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A room at Banner Good Samaritan's Trauma Center in Phoenix. (Photo by Lauren Saria/Cronkite News)

PHOENIX -- Arizona's free enterprise-based trauma system would benefit from increased government control and an updated comprehensive plan, according to a recent report by the American College of Surgeons.

The 109-page evaluation, which was released earlier this year, offers suggestions for improving the state's system of specialty hospitals. It follows up on an American College of Surgeons report written in 2007.

Experts say some of the issues identified in the consultation reflect the rapid growth of the state's system since the last visit. If left alone over time, the free-market system may correct itself, they say.

Will Humble, director of the Arizona Department of Health Services, said the department will use the report to set new priorities but isn't interested in trying to expand controls on the system.

"I want to save lives in the most efficient way I can," Humble said. "Even after the ACS report it makes it really clear that the best way to save lives … is still by building out and reinforcing the rural part of the system."

At the time of the initial report, Arizona's trauma system consisted of seven Level 1 hospitals, all of which were located in larger cities. Now the system includes 25 hospitals of varying levels spread throughout the state. Most of the new trauma centers are low-level facilities in rural areas.

"Basically, we've made a lot of progress over the last few years in developing the trauma system," Humble said. "Now, it's not where we want to be yet. We still have places to go and things to do."

The report recommends updating the the state's Arizona Trauma System Plan. It calls for needs-based assessments to govern the continued expansion of the system and suggests a moratorium on the creation of new trauma centers until a provision for such assessments is added.

Although the state's current trauma plan describes an inclusive system in which every hospital participates at some level, the report says the concept has been misapplied due to a lack of leadership. It says new centers have grown as the result of economic and business factors rather than in response to population needs.

Correcting the issues would require a change in statute, according to the report. But it says doing so would be difficult, though not impossible, due to a moratorium on state agencies creating new rules for hospitals unless they're "necessary for public safety."

Dr. Peter Rhee, chief of Trauma, Critical Care and Emergency Surgery at the University of Arizona, said the state is using the rule as an excuse to not change the system.

"This should not be a free market enterprise," he said. "This is not about money."

Rhee, who is also a member of the American College of Surgeons Committee on Trauma, said the trauma system should be a government function under the control of a "trauma czar." The system needs a leader to determine the location and level of all the trauma centers and give directives about where patients should be transported, he said.

According to Rhee, some hospitals are seeking a trauma center designation for financial reasons - and the competition for patients and dollars is hurting the efficiency of the system.

"If you take critical dollars away from major trauma centers and they fail, then the whole system fails," he said.

Denis Cortese, director of Arizona State University's Health Care Delivery and Policy Program, called the development of state's system "a major success story."

"From the standpoint of the free market responding to need, I don't think you have a better example than here in Arizona," he said.

Cortese said the state has a unique opportunity to look at tangible results and decide how to move forward. While most other states opt for central authority, he said Arizona's free market approach can now be examined based on its results so far.

Next, he said, the state will need to decide if it wants to continue with the current approach.

"The state of Arizona needs to make up their mind if they're a market-based system," he said. "And if so, why are they giving money to hospitals?"

Cortese said the money Level 1 trauma centers can receive through the Indian Gaming and Self-Reliance Act, approved by 2002 voter initiative, could undercut to the system's success. The initiative established the Arizona Benefits Fund, which consists of tribal gaming revenues paid to the state.

In 2011, the state's eight Level 1 trauma centers received a total $17,836,246, according to Arizona's Medicaid agency AHCCCS, which distributes the fund.

By next spring Chandler Regional Medical Center hopes to become the newest Level 1 trauma center in the system.

Brian Tiffany, the hospital's medical staff president said the hospital's decision had nothing to do with money. If anything, he said hospitals transitioning into Level 1 trauma centers tend to lose money. In return, he said, they will gain what's called the "halo effect," an all-around improvement in care throughout the facility.

"This is not something a hospital does because they want to make money," he said. "This is something they do as a service to their community. I firmly believe that."

Banner Health, which already operates one Level 1 center at Banner Good Samaritan Medical Center in downtown Phoenix, announced an initiative last year to create trauma centers of all of its 14 Arizona hospitals.

Dr. Paul Dabrowski, medical director of Banner Good Samaritan's Trauma Center, said the system needs better coordination between facilities to achieve the highest level of patient care. If the current system and is doing anything to complicate patient care, he said, then it should be reevaluated and changed.

"I think that if left to the way it is - you know, free enterprise - it's not going to necessarily accomplish that in a timely fashion," he said.

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