2005 related to inadequate facilities or space will no longer be a concern given the hospital’s current expansion. However, officials described that the most pressing concerns hospital leadership have with becoming a trauma center relate to the hospital’s aging surgical workforce, the lack of available surgeons to replace those who will soon retire, and inadequate funding. More specifically, officials explained that its aging surgical workforce has little desire to be on call around the clock, as required by trauma center guidelines. However, officials from Pomona stated that if funding were available through Measure B, the hospital would be open to discussing and potentially considering whether becoming a trauma center is feasible and in Pomona’s best interests. Given that the board has discretion in its allocation of Measure B The board could use Measure B funds, it could use this money or funds in its reserve to provide funds or its reserve to provide financial support that would enable a hospital to become designated financial support that would as a trauma center in East San Gabriel Valley. By formally discussing enable a hospital to become and better understanding Pomona’s concerns, particularly as they designated as a trauma center in relate to funding, the board could revisit its allocation of Measure B East San Gabriel Valley. funding, identify potential funding options to address Pomona’s concerns, and present its results to the hospital. However, to the extent that Los Angeles only continues its informal efforts to engage Pomona’s leadership, it may miss the opportunity to designate 32 California State Auditor Report 2013-116 February 2014 a trauma center within East San Gabriel Valley and forego its ability to demonstrate to taxpayers that it has attempted diligently to fulfill the intent of Measure B by expanding trauma services to East San Gabriel Valley. Additionally, we inquired about the possibility of Los Angeles constructing a county‑operated hospital to house a trauma center in East San Gabriel Valley. According to the controller of County Health Services (controller), doing so would have a significant financial impact on County Health Services because it would have to find a way to pay for the new hospital within its existing budget. Costs to build a hospital, which range widely depending on facility size, can reach hundreds of millions of dollars. The controller explained that for any portion of Measure B revenues that the board diverts to the construction of a hospital, it would have to either cut services at its existing trauma centers or other services it provides, or identify funding to replace the diverted revenues. Additionally, the director of EMS stated that building a new county hospital that would also serve as a trauma center in East San Gabriel Valley would likely be detrimental to the system as a whole. She explained that the cost of a hospital, staff, facility equipment, and management would be exorbitant. Further, she stated that funding for such a hospital would draw on County Health Services’ budget and may have a negative impact on the other county hospitals and health clinics. The director of EMS stated that building another hospital in East San Gabriel Valley would potentially negatively impact existing hospitals and that East San Gabriel Valley needs trauma services, not another hospital. Because Pomona is a local hospital in East San Gabriel Valley, we asked hospital officials for their perspective on the impact that building a county hospital to house The board should use the College a trauma center would have on the area. The officials explained that of Surgeons’ comprehensive the funding would be better spent supporting existing hospitals, assessment to better inform its since trauma patients on average comprise only about 2 percent of efforts and decision making patients that the hospital serves. Nevertheless, we believe the board surrounding the most feasible way should use the College of Surgeons’ comprehensive assessment, to meet trauma needs of residents described previously, to better inform its efforts and decision in East San Gabriel Valley. making surrounding the most feasible way to meet the trauma needs of residents in East San Gabriel Valley and fulfill the intent of Measure B. Los Angeles Has Identified and Addressed Some Shortcomings in Its Emergency Medical Services Over roughly the past 10 years, EMS has made some changes to improve its emergency medical services. Emergency medical services refers to prehospital and hospital critical and urgent California State Auditor Report 2013-116 33 February 2014 emergency care, including care provided in, en route to, from, or between acute care hospitals or other health facilities. EMS improved its emergency medical services by updating its policies to reduce the amount of time a hospital could continuously divert certain patients from busy hospitals. EMS also designated hospitals equipped