Payer status: The unspoken triage criterion

Avery B. Nathens, Ronald V. Maier, Michael K. Copass, Gregory Jurkovich

Research output: Contribution to journalArticle

109 Scopus citations

Abstract

Background: The cost of uncompensated trauma care is a significant barrier to trauma system development. Trauma center designation may burden an institution with an unprofitable mix of underinsured, severely injured patients. Concerns about inadequate reimbursement may motivate interhospital transfers on the basis of insurance status rather than medical necessity, potentially undermining the effectiveness of the system. We set out to explore whether this phenomenon exists in a mature trauma system. Methods: Trauma patients receiving definitive care at Level III or IV trauma centers were compared with patients transferred from these centers to the only Level I regional center. Insurance status was classified as either commercial or noncommercial. Logistic regression was used to determine the independent predictors of transfer after adjusting for differences in injury severity. Results: Only 12% of 2,008 patients initially evaluated at Level III/IV centers were transferred to the Level I center, an indicator of the effectiveness of prehospital triage protocols in the region. The presence of specific complex injuries, younger age, male gender, and insurance status were all associated with an increased likelihood of transfer. Insurance status was an independent predictor of transfer: patients without commercial insurance were 2.4 (95% confidence interval, 1.6-3.6) times more likely to be transferred to a Level I facility than patients with commercial insurance after adjusting for differences in injury severity. Conclusion: Insurance status influences the decision to transfer to higher levels of care. These findings suggest that the financial burden of a trauma system may be inequitably distributed. This inequitable distribution may be necessary for trauma system sustainability and calls for the development of disproportionate reimbursement strategies to support regional referral centers.

Original languageEnglish (US)
Pages (from-to)776-783
Number of pages8
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume50
Issue number5
DOIs
StatePublished - Jan 1 2001
Externally publishedYes

Keywords

  • Insurance
  • Payer mix
  • Trauma system
  • Triage

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

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