At the end of the last century and the beginning of this one, the nation's trauma centers faced increased caseloads and dwindling reimbursements. Disasters regularly pulled up to the emergency department door, but the greatest threat to the trauma center itself was the fact that nearly one-quarter of the patients were uninsured. Hospitals were able to recoup less than 20 percent of the costs of their inpatient care.
“We live in a society where we say no matter who you are, if you have an emergency, we will take care of you,” said John W. Scott, MD, MPH, a trauma and surgical critical care fellow at Harborview Medical Center at the University of Washington in Seattle. Dr. Scott and his colleagues evaluated the anticipated effect of full implementation of the Affordable Care Act and estimated that reimbursements for inpatient trauma care in 2010 would rise from $13.7 billion annually (for a national loss of 7.9 percent) to $15 billion once the ACA took full effect. (J Trauma Acute Care Surg. 2017;82:887; http://bit.ly/2FfCVVz.) They anticipated that 40 percent of previously uninsured trauma patients aged 18 to 64 would gain some form of private insurance and another 14 percent would enroll in Medicaid.
“Due to these changes in payer mix, we estimate that trauma centers could receive over $1 billion in increased revenue, corresponding to a more than 9 percent absolute increase in profit margin nationally,” the authors wrote. They estimated that more than 65 percent of trauma hospitals would have a positive margin, nearly double that before the implementation of the ACA.
Hospitals across the nation have seen that play out. Researchers led by Thomas G. Cheslik, MD, of the Boonshoft School of Medicine at Wright State University in Dayton, OH, found that the hospital saw self-pay and charity cases decrease, Medicaid charges increase, and total hospital supplemental payments decline in the first year of the ACA at a Level I trauma center in Dayton. They also noted a small but noteworthy downturn in the number of commercially insured patients. (J Trauma Acute Care Surg. 2016;80:1010.)
“Our article was projecting, using the best estimates of how the ACA was going to roll out,” Dr. Scott said. “Since then, the data have proven a lot of our ideas to be true.” But he added a caveat: Planned reductions in Medicaid's disproportionate share hospital program could compromise the ability of hospitals and trauma centers in safety-net institutions to realize the full potential of the ACA.
Health or Bankruptcy
Dr. Scott said, however, that the cost of trauma care, even with insurance, can bankrupt individual patients. “I have had situations where a patient in the emergency department will say, ‘I can't pay for this,’ even when they have gotten in a car crash or something similar,” he said. “The last thing a patient should be worried about is cost. Is it worth curing your body? People's lives are at stake. We have embraced the notion of keeping patients alive but at a considerable cost to the rest of their lives. I want to see them alive and thriving.”
Many trauma patients are working age, Dr. Scott said, and they cannot go into rehabilitation if they don't have insurance. “Now they are on disability. If they were insured, they could regain health and go back into the workforce. It's better for their lives and the well-being of the society.”
Before the ACA, seven of 10 trauma patients admitted to the hospital were at risk for catastrophic health expenditure. Even after the ACA, many working young people elect to go without insurance and their risk remains.
“For trauma patients, the ACA and Medicaid expansion make all the difference in the world,” said Cheryl K. Zogg, MD, an MD-PhD student at the Yale University School of Medicine with an interest in health policy. “High-cost trauma patients cannot pay, and that money may never be recouped. Ethically (and legally) as a provider, we cannot turn a patient away. That is the reason most of us went into emergency medicine and trauma care. It is difficult work but humbling and inspiring at the same time.”
She and colleagues studied 283,878 patients from Medicaid expansion states (currently 37 including Washington, DC) and 285,581 from 14 nonexpansion states. (JAMA Surg. 2019 Jan 2. doi: 10.1001/jamasurg.2018.5177.) Medicaid expansion, part of the ACA, extends eligibility for coverage to individuals up to 138 percent of the poverty rate for states that choose to expand it. Dr. Zogg and colleagues found a 13.7 percent decline in uninsured patients when comparing hospitals in expansion states with those that did not expand Medicaid.