with necessary resources as centers for receiving patients suffering from a certain type of heart attack, and it used Measure B funds to purchase specialized equipment to allow emergency medical technicians and paramedics to determine the severity of a patient’s heart attack prior to arrival at a hospital. Although EMS and other entities began reviewing the problem of EMS and other entities began the growing use of ambulance diversion (diversion) in Los Angeles reviewing the problem of the before the passage of Measure B, it took steps to address the growing use of ambulance diversion issue that, according to EMS reports, have resulted in a decrease in Los Angeles before the passage in diversion. Diversion is a request by a hospital to have certain of Measure B, and the steps it took patients bypass its facility for a limited period of time. This can to address the issue have resulted in occur for a couple of reasons, including when hospital emergency decreased diversion. department resources, such as beds, are fully committed and are not immediately available for additional incoming patients. Before the passage of Measure B, EMS and other entities brought this problem to the Hospital Association of Southern California (hospital association) for review and resolution. Subsequently, the hospital association convened a special task force consisting of officials from various entities, including hospitals, medical centers, and EMS to study emergency department diversion, review current county policy addressing diversion, and recommend changes in diversion policy and practice to optimize emergency medical services’ system performance. In the task force’s April 2003 report on its findings, it identified numerous underlying causes of hospitals diverting patients. These causes included a shortage of nurses and other technical and clinical staff; closure of hospitals and reduction of hospital inpatient capacity since 1995; and lack of adequate funding for health care, emergency, and trauma services in Los Angeles. Subsequently, EMS revised the diversion policy to mitigate the increasing diversion problem. Changes to the diversion policy included reducing the amount of time a hospital could continuously remain on diversion, from four hours to the current time of one hour. According to data reported by EMS, these changes resulted in a significant decrease in diversion rates. Specifically, EMS reported that in 2005, hospitals’ requests for diversion reached a high of 6.5 hours per day; however, diversion over the last several years has stabilized and fallen to an average of 2.4 hours per day per hospital. After updating its policy, the director of EMS explained that it has continued monitoring diversion by compiling monthly reports, looking for outliers within those reports, and posting the reports on its Web site. 34 California State Auditor Report 2013-116 February 2014 Los Angeles has also improved Los Angeles has also improved the emergency medical services it the emergency medial services provides to certain heart attack patients. In 2006, citing national it provides to certain heart interest in developing a systematic approach to the prehospital attack patients. care of ST elevation myocardial infarction (STEMI)—the deadliest form of heart attack—cardiac patients, County Health Services reported to the board that survival from a heart attack depends largely on prompt recognition and rapid intervention. As a result, County Health Services recommended that the board authorize EMS to approve and designate qualified private and public hospitals in the county as STEMI receiving centers to enable earlier definitive diagnosis and treatment, improving patient outcomes. STEMI receiving centers are facilities licensed by the California Department of Public Health and approved by EMS for cardiac catheterization laboratory and for cardiovascular surgery. According to the director of EMS, in the past, STEMI patients would be transported to the nearest hospital, unless the hospital was on diversion, and the time from electrocardiograph (EKG) to definitive care of heart catheterization and opening of the artery was greater than 90 minutes. These potential delays could be life threatening. The director of EMS explained that the STEMI system has ensured early identification of the patient’s condition in the field and decreased time to definitive treatment, along with providing other benefits. The board took a few important actions to address County Health Services’ 2006 recommendations. For example, it authorized a $4 million one‑time expenditure of Measure B funds to reimburse 30 paramedic service provider agencies throughout Los Angeles for the initial purchase of EKG machines and initial training of personnel on the use of the machines. According to documentation provided by County Health Services, Los Angeles ultimately purchased 182 EKG machines using Measure B funds. The board also instructed EMS to designate