Report 2013-116 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

HIGHLIGHTS

Our audit of Los Angeles County (Los Angeles) Measure B funds highlighted the following:

RESULTS IN BRIEF

Voters in Los Angeles County (Los Angeles) passed Measure B in 2002 to maintain and expand the trauma system countywide, to ensure the continued availability of emergency medical services, and to respond effectively to biological terrorism. The term trauma refers to a critical injury most often caused by a physical force that is frequently the consequence of a motor vehicle crash, a fall, a drowning, a gunshot, a burn, a stabbing, or a blunt assault. To better treat these injuries, in 1983 Los Angeles's trauma system became operational and within two years grew to include 22 county-operated and non-county-operated trauma centers. However, shortly after Los Angeles's trauma system reached this peak, trauma centers began to withdraw from the system, citing the costs of uncompensated care—for patients who are unable to pay for their care and have no third-party insurance coverage—as the reason for their withdrawal. This left some areas in Los Angeles without a trauma center. By 2002 Los Angeles's Department of Health Services was facing a significant budget deficit, which was threatening the already weakened trauma system. To, among other things, address the deficit and preserve and expand the trauma system, the Board of Supervisors for the County of Los Angeles (board) submitted a parcel tax measure to the voters in the November 2002 general election, referred to as Measure B, which voters ultimately approved. With the passage of the measure, the board implemented a parcel tax of 3 cents per square foot on generally all structural improvements, which it has increased over time. In fiscal year 2011-12, the measure generated more than $256 million in revenue.

More than a decade after voters approved the measure, existing trauma centers remain far removed from certain areas within Los Angeles despite Measure B's stated intent, which is to provide funding to, in part, maintain and expand Los Angeles's trauma system countywide. The director of Los Angeles's Emergency Medical Services Agency (EMS)—the county entity responsible for overseeing the trauma system—maintains that Los Angeles's efforts to expand the trauma system have fulfilled the intent of Measure B. However, although Los Angeles is only required to 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 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 Reporta 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 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 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.