The trauma safety-net hospital under the Affordable Care Act: will it survive?

Caring for Underserved Populations in Orthopedic Trauma

Contemporary care of patients with orthopedic trauma is complex from surgical, cultural, administrative, financial, and linguistic perspectives. Surgeons must understand patients' backgrounds and resources to have an idea of the manner in which care can be delivered most effectively. Recognizing patients from traditionally underserved or vulnerable groups will help the surgeon to individualize their approach to the care of each individual patient. Understanding patient funding, or lack thereof, will inform the provider as to the extent of the resources and access available to the patient and assist in planning episodes of care.

Lifting the burden: State Medicaid expansion reduces financial risk for the injured

BACKGROUND

Injuries are unanticipated and can be expensive to treat. Patients without sufficient health insurance are at risk for financial strain because of high out-of-pocket (OOP) health care costs relative to their income. We hypothesized that the 2014 Medicaid expansion (ME) in Washington (WA) state, which extended coverage to more than 600,000 WA residents, was associated with a reduction in financial risk among trauma patients.

METHODS

We analyzed all trauma patients aged 18 to 64 years admitted to the sole level 1 trauma center in WA from 2012 to 2017. We defined 2012 to 2013 as the prepolicy period and 2014 to 2017 as the postpolicy period. We used a multivariable linear regression model to evaluate for changes in length of stay, inpatient mortality, and discharge disposition. To evaluate for financial strain, we used WA state and US census data to estimate postsubsistence income and OOP expenses for our sample and then applied these two estimates to determine catastrophic health expenditure (CHE) risk as defined by the World Health Organization (OOP health expenses ≥40% of estimated household postsubsistence income).

RESULTS

A total of 16,801 trauma patients were included. After ME, the Medicaid coverage rate increased from 20.4% to 41.0%, and the uninsured rate decreased from 19.2% to 3.7% (p < 0.001 for both). There was no significant change in private insurance coverage. Medicaid expansion was not associated with significant changes in clinical outcomes or discharge disposition. Estimated CHE risk by payer was 81.4% for the uninsured, 25.9% for private insurance, and less than 0.1% for Medicaid. After ME, the risk of CHE for the policy-eligible sample fell from 26.4% to 14.0% (p < 0.01).

CONCLUSION

State ME led to an 80% reduction in the uninsured rate among patients admitted for injury, with an associated large reduction in the risk of CHE. However, privately insured patients were not fully protected from CHE. Additional research is needed to evaluate the impact of these policies on the financial viability of trauma centers.

LEVEL OF EVIDENCE

Economic analysis, level II.

Undertriage after severe injury among United States trauma centers and the impact on mortality

INTRODUCTION

Severely injured patients should receive definitive care at high acuity trauma centers. The purposes of this study were to determine the undertriage (UT) rate within a national sample of trauma centers and to identify characteristics of UT patients.

METHODS

Severely injured adults ≥16 years were identified from the 2010-2012 NTDB. UT was defined as those who received definitive care or died at hospitals without state or ACS level I or II verification. Risk factors for UTT and the impact of UT on mortality were determined.

RESULTS

Of 348,394 severely injured patients, 11,578 (3.3%) were UT. Older, less severely injured, and certain minority patients were most likely to be UT. After risk adjustment, predictors of UT included increased age and minority race. Increased injury severity and comorbidity were protective (all p < .05). Mortality was greater in UT patients regardless of ISS (OR = 1.32, p < .001).

CONCLUSION

The low UT rate in this study demonstrates the effectiveness of triage practices amongst ACS and state verified centers however age, race, and insurance disparities in UT should be improved.

Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals

BACKGROUND

Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability.

STUDY DESIGN

We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin.

RESULTS

California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n = 4) and nonprofit-owned SNHs (64%, n = 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p < 0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively.

CONCLUSIONS

The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system.

Potential impact of Affordable Care Act-related insurance expansion on trauma care reimbursement

BACKGROUND

Nearly one quarter of trauma patients are uninsured and hospitals recoup less than 20% of inpatient costs for their care. This study examines changes to hospital reimbursement for inpatient trauma care if the full coverage expansion provisions of the Affordable Care Act (ACA) were in effect.

METHODS

We abstracted nonelderly adults (ages 18-64 years) admitted for trauma from the Nationwide Inpatient Sample during 2010-the last year before most major ACA coverage expansion policies. We calculated national and facility-level reimbursements and trauma-related contribution margins using Nationwide Inpatient Sample-supplied cost-to-charge ratios and published reimbursement rates for each payer type. Using US census data, we developed a probabilistic microsimulation model to determine the proportion of pre-ACA uninsured trauma patients that would be expected to gain private insurance, Medicaid, or remain uninsured after full implementation of the ACA. We then estimated the impact of these coverage changes on national and facility-level trauma reimbursement for this population.