private and public hospitals as STEMI receiving centers. According to documents provided by EMS, as of December 2013, 34 hospitals and medical centers throughout the county—three of which are located in East San Gabriel Valley—have received STEMI center designation. With this established care program, according to County Health Services’ documentation and the director of EMS, emergency medical personnel are able to utilize the EKG machines on patients in the field and transport those experiencing a STEMI directly to a 24‑hour facility equipped to treat them. Recommendations To determine whether its trauma system is appropriately designed and serving the needs of residents in underserved areas and the needs of the most at‑risk populations, the board should use California State Auditor Report 2013-116 35 February 2014 Measure B funds to engage the College of Surgeons by July 2014 to perform a comprehensive assessment of the trauma system and then make the results available to the public. To the extent the assessment identifies weaknesses in the trauma system, the board should develop strategies to address those weaknesses where feasible. Specifically, the board should ask the College of Surgeons to do the following: • Assist the board in better defining and identifying underserved areas in Los Angeles. • Review Measure B allocations to ensure that they are addressing the most pressing needs of at‑risk populations in Los Angeles. • Assess the adequacy of helicopter services it provides in underserved areas. • Analyze how EMS might better use the data it collects to evaluate, improve, and report continuously on its trauma system. To ensure that it allocates Measure B funds to address the most significant needs of residents within its trauma system, the board should reinstate a Measure B oversight committee, with participation from departments with trauma, EMS, and bioterrorism preparedness expertise, as well as representatives of the public. The oversight committee should review trauma system and other county needs annually and advise the board on Measure B expenditures. As part of its responsibilities, the oversight committee should reevaluate the Measure B allocation approach, taking into consideration the results of Los Angeles’s comprehensive assessment and the effects of the Act, and issue a report on its findings no later than December 2015. To determine the adequacy and effectiveness of the helicopter services it provides to residents of underserved areas who suffer a trauma injury, EMS should collect, assess, and report accurate and complete data on the following: • The number of flights flown by each provider to underserved areas. • The time it takes to transport each trauma patient. • The health outcomes, including mortality rates, of trauma patients transported by helicopter. • The number of cancelled flights in each of these underserved areas, including the method of transportation used instead of helicopters and the transport times and trauma patient outcomes. 36 California State Auditor Report 2013-116 February 2014 Los Angeles should undertake formal discussions with Pomona’s management regarding the hospital becoming a trauma center. In doing so, Los Angeles should analyze its current Measure B revenues and allocations to determine whether financial opportunities exist that would meet the needs of Pomona and present the resulting analysis to Pomona. Further, it should document its efforts and the resulting outcome so that both voters and taxpayers are aware of the diligence Los Angeles has undertaken in fulfilling the spirit of Measure B. We conducted this audit under the authority vested in the California State Auditor by Section 8543 et seq. of the California Government Code and according to generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives specified in the scope section of the report. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. Respectfully submitted, ELAINE M. HOWLE, CPA State Auditor Date: February 20, 2014 Staff: Laura Georgina Kearney, Project Manager Jordan Wright, CFE Tamar Lazarus, MPPA Inna Prigodin Legal Counsel: Richard B. Weisberg, J.D., Senior Staff Counsel For questions regarding the contents of this report, please contact Margarita Fernández, Chief of Public Affairs, at 916.445.0255. California State Auditor Report 2013-116 37 February 2014 Appendix REIMBURSEMENTS TO HOSPITALS IN LOS ANGELES COUNTY FROM THE MEASURE B SPECIAL TAX REVENUE FUND FOR EMERGENCY MEDICAL SERVICES, TRAUMA CENTERS, AND BIOTERRORISM RESPONSE FOR UNCOMPENSATED CARE COSTS, FISCAL YEARS 2008–09 THROUGH 2011–12 The Joint Legislative Audit Committee directed the California State Auditor to determine the total Measure B funds allocated to medical service providers by area or other relevant allocation factors for the past four years. We defined the past four years as fiscal years 2008–09 through 2011–12. As explained in the Audit Results, the Board of Supervisors for the County of