Rush­ing for trauma cen­ters

Bet­ter fi­nanc­ing drives a build­ing boom­let in Level 1 trauma cen­ters

Modern Healthcare - - NEWS - By Steven Ross John­son

For the past 20 years, MetroHealth Med­i­cal Cen­ter has been the sole provider of Level 1 adult trauma care for the met­ro­pol­i­tan Cleve­land area’s 2 mil­lion res­i­dents. Lo­cated on the city’s west side, Cuya­hoga Coun­ty­owned MetroHealth op­er­ates one of the busiest trauma cen­ters in the coun­try. Its spe­cial­ized fa­cil­ity and highly trained clin­i­cal staff han­dle more than 3,000 sud­den and se­ri­ous in­juries a year, in­clud­ing gun­shots, stab­bings, falls and mo­tor-ve­hi­cle ac­ci­dents. “Emer­gen­cies come first here,” said Dr. Jef­frey Clar­idge, di­rec­tor of the trauma di­vi­sion at MetroHealth.

But his cen­ter is about to face some stiff com­pe­ti­tion. Next month, Case Western Re­serve’s Univer­sity Hos­pi­tals (UH), an­chored by its mas­sive 1,032-bed ter­tiary-care hos­pi­tal on the city’s east side, will open the re­gion’s sec­ond Level 1 trauma cen­ter. Its ra­tio­nale: The largely African-- Amer­i­can east­ern side of Cleve­land has been un­der­served for years be­cause of the dis­tance to reach MetroHealth.

“When we first started to look at the de­liv­ery of adult trauma care, we really looked at it from a pub­lic health need,” said Dr. Michael An­der­son, UH’s chief med­i­cal of­fi­cer. “Cleve­land is of­ten thought of as east side and west side, so for those pa­tients on the east side of town, rapid ac­cess to trauma care was sorely lack­ing.”

Such sce­nar­ios are play­ing out in a num­ber of metro ar­eas across the coun­try. More ur­ban hos­pi­tals are look­ing to open trauma-care cen­ters or el­e­vate the des­ig­na­tion of an ex­ist­ing fa­cil­ity to Level 2 or Level 1. Ex­perts say the des­ig­na­tion up­grade not only steps up the med­i­cal ser­vices they can pro­vide, but gen­er­ates sub­stan­tially higher fa­cil­ity fees from both gov­ern­ment and pri­vate pay­ers.

Since 2012, 117 Level 1 and Level 2 trauma cen­ters have opened in the U.S., bring­ing the to­tal of such fa­cil­i­ties to more than 520, ac­cord­ing to the Ameri-

can Trauma So­ci­ety. “You have a surge of open­ings in trauma-care cen­ters right now that has re­placed prob­a­bly the main prob­lem that we have had for decades, (which was) not enough,” said Greg Bishop, pres­i­dent and founder of Bishop and As­so­ciates, a health­care re­search con­sult­ing firm that spe­cial­izes in trauma-cen­ter de­vel­op­ment and man­age­ment.

Some say the growth in trauma cen­ters re­flects an in­crease in trauma cases and lo­cal pop­u­la­tion booms. But the fi­nan­cial in­cen­tives for trauma-cen­ter ex­pan­sion have clearly been a fac­tor, as a greater share of trauma-care pa­tients are now cov­ered by pub­lic and pri­vate in­sur­ance. If the ex­pan­sions lead to over­ca­pac­ity, it could be detri­men­tal for pa­tient care and the bot­tom lines of those hos­pi­tals.

“If some­body opens the spigot, some­body should know how to turn the spigot off,” said Mike Wil­liams, for­mer di­rec­tor of Emer­gency Med­i­cal Ser­vices for Or­ange County, Calif., and pres­i­dent of the Abaris Group, a con­sult­ing firm. “Th­ese hos­pi­tals are learn­ing that there are not a lot of con­straints as to whether they can go af­ter trauma or not. At some point, we’ll have too many trauma cen­ters and that doesn’t help any­body.”

In­creased in­sur­ance and Med­i­caid cov­er­age un­der the Af­ford­able Care Act con­trib­utes to the re­cent ex­pan­sion. For years, most hos­pi­tals saw Level 1 or Level 2 trauma cen­ters as money-los­ing oper­a­tions that re­quired sub­stan­tial in­vest­ments in equip­ment, fa­cil­i­ties and staffing, in­clud­ing keep­ing 24-hour, on-call sur­gi­cal spe­cial­ists. Be­fore the ACA, a num­ber of trauma cen­ters that served peo­ple on Med­i­caid or the unin­sured closed.

Be­tween 1990 and 2005, the num­ber of trauma cen­ters fell from 1,125 to 786, ac­cord­ing to a 2011 Health Af­fairs study co-au­thored by Dr. Re­nee Hsia, pro­fes­sor and di­rec­tor of health pol­icy stud­ies at the Univer­sity of Cal­i­for­nia at San Francisco’s Emer­gency Medicine Depart­ment.

But that has turned around over the past few years. “Re­search shows that, on the whole, trauma cen­ters tend to be ex­pen­sive. They’re not re­im­bursed ap­pro­pri­ately, so hos­pi­tals may end up hem­or­rhag­ing fi­nan­cially,” Hsia said. “On the other hand, a lot of hos­pi­tals want to be­come trauma cen­ters, so both things are hap­pen­ing.”

