Cover Story – July 2010
Tex Med. 2010;106(7):22-28.
By Crystal Conde
When a critically injured homeless man arrived at Austin's University Medical Center Brackenridge after a hit-and-run driver ran over him while fleeing police last year, the Level I trauma facility's medical team did all it could to save his life. Physicians amputated one of his legs and treated him for severe internal and head injuries. But he died after spending weeks in the intensive care unit.
"That type of trauma scenario can easily cost a hospital hundreds of thousands of dollars," said Christopher Ziebell, MD, medical director of the Department of Emergency Medicine at University Medical Center Brackenridge. "But the patient is the No. 1 priority. At Brackenridge and at trauma facilities throughout Texas, care is rendered in every way without concern of whether we get paid."
Significant funds appropriated from the controversial Driver Responsibility Program (DRP) help make it possible for Brackenridge and other trauma centers to treat every trauma patient who comes through the doors, regardless of insurance status. But the Texas Legislature has held in reserve almost as much money as it has doled out since it approved the DRP in 2003. And a potential $11 billion to $18 billion budget deficit facing legislators next year, plus growing opposition from some local judges, lawmakers, and upset residents, has placed the program in jeopardy.
Last year, Dr. Ziebell says, uncompensated health care, not just trauma care, cost the Seton Family of Hospitals $250 million. University Medical Center Brackenridge received about $2.2 million in DRP funds for uncompensated trauma care in fiscal year 2009.
"We used that money to purchase new equipment and do some upgrades," Dr. Ziebell said. "The DRP money helps keep us up and running and capable of ramping up our trauma infrastructure in times of urgency."
Specifically, Dr. Ziebell says, DRP funds helped Brackenridge pay for new, expanded rooms with ultrasound capabilities, a full range of life-support equipment, and a blood bank.
DRP Under Attack
However, DRP has its critics, including local judges, some lawyers and legislators, and some residents who've been fined surcharges. They say the surcharges disproportionately affect low-income Texans, create a backlog of driving-while-intoxicated cases in state courts, and lead to more uninsured drivers in the state.
At press time, an online petition asking the legislature to repeal the DRP had 4,300 signatures. Tamara Shippy, of Friendswood, created the petition after her driver's license was suspended for not paying the surcharge on a traffic violation.
On top of opposition to the DRP, the Texas Health and Human Services Commission has proposed cutting indigent trauma care funding to hospitals by 10 percent.
The potential budget reduction worries Dr. Ziebell.
"We can't reduce the number of injured people by 10 percent. It's not in our control. The money will have to be made up somewhere, or trauma facilities will have to scale back some services. That leads to an access-to-care problem for patients," he said.
Dr. Ziebell adds that scaling back services at trauma facilities could mean less availability for patient follow-up care in specialist clinics or reduced support from social services and chemical dependency counselors, who often help people whose trauma resulted from inappropriate use of intoxicating substances. Funding cuts, he says, could even lead hospitals to stop offering nontrauma services, such as gastroenterology or obstetrics and gynecology.
Ronald Stewart, MD, chair of the Trauma Systems Committee of the Governor's EMS & Trauma Advisory Council (GETAC), recognizes the growing disenchantment with the DRP among residents who have been fined.
"The Texas Driver Responsibility Program is under attack," he said. "It's not a minor attack; it's a major attack. If you go online, you'll find a number of grassroots videos and blogs that depict the program as evil. Many judges and law enforcement officers are also unhappy with the program."
Some Texans simply can't or won't pay the surcharges. As of April, 1.2 million Texans owed the state more than $1 billion in unpaid surcharges. The Texas Department of Public Safety (DPS) sends drivers written notices when they owe surcharges. If drivers don't pay within 30 days of conviction, DPS suspends their license.
Dr. Stewart says most trauma physicians and trauma facility administrators are sympathetic to the challenges inherent in the DRP and are willing to work to improve the program.
"We're not opposed to making the system better," he said. "We believe that in spite of its problems, the DRP is, in general, a fair and equitable way to pay for uncompensated trauma care in Texas. It has been effective in improving access to care for trauma patients across the state."