Los Angeles has allocated the majority of Measure B funds to county‑operated hospitals for uncompensated trauma and emergency care and to non‑county‑operated trauma centers specifically for uncompensated trauma care. Table A presents the amounts of Measure B funds each of the hospitals received for fiscal years 2008–09 through 2011–12. As the table shows, county‑operated hospitals receive the largest amount of Measure B funds. Table A Reimbursements to Hospitals in Los Angeles County From the Measure B Special Tax Revenue Fund for Emergency Medical Services, Trauma Centers, and Bioterrorism Response for Uncompensated Care Costs Fiscal Years 2008–09 Through 2011–12 FISCAL YEARS NON‑COUNTY‑OPERATED TRAUMA CENTERS 2008–09 2009–10 2010–11 2011–12 Antelope Valley Hospital $0 $369,636 $1,295,594 $1,221,633 California Hospital Medical Center 7,564,957 7,999,227 9,772,363 8,827,626 Cedars‑Sinai Medical Center 1,703,800 1,868,057 1,423,104 1,225,372 Henry Mayo Newhall Memorial Hospital 1,154,849 1,061,981 1,421,298 908,812 Long Beach Memorial Medical Center 3,003,632 3,116,628 2,755,735 3,204,822 Northridge Hospital Medical Center 2,145,208 2,319,976 2,699,592 3,259,206 Huntington Memorial Hospital 1,794,256 1,661,835 1,992,658 1,605,940 Providence Holy Cross Medical Center 6,646,982 6,395,024 5,770,311 6,253,446 St. Francis Medical Center* 7,357,477 6,942,413 6,804,980 7,778,873 St. Mary Medical Center 1,447,584 1,166,462 1,475,866 1,854,837 Ronald Reagan UCLA Medical Center 1,743,580 2,129,314 1,863,539 1,997,971 Children’s Hospital Los Angeles 396,487 426,139 876,716 898,379 Totals for non‑county‑operated hospitals $34,958,812 $35,456,692 $38,151,756 $39,036,917† continued on next page . . . 38 California State Auditor Report 2013-116 February 2014 FISCAL YEARS COUNTY‑OPERATED HOSPITALS 2008–09 2009–10 2010–11 2011–12 LAC+USC Medical Center $109,700,855 $106,852,581 $107,247,000 $72,696,500 Harbor‑UCLA Medical Center 59,259,822 50,942,275 52,690,000 63,363,500 Olive View‑UCLA Medical Center‡ 42,451,323 34,617,144 41,695,000 58,072,000 Totals for county‑operated hospitals $211,412,000 $192,412,000 $201,632,000 $194,132,000 Sources: Unaudited annual statements of financial activity filed by the Los Angeles County (Los Angeles) Department of Auditor Controller with the Los Angeles Board of Supervisors, fiscal years ending June 30, 2009, through June 30, 2012, as well as final installment schedules provided by the Los Angeles County Department of Health Services for fiscal years 2008–09 through 2011–12. Note: Non‑county‑operated trauma centers are reimbursed for costs including uncompensated care associated with providing trauma services and for providing medical direction and destination to prehospital care personnel within the Los Angeles emergency medical services system. The county‑operated hospitals are reimbursed for uncompensated care costs associated with providing trauma and emergency medical services. * St. Francis Medical Center also receives payments to ensure that it has adequate capacity and capability to handle additional trauma and emergency room patients redirected due to the closure of another trauma center. † This amount does not agree with the total shown in Figure 3 on page 24 because it represents the amounts reimbursed rather than those that were allocated. Los Angeles makes a final payment in the following fiscal year after the costs for uncompensated care have been finalized. ‡ Olive View‑ULCA Medical Center is not a trauma center and receives Measure B funds for uncompensated care costs associated with providing emergency medical services, an allowable use of these funds. California State Auditor Report 2013-116 39 February 2014 * 1 1 2 3 1 * California State Auditor’s comments begin on page 53. Note: Los Angeles County provided copies of several documents, including newspaper articles, pamphlets, and flyers relating to Measure B, to which Los Angeles refers in its response. We have not included them with Los Angeles’s response, but they are available for inspection at the California State Auditor’s Office during business hours upon request. 40 California State Auditor Report 2013-116 February 2014 4 California State Auditor Report 2013-116 41 February 2014 4 42 California State Auditor Report 2013-116 February 2014 5 1 2 California State Auditor Report 2013-116 43 February 2014 2 6 6 44 California State Auditor Report 2013-116 February 2014 California State Auditor Report 2013-116 45 February 2014 7 1 8 46 California State Auditor Report 2013-116 February 2014 9 9 California State Auditor Report 2013-116 47 February 2014 2 2 10 3 48 California State Auditor Report 2013-116 February 2014 1 1 California State Auditor Report 2013-116 49 February 2014 50 California State Auditor Report 2013-116 February 2014 California State Auditor Report 2013-116 51 February 2014 52 California State Auditor Report 2013-116 February 2014 California State Auditor Report 2013-116 53 February 2014 Comments CALIFORNIA STATE AUDITOR’S COMMENTS ON THE RESPONSE FROM LOS ANGELES COUNTY To provide clarity and perspective, we are commenting on the response to our audit report from Los Angeles County (Los Angeles). The numbers below correspond to the numbers we placed in the margin of Los Angeles’s response. 