Changes in payer mix of new and established trauma centers: the new trauma center money grab?

Abstract

Background: Although timely access to trauma center (TC) care for injured patients is essential, the proliferation of new TCs does not always improve outcomes. Hospitals may seek TC accreditation for financial reasons, rather than to address community or geographic need. Introducing new TCs risks degrading case and payer mix at established TCs. We hypothesized that newly accredited TCs would see a disproportionate share of commercially insured patients.

Study design: We collected data from all accredited adult TCs in Pennsylvania using the state trauma registry from 1999 to 2018. As state policy regarding supplemental reimbursement for underinsured patients changed in 2004, we compared patient characteristics and payer mix between TCs established before and after 2004. We used multivariable logistic regression to assess the relationship between payer and presentation to a new versus established TC in recent years.

Results: Over time, there was a 40% increase in the number of TCs from 23 to 38. Of 326 204 patients from 2010 to 2018, a total of 43 621 (13.4%) were treated at 15 new TCs. New TCs treated more blunt trauma and less severely injured patients (p<0.001). In multivariable analysis, patients presenting to new TCs were more likely to have Medicare (OR 2.0, 95% CI 1.9 to 2.1) and commercial insurance (OR 1.6, 95% CI 1.5 to 1.6) compared with Medicaid. Over time, fewer patients at established TCs and more patients at new TCs had private insurance.

Conclusions: With the opening of new centers, payer mix changed unfavorably at established TCs. Trauma system development should consider community and regional needs, as well as impact on existing centers to ensure financial sustainability of TCs caring for vulnerable patients.

Level of evidence: Level III, prognostic/epidemiological.

Keywords: Health Care Economics And Organizations; Health Care Quality, Access, And Evaluation; health policy; insurance.

Figure 1. Adult trauma centers and trauma volume in Pennsylvania over time, 1999–2018. The black line with red dots represents the number of trauma centers over our period of observation, as depicted by the first y-axis. The yellow line represents the corresponding increase in the number of patients reported to the state trauma registry as measured by the secondary y-axis. The green line represents the trauma volume at established trauma centers, while the purple line represents corresponding trauma volume at new trauma centers over our period of observation. Source: Pennsylvania Trauma Outcomes Study.

Figure 2. New versus established trauma center payer mix over time, 1999–2018. This graph represents the changes in payer mix (private, Medicare, and Medicaid/uninsured) between established trauma centers (the warm red-orange colors) and new trauma centers (the cool blue-green colors) over time. Source: Pennsylvania Trauma Outcomes Study.

Figure 3. Commercially insured patients at new versus established trauma centers over time, 1999–2018. The blue bars represent the proportion of privately insured patients at established trauma centers over time, while the red bars represent the proportion of privately insured patients at new trauma centers over the same time period, both reflected on the primary y-axis. The yellow line represents the coinciding increase in trauma volume during this time period, as depicted on the secondary y-axis. The green line represents the coinciding trend in trauma volume at established trauma centers, while the purple line represents the increase in volume at new trauma centers. Source: Pennsylvania Trauma Outcomes Study.