RESULTS

There were 145,849 patients (representing 737,852 patients nationwide) included. National inpatient trauma costs for patients aged 18 years to 64 years totaled US $14.8 billion (95% confidence interval [CI], 12.5,17.1). Preexpansion reimbursements totaled US $13.7 billion (95% CI, 10.8-14.7), yielding a national margin of -7.9% (95% CI, -10.6 to -5.1). Postexpansion projected reimbursements totaled US $15.0 billion (95% CI, 12.7-17.3), increasing the margin by 9.3 absolute percentage points to +1.4% (95% CI, -0.3 to +3.2). Of the 263 eligible facilities, 90 (34.2%) had a positive trauma-related contribution margin in 2010, which increased to 171 (65.0%) using postexpansion projections. Those facilities with the highest proportion of uninsured and racial/ethnic minorities experienced the greatest gains.

CONCLUSION

Health insurance coverage expansion for uninsured trauma patients has the potential to increase national reimbursement for inpatient trauma care by over one billion dollars and nearly double the proportion of hospitals with a positive margin for trauma care. These data suggest that insurance coverage expansion has the potential to improve trauma centers' financial viability and their ability to provide care for their communities.

LEVEL OF EVIDENCE

Economic analysis, level II.

An effectiveness-implementation hybrid trial study protocol targeting posttraumatic stress disorder and comorbidity

BACKGROUND

Each year in the USA, 1.5-2.5 million Americans are so severely injured that they require inpatient hospitalization. Multiple conditions including posttraumatic stress disorder (PTSD), alcohol and drug use problems, depression, and chronic medical conditions are endemic among physical trauma survivors with and without traumatic brain injuries.

METHODS/DESIGN

The trauma survivors outcomes and support (TSOS) effectiveness-implementation hybrid trial is designed to test the delivery of high-quality screening and intervention for PTSD and comorbidities across 24 US level I trauma center sites. The pragmatic trial aims to recruit 960 patients. The TSOS investigation employs a stepped wedge cluster randomized design in which sites are randomized sequentially to initiate the intervention. Patients identified by a 10-domain electronic health record screen as high risk for PTSD are formally assessed with the PTSD Checklist for study entry. Patients randomized to the intervention condition will receive stepped collaborative care, while patients randomized to the control condition will receive enhanced usual care. The intervention training begins with a 1-day on-site workshop in the collaborative care intervention core elements that include care management, medication, cognitive behavioral therapy, and motivational-interviewing elements targeting PTSD and comorbidity. The training is followed by site supervision from the study team. The investigation aims to determine if intervention patients demonstrate significant reductions in PTSD and depressive symptoms, suicidal ideation, alcohol consumption, and improvements in physical function when compared to control patients. The study uses implementation science conceptual frameworks to evaluate the uptake of the intervention model. At the completion of the pragmatic trial, results will be presented at an American College of Surgeons' policy summit. Twenty-four representative US level I trauma centers have been selected for the study, and the protocol is being rolled out nationally.

DISCUSSION

The TSOS pragmatic trial simultaneously aims to establish the effectiveness of the collaborative care intervention targeting PTSD and comorbidity while also addressing sustainable implementation through American College of Surgeons' regulatory policy. The TSOS effectiveness-implementation hybrid design highlights the importance of partnerships with professional societies that can provide regulatory mandates targeting enhanced health care system sustainability of pragmatic trial results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02655354 . Registered 27 July 2015.

New care measures and their impact on pain medicine: One pain specialist's perspective

Value-based purchasing (VBP) goes into effect this year and it links the quality of care to payments for care. Starting in fiscal year 2013, the Centers for Medicare and Medicaid Services reduces all inpatient prospective payment system reimbursements by 1%. This money then can be returned to hospitals in the form of a bonus through VBP. Value-based purchasing holds hospitals accountable for both cost and quality. With VBP, hospitals get a score that is based on the process of care, the outcomes, and patient-centeredness. This means that reimbursements in health care, which keep hospitals in business, are transitioning from "volume of services" to VBP. Although VBP sounds like a great idea, particularly to politicians in Washington tasked with managing out-of-control health care expenditures, there is very little high-quality evidence that VBP will actually improve care. Nevertheless, this is the way we are going to be moving forward. The perception of pain is a highly personalized phenomenon, and chronic pain affects every aspect of a patient's life. The biopsychosocial model and the concept of utilizing an interdisciplinary team approach in the management of chronic pain make sense, but there are concerns that it could result in higher overall costs and no measurable improvements in the patient's perception of care. Both results. could have a negative impact on pain specialists.