1 We believe Los Angeles is using its response to obfuscate our main point. We do not question the fact that Measure B funds have strengthened the trauma care network. We do, however, discuss Los Angeles’s assertion that it has addressed the county’s most pressing trauma needs in several places in our report. For example, as we indicate on page 16, Los Angeles’s director of the Emergency Medical Services Agency (EMS) asserted that the county’s trauma system is adequate and is meeting the needs of all areas in Los Angeles, including those areas that are underserved. However, she also acknowledged that Los Angeles has not conducted an evaluation of its trauma system to demonstrate it has fulfilled the intent of Measure B. Further, as we state on page 16, Los Angeles’s current monitoring efforts do not enable it to examine whether its trauma system serves residents, such as those in underserved areas and at‑risk population groups, equitably. Without this kind of assessment, Los Angeles cannot demonstrate that it is meeting its most pressing trauma needs. Thus, we stand by our report’s title and our conclusion that Los Angeles is unable to demonstrate that Measure B funds were used “to address the most pressing trauma needs.” 2 Although we agree that Los Angeles has implemented helicopter transport in underserved areas, EMS was unable to demonstrate the effectiveness of these services. As we explain on page 28 of the report, EMS’s efforts to review helicopter data are undocumented and not specific to underserved areas. Thus, EMS cannot demonstrate that underserved areas fare as well as other areas of the county in terms of transport times. 3 During our fieldwork, EMS provided us its analysis of the county’s mortality rates, however, we found that it was not useful for purposes of determining the effectiveness of the helicopter transport services Los Angeles uses in East San Gabriel Valley. Specifically, the analysis does not isolate the mortality rates of patients transported by helicopter from the rates of those transported by ambulance. Thus, the analysis does not provide any assurance that patients transported by helicopter experienced a similar mortality rate compared to those transported by ambulance. 54 California State Auditor Report 2013-116 February 2014 Without this assurance, EMS and Los Angeles cannot demonstrate that the decision to use helicopter transport in East San Gabriel Valley is effective. 4 We do not dispute the fact that Los Angeles has performed a number of studies and has taken various steps to identify and address some of its shortcomings in its emergency medical services over the last 10 years, which we describe in more detail on pages 32 through 34 of our report. For example, we discuss Los Angeles’s efforts to authorize, approve, and designate qualified private and public hospitals in the county as ST‑elevation myocardial infarction receiving centers to enable earlier definitive diagnosis and treatment of cardiac patients. However, we disagree with Los Angeles, in that none of these efforts represent a comprehensive assessment of the county’s trauma system as we describe on page 17 of the report. 5 We disagree with Los Angeles. As we state on page 23, the Board of Supervisors for the County of Los Angeles (board) has generally allocated Measure B funds in the same proportions year after year. Specifically, the board continues to allocate Measure B funds primarily to reimburse non‑county‑operated trauma centers and county‑operated hospitals for uncompensated care costs, as originally recommended more than nine years earlier. Additionally, on page 25 we conclude that this approach appears overly conservative because it has resulted in significant fund balances at year end. Further, as we state on page 26, another concern we have with this approach is that it focuses on uncompensated care at existing trauma centers and does not consider the overall trauma care needs of Los Angeles’s population, particularly those population groups at the greatest risk of trauma injury. Finally, as we state on page 26, by not revisiting its allocation of Measure B funds, Los Angeles may have missed opportunities to assist existing hospitals in underserved areas become trauma centers and, therefore, may have fallen short of fulfilling the intent of Measure B. 6 Again, Los Angeles is attempting to obfuscate our main points. We do not suggest in the report that “expanding a region’s trauma system is not properly gauged solely by the addition of new trauma hospitals” nor do we suggest that the “county has not fulfilled the intent of Measure B because there is no trauma hospital in the Malibu