DPS is working to remove the payment barrier. In March, it proposed changing the DRP to lessen its financial impact on low-income drivers. As part of the proposal, those at 125 percent of the federal poverty level, or an income of $10,803 for one person, would pay a reduced, one-time surcharge.
Jorie Klein, RN, director of Trauma & Disaster Preparedness at Parkland Health & Hospital System in Dallas, recognizes that next year the legislature may explore alternative fee structures and fine levels for some drivers subject to DRP surcharges.
"I'd rather compromise than lose the DRP funds altogether," she said.
The mounting threat to precious DRP funds has trauma physicians and nurses, emergency medical services (EMS) officials, hospital administrators, and others collaborating to save the resources on which trauma facilities rely.
This isn't the first time the DRP has been in danger. During the 2009 legislative session, the Texas Medical Association worked to block efforts to eliminate the program. In addition, Rep. John Zerwas, MD (R- Richmond), a member of the House Committee on Public Health, authored Rider 90, which calls on the Texas Department of State Health Services (DSHS) to study the need for additional Level I and Level II trauma facilities in Texas. (See " Study to Evaluate Texas' Trauma Center Needs .")
Dr. Stewart says preserving the DRP isn't just about funding. The program allows centers to improve patient care.
"The expansion of Texas trauma centers under the DRP has led to improved coverage of timely access to care when people need it the most. What we're talking about is access and quality of care," said Dr. Stewart, trauma medical director at University Hospital in San Antonio. "That's why preserving the DRP and other funding programs is important."
DRP Funding Saves Lives
Ms. Klein knows the destruction a traumatic injury can wreak on people's lives.
Last year, an uninsured 14-year-old West Texas girl suffered severe pelvic fractures and internal injuries in a car collision. She arrived at a small, rural Level IV trauma center, which sent her to a Level III trauma facility in West Texas. She remained there for one day until she was stable enough to be transferred to Parkland.
"If she hadn't had access to Parkland's orthopedic surgeons, she would be disabled for life and would have difficulty with pregnancy," said Ms. Klein, president of the Texas EMS, Trauma & Acute Care Foundation (TETAF) and vice chair of the GETAC Trauma Systems Committee.
The girl was discharged from Parkland two weeks later.
Ms. Klein says Parkland and other designated trauma facilities throughout Texas rely on DRP funds to continue caring for patients like that girl.
"We need that funding to purchase necessary equipment and to employ nurses and physicians with the skills and expertise to provide critical lifesaving care," she said. "The services DRP funding makes it possible for trauma centers to provide are for all Texans -- rich or poor. If DRP funding is cut and facilities cut back services or close, residents may not get the timely, livesaving care they need."
In 2008, according to Ms. Klein, Parkland spent $61 million on uncompensated trauma care. Since fiscal year 2004, Parkland has received $31.6 million to help offset the cost of uncompensated trauma care.
None of this funding would exist if it weren't for a law the legislature passed in 2003. House Bill 3588 established the DRP for funding trauma care centers and transportation projects via surcharges on some moving violations and other driving offenses. (See "DRP Traffic Violation Surcharges.")
Former Rep. Diane White Delisi (R-Temple), chair of the House Committee on Public Health in 2003, championed and cowrote the bill. At the time, hospitals' uncompensated care costs were skyrocketing and some hospitals had to transfer patients to other facilities because they lacked the resources to care for every patient, according to Ms. Klein.
DSHS disburses DRP funds from the Designated Trauma Facility and Emergency Medical Services (DTF/EMS) account. Surcharges collected by the DRP, which total about $200 million each year, are divided evenly and deposited into the DTF/EMS account and the Texas Mobility Fund for financing the construction, reconstruction, acquisition, and expansion of state highways.
According to DSHS, the legislature gave the state health department $75 million per year for fiscal years 2010 and 2011 in DRP funds to help finance county and regional EMS operations, designated trauma facilities, and trauma care systems. That amount, however, doesn't nearly cover hospitals' total uncompensated trauma care costs.
