Trauma centers make a strong comeback after years of financial chaos
Trauma centers make a strong comeback after years of financial chaos
Managed care has given in to hospitals as payment sources abound
Trauma medicine is basking in a golden era of financial security. And, although many hospitals are hungrily eyeing opportunities to land a Level 1 trauma designation, the field isn't opening up to everyone.
In fact, trauma care has become a highly-coveted half-sister of emergency medicine due primarily to the lack of new opportunities for hospitals to get into trauma care and the almost sure-fire chance of getting paid full freight by health plans for saving their enrollees' lives.
Still, hospitals are known to drop out of their trauma networks for various reasons, including mergers and closures. Others are financially troubled or poorly managed. As a result, hospitals continue to see prospects of getting into one of medicine's last remaining bastions of unquestioned, fee-for-service medical care, trauma experts say.
Proceed with caution into trauma care
But if your hospital and physicians are thinking about venturing into trauma medicine, tread carefully before dedicating that wing in the ED to your surgeons, the same experts warn. Here's why:
From a managed care standpoint, payers have had little choice but to live with disbursing huge sums to providers for the treatment of victims of catastrophic emergencies.
But, they still dog physicians with their concerns about patient status. In most cases, payers don't want to keep the patient at a noncontracting hospital any longer than necessary. In subtle but frustrating ways, they continue to pressure clinicians for immediate stabilization of their health plan enrollee and a transfer to a facility that has an existing contract with the plan.
"These occurrences are still happening more than they should, and they take up an awful lot of a clinician's time" says Andre Campbell, MD, a trauma surgeon at San Francisco (CA) General Hospital, which has the city's only trauma center and one of the busiest in the state.
Furthermore, demand for trauma services has reached a plateau in many large urban areas. The number of life-threatening accidents, especially involving victims of penetrating-wound traumas, has strangely leveled off in recent years.
Penetrating-wound victims currently represent about 40% of trauma cases nationwide. Experts aren't certain why this is occurring, but they speculate that the number of trauma patients seen annually coincides somehow with a statistical decline nationally in homicides and violent crimes.
Of course, a lot of the flat results have to do with the number of trauma centers located in a particular city, Campbell suggests. Certainly, the trends do not show that trauma center activity is waning nationally by any means. Some communities are still under-served. But current, overall demand suggests that most cities have sufficient trauma-care services for their populations, Campbell adds.
Financially, trauma centers could not be doing better overall. "The tide has turned dramatically in the past five years," says consultant Michael Williams, a trauma expert and president of The Abaris Group in Walnut Creek, CA.
Indigent care still ranks high as a problem
A decade ago, hospitals that had gotten a trauma designation were eager to drop out after only a few years and many did in reaction to rampant over-utilization, low payments, high indigent care, and mismanagement of trauma systems by government jurisdictions.
Indigent care still ranks high on their problem lists. But, in recent years, hospitals have significantly overcome many of these hurdles through better cost management and government support. In fact, trauma medicine is today potentially one of the most lucrative business lines for any hospital. "It's pretty much a carve-out for managed care," says Williams. This is true for the following reasons, he contends.
· Due to the huge cost of treating trauma patients relative to other forms of acute-care and relatively few providers, health plans have been forced out of necessity to avoid cutting deals with the limited number of specialized trauma care hospitals.
· In addition, most hospitals have successfully mastered the operational and financial difficulties of running trauma operations by implementing techniques borrowed in principal from other clinical disciplines such as emergency medicine, Williams says.
These include case management, clinical best practices, and outcomes-management protocols that have boosted efficiencies and led to lower costs per patients.
· Furthermore, trauma care is privileged with having additional payer sources that don't apply to most clinical specialties, Williams notes. Auto insurance companies, indemnity plans covering death or dismemberment, and legal covenants that cover medical claims through liens and other provisions.
Unfortunately, Williams says, hospitals aren't pursuing these other payment sources aggressively. But they represent lucrative sources of cost-plus earned revenue for providers.
Statistics in trauma medicine are sketchy. But the cost of treating a trauma case averages about $28,000. Patients tend to be younger (60% are males between the ages of 15 and 30) and 15-20% of cases come from Medicaid, self-pay, and no-pay sources, according to Williams. In comparison, the specialty has very little Medicare business.
Nationally, the average length of inpatient stays for most trauma cases range about nine days, including 2.5 days spent in an intensive care unit. Most, if not all, of these services are paid for on a negotiated cost-plus basis, Williams notes. For many large teaching hospitals and tertiary-care centers, trauma is the best revenue generator in the ED, Williams adds.
Payers are anxious but wrong on costs
Nevertheless, life would be a lot less frustrating to surgeons if repatriation weren't a factor. Repatriation is the term used by surgeons to describe the process of transferring injured health plan enrollees to a contracting facility. "The core issue here is money. The plans don't want to have to pay on the basis of an out-of-plan provider for a medical case that is already quite expensive," says Campbell of San Francisco General.
Payers are quite subtle and civil when they ask, adds Campbell. The telephone calls are frequent, but they are never forceful, and they never infringe on our assessment of when the patient is sufficiently stable for transfer. "That is usually not the issue," Campbell states, "But, they still ask."
However, research shows that in terms of resource-usage, repatriation doesn't necessarily support the aims of managed care, Campbell observes. A 1995 study of trauma centers and managed care explored the repatriation issue.1
Campbell and fellow researchers at San Francisco General and Kaiser Permanente Medical Center, which is also located in San Francisco, tracked the progress of 7794 trauma patients enrolled in the Kaiser plan who were initially admitted to San Francisco General's trauma center.
Compared with a control group of non-Kaiser patients, the Kaiser cases experienced a median length of stay of three days compared with 2.5 days for the control group. The mean length of stay was 7.6 days compared with 4.8 days, respectively. Yet, despite growing evidence to the contrary, health plans continue to urge trauma centers about the need for patient transfers.
And Campbell reports that most such cases end up in repatriation once the patient is deemed stabilized according to the hospital's internally developed clinical guidelines and principles recommended by the American College of Surgeons in Chicago. "These events usually get resolved but they are still a hot button in trauma care," Campbell concludes.
Reference
1. Campbell AR, Vittinghoff E, Morabito D, et al. Trauma centers in a managed care environment. J Trauma Injury Infect Crit Care 1995;39:246-253.
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