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Insurance Status a Factor in Trauma Care, Study Says

 |  By cclark@healthleadersmedia.com  
   February 24, 2014

Insured patients who are admitted to non-trauma hospitals may be getting "suboptimal" care in comparison to uninsured trauma patients who are "dumped" or  transferred to trauma centers, a counterintuitive study finding suggests.

Emergency doctors at non-trauma hospitals are less likely to transfer severely injured patients to a designated trauma center if the patients are insured than if they are not insured, according to a study published in JAMA Surgery.

The implication is that insured patients admitted to non-trauma hospitals may be getting "suboptimal" care simply because hospitals want to keep patients whose care would be well reimbursed compared with patients without health insurance coverage.

Researchers from the University of Pennsylvania Department of Emergency Medicine say the problem is well documented and serious enough that a law should be passed to prohibit the practice, much like the anti-dumping law, which requires hospitals to give stabilizing care to any patient, regardless of ability to pay, before transferring them.

"I don't think these decisions are being made maliciously," says M. Kit Delgado, MD, principal author of the report. "I think it's that these might be (ED doctors) who work in pretty big hospitals that have some resources, like neurosurgeons and orthopedic surgeons, and (they) honestly feel (they) can take care of those patients."

But the evidence shows that with severely injured patients, clinicians can't always provide the best care quickly enough.

Previous research shows that the risk that a patient will die in a trauma center is 25% less than if they are cared for in a non-trauma center, Delgado says. In effect, what his study found, he says, is that non-trauma hospitals are more likely to send uninsured patients to trauma centers where they get better care, than they are to send insured patients.

"It is a counterintuitive finding, and of course, 'dumping' is a harsh word to use. But maybe in this case, 'dumping' actually has an advantage for uninsured patients" whose transfers result in better care.

"While they may have the same resources on paper—neurosurgeons, orthopedic surgeons and intensivists—the hospitals designated as trauma centers go through an accreditation process with the American College of Surgeons or state committees. They've demonstrated that they not only have the people on paper, but they have the processes in place in order to optimize the care of these patients."

These vital elements include having key specialists immediately available and subspecialists available within 15 minutes. "They have quality improvement and teaching programs, and track their outcomes with registry data," Delgado says.

He adds, "A lot of the difference in outcomes is not just in the difference in initial management of the resuscitation, such as giving blood products, fluids, and managing the breathing, but also includes performing surgery, managing complications from the surgery, and the rehabilitation process, which are typically done better at trauma centers.

The Pennsylvania research team used the 2009 Nationwide Emergency Department Sample to analyze 19,312 encounters involving adult major trauma patients under age 65 in 636 non-trauma center emergency departments whether they were admitted or transferred.

Compared with patients who were uninsured, those who were covered by Medicaid had a rate of admission vs. transfer that was 14.3% higher, the researchers found. Medicare patients were 13.2% more likely to be admitted than transferred, privately insured patients were 11.2% more likely to be admitted and patients with other commercial insurance 13.1% to be admitted to the non-trauma hospital.

Questions About the Study
In an accompanying invited commentary, "Does a Wallet Biopsy Lead to Inappropriate Trauma Patient Care?" Charles Mabry, MD, of the University of Arkansas for Medical Sciences Department of Surgery in Little Rock, raised several concerns about the Penn report:

  • The study assumed all patients who were transferred were transferred to a trauma center, but that may not have been the case, Mabry suggests.
  • The study removed a large segment of the severely injured population, those covered by Medicare, which may have skewed the data.
  • Availability of specialists at trauma centers may have influenced the non-trauma hospital's decision to admit the patient.
  • How did the physicians at the non-trauma center know the patient's insurance status? "It is a common observation that a patient's financial status listed at the time of injury on the ED medical record is often misleading or completely wrong," Mabry wrote.

Lastly, he wrote, with more emergency room physicians becoming hospital employees, "it will be interesting to se if that change in compensation will have any influence on the decisions to admit or transfer."

Why this practice is really occurring remains an important question, Delgado acknowledges, and is the subject for numerous other studies now underway, he says. It may be that for many patients, proximity to their home is an important priority. "Or they may ask that they not be transferred to the 'county' hospital that treats mostly minority patients without insurance.' "

A Question of Distance
"If we find out that there is a strong patient preference for those with insurance to stay at their local hospital, the next step is to educate that population about the benefits of being treated in a trauma center when you have severe injuries," Delgado says.

Distance between the non-trauma hospital and the trauma center could be an issue, but probably isn't in this study, he says. "We know from our research at Penn that more than 86% of Americans have access via EMS transport to a level I or level II trauma center, either by helicopter or ground ambulance today." Another element of the story is that the researchers found this non-transfer trend at urban hospitals that are "very close to hospitals that are trauma centers."

There's also the possibility that emergency doctors at the non-trauma center are overly reassuring to the patient, minimizing the severity of their injuries, which in this study were largely due to falls and motor vehicle collisions.

"Our study raises more questions than it answers," acknowledges Delgado, who is working on a project to interview patients with severe trauma who stay in non-trauma hospitals for care. He hopes to learn more about why they stayed in the non-trauma facility.

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