area.” Again, to reiterate our concerns: First, as we state on page 16, Los Angeles’s current monitoring efforts do not enable it to examine whether its trauma system is effectively meeting the needs of its residents, such as those in underserved areas—which would include the Malibu area—and at‑risk population groups. Second, as we indicate on page 27, Los Angeles has not regularly reviewed and analyzed helicopter service specific to underserved areas—including the Malibu area—in an effort to California State Auditor Report 2013-116 55 February 2014 ensure that helicopters are adequately serving trauma patients transported from these areas. Thus, it cannot demonstrate to the public as it believes, that it has addressed the most pressing trauma needs using Measure B funds. 7 Los Angeles appears to have misunderstood our point. As we state on page 26, we agree with Los Angeles that its administration of the Measure B funds through the county’s budget process appears appropriate and efficient. However, although this may be true about its budget process, as we also point out, Los Angeles cannot demonstrate to voters that it is directing funds to the most pressing needs of its trauma system because it lacks ongoing oversight and analysis of its approach to allocating Measure B funds. As we indicate on page 23, for more than nine years, the board has generally allocated Measure B funds in the same proportions year after year through the county budget process. Thus, as we state on page 25, we believe that ongoing input from an advisory body, such as an oversight committee, to review the allocation approach and advise the board on whether the current funding strategy is best fulfilling the intent of Measure B, would provide the public with some certainty that the county is investing its resources most effectively toward the allowable purposes set forth in Measure B. 8 Los Angeles’s assertion that the county’s Department of Health Services (County Health Services) assumed the responsibility of the original Measure B Oversight Committee (oversight committee) misses our point. While County Health Services could certainly be included, an advisory body, such as an oversight committee, would be made up of various other stakeholders and departments with expertise in Los Angeles’s trauma and EMS systems as well as in bioterrorism preparedness activities, as we recommend on page 23 of the report. This composition would be consistent with the board‑approved motion that created the oversight committee. As we explain on page 23, this motion specified the importance of having proper safeguards in place to ensure that Measure B funds were spent on their intended goals and having county departments with proper expertise involved in reviewing the use of these funds. 9 We do not agree that the two‑tiered approach described by Los Angeles is comparable to a comprehensive assessment. First, the State Emergency Medical Services Authority’s approval of Los Angeles’s trauma plan was never intended to be, nor did it constitute a comprehensive assessment of the trauma system. Further, on page 16 we discuss Los Angeles’s evaluation efforts conducted in conjunction with the American College of Surgeons (College of Surgeons), and indicate that because those efforts are focused on the performance of individual trauma centers, they do not enable EMS or Los Angeles to examine whether the system as a whole serves Los Angeles’s residents equitably or identifies any gaps 56 California State Auditor Report 2013-116 February 2014 in service by population group or geographic area. Thus, we stand by our conclusion that a comprehensive assessment conducted by the College of Surgeons would provide greater transparency to the public regarding Los Angeles’s existing trauma system’s needs and challenges, as well as recommendations for future trauma system development. 10 As we describe in the Scope and Methodology table item 4.c on page 11, we were specifically asked to determine why and how often helicopters and air paramedic services have been used and in what areas, such as in underserved areas without trauma services. Los Angeles did not provide us with an analysis supporting the proportion of transports from East San Gabriel Valley that are performed by helicopter services. Therefore, we are unable to comment on its accuracy. However, because helicopters are used to reach outlying areas and, as we report on page 27, the former director of County Health Services acknowledged helicopter transport is not the optimal method and there are inherent safety and weather limitations, we believe a focused review of helicopter transports is warranted. California State Auditor Report 2013-116 57 February 2014 cc: Members of the Legislature Office of the Lieutenant Governor Little Hoover Commission Department of Finance Attorney General State Controller State Treasurer Legislative Analyst Senate Office of Research California Research Bureau Capitol Press