Life and death in the emergency room - includes article on Dr. John West - part 1

Washington Monthly, Nov, 1985 by Paul Glastris

The free market strategy

Pennsylvanians who want to see what a little free enterprise looks like in emergency medical care can take a look a thousand miles to the south at Florida. Like Pennsylvania, Florida took several million dollars worth of federal EMS grants in the seventies and began to designate trauma centers but failed to come up with a comprehensive state-wide plan. After the federal money ran out, Florida embarked on a new course. One jealous hospital that wasn't going to be designated a trauma center challenged in court the state's right to designate hospitals as such. Rather than meeting the challenge with a law empowering the state to designate selectively, the legislature mollified the hospitals in 1982 with a law allowing any hospital to call itself a trauma center. All the hospital had to do was file a long application promising to fulfill minimum manpower and equipment standards and then pay a small fee to cover the costs of state inspections.

Problems surfaced almost immediately. Most of the hospitals that applied were those competing in areas that already had enough trauma treatment facilities. Jacksonville, for instance, was well-served by the University of Florida Medical Center. Today, the city has eight trauma centers. Since the university hospital is tax-supported, the patients it now receives--about half of the total--are predominately those who can't pay, and these account for the lion's share of the gunshot and stabbing victims. The other seven hospitals are all private, and their patients are typically car accident victims who can pay their bills, thanks to car insurance. This skimming off of the profitable trauma victims, revolting as it may be, is probably less harmful in the long run than the shortage of cases that the surgeons and staff have at these seven hospitals. Without that volume, these practitioners simply won't be as effective at saving lives.

Jacksonville, though, has the distinct advantage of having trauma centers. In southern Florida, where there were none before the 1982 law, only a few applied after its passage. One reason hospitals held back was the fear that indigent patients, such as those from the large population of illegal aliens in the area, would be dumped on the first hospital to step forward. Another was the unwillingness of the local surgeons to make the commitment in time and effort to meet the state guidelines, one of which is to have at least some surgeons in the hospital at all times. In response, EMS officials purposely watered down the commitment statements to require only that the surgeons get to the hospital as quickly as possible--all in the hope of persuading more surgeons to take trauma care seriously. The changes were made despite the well known need for prompt action in cases of traumatic injury.

If the more lenient guidelines were meant to get more hospitals and surgeons involved, the effort didn't work too well. In Dade County, hospitals feared that if only a few institutions sought designation as trauma centers, they would be stuck with caring for most of the poor patients and those without insurance. To avoid the problem, the hospitals conspired to seek the designation en masse, effectively defeating the idea of having certain hospitals that specialize in emergency medicine. Elsewhere in southern Florida, hospitals didn't even make this gesture. Outside of Dade County, there isn't a single trauma center in the southern third of the state.