According to the 2008 edition of Code Red: The Critical Condition of Health in Texas , Texas hospitals spent about $208 million treating uninsured trauma patients in 2003 alone. That figure does not include uncompensated trauma care provided by physicians or EMS. Dr. Stewartsays more recent data estimate the cost of providing uncompensated trauma care at Texas hospitals totals $220 million annually.
He also points out that the legislature hasn't appropriated more than $300 million that remains in the DTF/EMS account. In 2005, the legislature limited disbursement of funds, and the state uses money left in the account to balance the general revenue budget.
Dr. Ziebell says the legislature's failure to distribute the full amount of the funds is frustrating.
"The state is holding back on distributing the total designated funds. The people paying into the DRP aren't getting the full benefit of it in their communities because it's not all being distributed," he said.
Regardless of the limitation on appropriations, Dr. Stewart stresses the need to continue the program.
"HB 3588 funding, or the Texas DRP, has been a significant addition to Texas trauma centers. It has benefited every level of Texas trauma center from Level I to Level IV," he said.
In fact, since 2003, DSHS has distributed about $309 million from the DTF/EMS account to approximately 250 eligible Texas hospitals to cover part of their uncompensated trauma care. (See "DRP Good for Patients, Doctors, Trauma System.")
DSHS distributes 96 percent of the DTF/EMS account funds to hospitals for uncompensated trauma care, 2 percent to EMS providers, and 1 percent to regional advisory councils. The remaining 1 percent goes to DSHS to administer the program.
Stakeholders Rally to Save DRP
In May, TETAF hosted a leadership summit in Austin with one primary goal: to preserve HB 3588. Physicians, EMS providers, nurses, state health agency officials, hospital administrators, nonprofit directors, and other trauma care stakeholders attended. Kenneth Mattox, MD, professor and vice chair of surgery in the General Surgery Division at Baylor College of Medicine and chief of staff at Ben Taub General Hospital, was the facilitator.
"We need to preserve the existing trauma funding we have in Texas, … get to know the legislators and our local judges, educate them on the value of funding uncompensated trauma care, … and develop a plan," he said.
Dr. Stewart spoke of the impact trauma has on the state's residents.
"The typical patient I would see would be a working Texan who doesn't have health insurance who ends up in the trauma system, often due to a car collision," he said. "The costs can be really devastating to the patient, to the hospital, and to the physician. It's not uncommon to have a number of trauma patients with hospital and physician bills that total more than $500,000."
Texas Vital Statistics death data for 2006, the most recent available, show motor vehicle collisions are the leading cause of death due to injury in Texas, at nearly 16 deaths per 100,000, or 29 percent. Suicide, unintentional poisoning, homicide, and unintentional falls round out the top five causes.
At the conclusion of the summit, stakeholders discussed developing a public relations campaign, partnering with the business community, generating a petition, and using social media to gain support for the DRP.
Saving the DRP from repeal is going to require a lot of support from physicians, particularly those who work in Texas trauma centers, Dr. Stewart says. He encourages his colleagues to educate their local legislators about the benefits of the program, ask past trauma patients to share their stories with government officials, and inform the public on the worthwhile purpose of DRP funds.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde.
Study to Evaluate Texas' Trauma Center Needs
Rep. John Zerwas, MD (R-Richmond), says Hurricane Ike inspired him to author Rider 90 of the 2010-11state appropriations bill, which requires the Texas Department of State Health Services (DSHS) to study the need for additional Level I and Level II trauma facilities. DSHS contracted with the American College of Surgeons (ACS) to perform the assessment.
"When Hurricane Ike left The University of Texas Medical Branch in Galveston devastated and out of commission, not surprisingly the trauma system was overwhelmed in Houston," said Representative Zerwas, a member of the House Committee on Public Health. "I wanted the study to assess the state's Level I and Level II trauma center needs."
Currently, Texas has 24 Level I and Level II trauma facilities. Kathy Perkins, assistant commissioner of the DSHS Division for Regulatory Services, says that while Level I and Level II trauma facilities are vital, the state's network of Level III facilities is integral to patients' access to care. Texas has 45 designated Level III trauma facilities.
"Level III trauma facilities play a major role in communities throughout the state," Ms. Perkins said. "They function to keep some of the pressure off the Level I and Level II centers."