Discharge to rehabilitation increased 7.4 percent in expansion states. The authors concluded that participating states showed significant change in insurance coverage and discharge to rehabilitation, and the change was much greater in states that expanded Medicaid. “By targeting subgroups of the trauma population most likely to be uninsured, rehabilitation gains associated with Medicaid have the potential to improve survival and of functional outcomes for more than 60,000 additional trauma patients nationally in expansion states,” the authors wrote.
Trauma is the number one killer of working-age people. Solving their problems is two-pronged: keeping hospitals that care for them financially afloat and getting them out of the hospital alive and financially independent. “Financial barriers are manmade,” said Dr. Scott. “We are writing a study now that looks at the rate of people who are underinsured. Many patients are underinsured, especially in trauma. Trauma affects all classes and sexes, but there is a disproportionate burden among low-income [patients].”
The expansion of Medicaid eligibility was a boon, particularly to safety-net and rural hospitals, in areas with many low-income, uninsured people. States like Dr. Scott's native South Carolina, which didn't expand Medicaid, has a higher proportion of uninsured patients. “That's a shame because a subsequent study shows that in states that did not expand Medicaid, hospital closures are more common, particularly in rural areas,” he said. “The most vulnerable of the vulnerable were those most helped by Medicaid expansion.”
Dr. Scott did his surgical training in Boston, and Massachusetts expanded Medicaid as part of its own health care plan. Because of that prior expansion, the state did not feel the same kind of effect. “The states that could have gained the most [from Medicaid expansion] are the ones that didn't, and that drives the gap in care farther apart,” he said. “Counties and communities are further behind, and safety-net hospitals are worse off.”
Matching the distribution of trauma centers to the needs of the population is a well-known problem, and that is where insurance comes in, Dr. Scott said. “Trauma centers shouldn't have to worry that taking care of this population of [low-income] patients will turn the lights out. The policy means the hospital gets some reimbursements, and patients are not leaving the hospital financially ruined.”
The American College of Surgeons noted in a 2015 statement that beneficial changes in the health economy led to the establishment of more trauma centers than needed by populations in some areas. The group warned that those designations could be easily dropped when the economics become undesirable, especially when designations are sought for reasons other than need. The group said that such facilities should only be constructed when and where the need is real.
Trauma care in some places has gone from a cost center to revenue center where you might make money, Dr. Scott said. “New trauma centers are being built, but is that going to happen in places where there is real need? Imagine a situation where you put a new trauma center next to a safety-net hospital. They could cherry-pick the patients.”
Yet he said he appreciated the role health care reform plays in the care of patients. “I think it is taking care of patients, and we have to do that as emergency and trauma providers,” Dr. Scott said. “Injury was a huge interruption in their lives. We need to get them back among the living. I appreciate that it's complicated.” He said insurance coverage could be expanded by increasing the number of patients with some sort of coverage, adding the conditions that insurance will cover or raising the dollar amount of the bill that insurance will cover.
“The facilities are there to take care of the patient,” he said. “If the patients cannot pay for care, then the taxpayers are. Safety-net hospitals can take care of a community in need. We have to keep the door open and lights on. People will die if those hospitals are closing. On the flip side, no one should be driven into poverty from an injury.”
County-by-county and state-by-state, trauma funds are set up to pay for it. “That is a community saying we are better than that,” said Dr. Scott.
Concern about the piecemeal dismantling of the ACA is justified, he said. Medicaid expansion was supposed to occur in all 50 states, but so far 14 have opted out. The threat to hospitals that receive federal disproportionate share payments because they care for a high volume of poor or uninsured patients is real, yet such payments would not be needed if everyone had insurance.
Dr. Scott said he sees bias against trauma patients and even trauma centers. “When I go, my insurance pays. It makes sense,” he said, adding that insured patients have a pathway to rehabilitation that can ensure a more productive future.
The State of Trauma
How did insurance—or the lack of it—affect the trauma systems in Texas, Mississippi, and Maryland? Find out in the Aug. 13 EMN enews, which can be found at http://bit.ly/EnewsEMN. Or sign up for the enews to have the article delivered directly to your inbox: http://bit.ly/EMNenewsSignup.
Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.