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The financial impact of the loss of county indigent patient funding on a single orthopedic trauma surgery service

Forsh, David A. MD; Amanantullah, Derek F. MD, PhD; Coleman, Sheldon MD; Wolinsky, Philip R. MD

Journal of Trauma and Acute Care Surgery: February 2014 - Volume 76 - Issue 2 - p 529–533
doi: 10.1097/TA.0000000000000093
Original Articles

BACKGROUND We examined the financial ramifications on the orthopedic trauma service after loss of payment to our institution for care of indigent patients. Our institution is the only Level I trauma center located within the county. Before mid-2009, county insurance-eligible patients treated at our institution had their health care paid for by the county. After mid-2009, the county no longer reimbursed our institution for care provided.

METHODS A retrospective review was performed on 653 county patients treated by the four orthopedic trauma surgeons during a 4-year period including the 2 years before the loss of county payments as well as the 2-year period following the loss of payment. Data collected included demographics, admitting service, injuries treated, length of stay, surgeon billing, and reimbursement. We also classified the urgency of care that was rendered into one of three categories as follows: emergent, urgent, or elective.

RESULTS There was a higher frequency of emergent and urgent procedures and a lower frequency of elective cases performed in the noncontracted period versus the contracted period. During the contracted period, we billed and collected $1,161,036. After the loss of reimbursement from the county, we billed $870,590 and were paid $0. County reimbursements made up 33.5% of the total professional fees billed. There was a 20% net drop in total billing during the noncontracted period, of which the money not reimbursed by the county accounted for 31%.

CONCLUSION Despite the lack of county payment, our institution continues to provide care to the indigent population. This lack of payment may have significant long-term economic ramifications for the orthopedic trauma surgeons and for our institution. The financial burden preferentially falls on the “safety net” Level I trauma centers and the physicians who take care of patients with urgent and emergent injuries. This burden may be unsustainable in the future.

LEVEL OF EVIDENCE Economic and value-based evaluation, level V.

From the Icahn School of Medicine (D.A.F.), Mt. Sinai Hospital, New York, New York; and Department of Orthopedic Surgery (D.F.A., S.C., P.R.W.), University of California, Davis, Sacramento, California.

Submitted: June 13, 2013, Revised: October 18, 2013, Accepted: October 18, 2013.

This study was accepted for poster presentation at 126th AOA meeting June 11 to 15, in Denver, Colorado, and as podium presentation at 77th Annual Western Orthopaedic Association Annual Meeting, July 31 to August 3, in Lake Tahoe, California.

Address for reprints: David A. Forsh, MD, Icahn School of Medicine at Mt. Sinai Hospital 5 E 98th St, 9th Floor, New York, NY 10029; email:

© 2014 Lippincott Williams & Wilkins, Inc.