Jane Guerrero, director of the DSHS Office of EMS and Trauma Systems Coordination, says DSHS also asked ACS to evaluate the trauma system as a whole, identify opportunities for improvement, and recommend ways the state can enhance the system.
Ms. Perkins says the system evaluation component of the study will help the state develop a plan for the future.
"This assessment will help us determine what we need to do to ensure our state trauma system is cemented permanently," she said. "Funding can come and go, but there will always be traumatic events and disasters. I'd like the regional EMS and trauma systems to be permanent to continue to reduce death and disease in Texas."
ACS made a site visit to Austin in May, during which the organization reviewed a more-than-6,500-page pre-review questionnaire submitted by DSHS. The lengthy document includes information on Texas' trauma system policy, response plans, funding programs, prevention and outreach, emergency medical services, disaster preparedness, and much more.
Ms. Perkins says ACS has a challenge in assessing Texas' massive trauma system, made up of 22 regional advisory councils (RACs).
"It will be challenging for ACS not to get caught up in evaluating each individual RAC," Ms. Perkins said. "That would take a long time. With the pre-review questionnaire, DSHS tried to show ACS what we do at the state level so they can look at the whole umbrella of the system."
DSHS expects the final report from ACS in early September. The department will submit the report to the legislature by Dec. 1. Ms. Perkins says the report will likely be posted on the DSHS website .
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DRP Traffic Violation Surcharges
The Driver Responsibility Program (DRP) employs two methods for assessing surcharges: the driver's license point system and cumulative automatic fines for certain convictions.
Drivers who receive six points on their license over the course of three years have to pay a $100 annual fine, plus $25 for each additional point, for the next three consecutive years. The Texas Department of Public Safety (DPS) assigns three points to a moving violation resulting in a crash and two points to any other moving violation. DPS doesn't assign points for speeding less than 10 percent over the posted limit or for seat belt violations.
Under the DRP, drivers convicted of certain violations must pay surcharges annually for three years from the date of conviction. The current annual surcharges, according to the DPS website, are:
- Driving while intoxicated (DWI) or a DWI-related offense: $1,000 for the first offense, $1,500 for the second offense, and $2,000 if blood alcohol content exceeds 0.16.
- Failure to maintain insurance: $250.
- Driving with an invalid license: $250.
- Driving without a license: $100.
DPS suspends driver's licenses of those who fail to pay the surcharges within 30 days of conviction.
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DRP Good for Patients, Doctors, Trauma System
In fiscal year 2004, the Texas Department of State Health Services distributed the first Designated Trauma Facility and Emergency Medical Services account funds at a minimum amount of $11,686 to applicant hospitals. Minimum disbursements increased to $42,165 to eligible hospitals for fiscal year 2009.
Ronald Stewart, MD, chair of the Governor's EMS & Trauma Advisory Council Trauma Systems Committee and trauma medical director at University Hospital in San Antonio, says increased funding for uncompensated trauma care led to an increase in the number of Texas trauma facilities. Physicians have benefitted from Driver Responsibility Program (DRP) funds, as well, Dr. Stewart says.
"You can't have a trauma center of any designation level without a viable, healthy partnership between the hospitals and the doctors who practice there. Doctors are absolutely critical to those trauma centers," Dr. Stewart said.
Texas now has 254 trauma facilities, a 35-percent increase since 2003. Of those, 16 facilities have Level I comprehensive designation, eight are Level II major facilities, 45 are Level III advanced facilities, and 185 are Level IV basic trauma centers. For a breakdown of trauma facilities by location, click here .
Level I facilities manage major and severe trauma patients and conduct trauma research. They are ready 24 hours per day, 365 days per year for all types of injuries. Level II facilities provide similar services, although research and some medical specialty areas aren't part of the criteria for designation.
Level III centers provide resuscitation, stabilization, and assessment of injury victims. They also either provide treatment or arrange for appropriate transfer to a higher level trauma facility. Level IV facilities provide resuscitation and stabilization and arrange for appropriate transfer of major and severe trauma patients to a higher level trauma facility.
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