In Septem­ber, the Univer­sity of Chicago Med­i­cal Cen­ter an­nounced plans to part­ner with lo­cal safety net provider Si­nai Health Sys­tem to build and run a Level 1 adult trau- ma cen­ter on the city’s South Side, an area that has one of the high­est rates of vi­o­lent trauma cases in the na­tion. UChicago is pro­vid­ing $40 mil­lion for the cen­ter that will be housed in Si­nai’s Holy Cross Hos­pi­tal.

“When we looked at a map of where the trauma was oc­cur­ring, it be­came abun­dantly clear to us that there was a huge amount clus­ter­ing around the Holy Cross com­mu­nity,” said Karen Teit­el­baum, CEO of Si­nai Health Sys­tem. The move comes more than 20 years af­ter the last hos­pi­tal that pro­vided trauma care on the South Side closed.

But not all new trauma cen­ters are open­ing in un­der­served ar­eas. And even when that ar­gu­ment is made, as in Cleve­land, it may cre­ate prob­lems for ex­ist­ing cen­ters by split­ting the avail­able pool of pa­tients.

Ac­cord­ing to an­nual re­ports from the Amer­i­can Col­lege of Sur­geons’ Na­tional Trauma Data Bank, the num­ber of cases re­ported from trauma cen­ters has been on the rise, from 681,000 in­ci­dents in 2010 to 860,000 in 2014. But na­tional trends have shown the num­ber of fa­tal­i­ties from firearms and car ac­ci­dents, two of the ma­jor causes of trauma, has been slowly de­clin­ing over the past decade.

Clar­idge at MetroHealth wor­ries the ad­di­tion of a sec­ond Level 1 trauma cen­ter in Cleve­land will spell fi­nan­cial trou­ble for his institution. UH’s plan puts it in direct com­pe­ti­tion with the al­ready-es­tab­lished North­ern Ohio Trauma Sys­tem, or NOTS. The re­gional trauma net­work, led by MetroHealth, in col­lab­o­ra­tion with the Cleve­land Clinic, was de­signed to co­or­di­nate re­gional trauma care. UH de­clined to join NOTS.

“Trauma cen­ters shouldn’t be brought up for com­pet­i­tive pur­poses and mar­ket share,” Clar­idge said. “They should work to­gether with an ex­ist­ing sys­tem that’s al­ready there for what’s best for pa­tients.”

Other ex­perts worry that split­ting the avail­able pa­tient pool be­tween two trauma cen­ters will worsen out­comes. “The more the num­ber of cases gets di­luted be­cause we have too many cen­ters, the less ex­pe­ri­ence any one cen­ter has,” said Dr. Ir­win Redlener, di­rec­tor of the Na­tional Cen­ter for Dis­as­ter Pre­pared­ness at Columbia Univer­sity.

The big­gest fac­tor driv­ing hos­pi­tal de­ci­sions is the avail­abil­ity of in­sur­ance cov­er­age, Hsia said. “If you’re lo­cated in an area where you have a lot of good in­sur­ance—pri­vate and com­mer­cial in­sur­ance, as well as Medi­care—then a lot of those hos­pi­tals tend to want to have Level 1 trauma cen­ters be­cause they can bill for a fa­cil­ity fee, a trauma-ac­ti­va­tion fee, and a lot of those things are re­im­bursed at a fairly good rate.”

Pay for Level 1 and Level 2 trauma care in­creas­ingly comes from Medi­care and Med­i­caid. The 2015 an­nual Na­tional Data Trauma Bank re­port from the Amer­i­can Col­lege of Sur­geons, which ver­i­fies des­ig­na­tion for more than 740 trauma cen­ters, found that Medi­care now

“Trauma cen­ters shouldn’t be brought up for com­pet­i­tive pur­poses and mar­ket share. They should work to­gether with an ex­ist­ing sys­tem that’s al­ready there for what’s best for pa­tients.”

Dr. Jef­frey Clar­idge, trauma di­vi­sion di­rec­tor, MetroHealth, Cleve­land

ac­counts for 25.8% of all cen­ter pay­ments, up from just 16.6% in 2005, and Med­i­caid is at 14%, up from 11.2%. Pri­vate and com­mer­cial in­sur­ance is now 26.3% com­pared with 29% a decade ago, while self-pay­ing pa­tients—many of whom never pay—have fallen from 21.1% to just 12.5% over the past decade.

“It’s not pop­u­lar to say that your emer­gency room or your trauma cen­ter makes money,” Wil­liams said. “But I have looked at the fi­nan­cials of hun­dreds of th­ese hos­pi­tals. They do make money when they’re prop­erly con­structed.”

Op­er­at­ing a trauma cen­ter can bring an­cil­lary ben­e­fits to a hos­pi­tal sys­tem, ex­perts say, by act­ing as a pow­er­ful mar­ket­ing tool that at­tracts other pa­tients and top spe­cial­ists. Some­times called “the halo ef­fect,” many hos­pi­tals see an in­crease in emer­gency depart­ment vis­its af­ter open­ing a trauma cen­ter, since they be­come known for han­dling emer­gen­cies.

For-profit HCA, based in Nashville, has ac­tively pur­sued that strat­egy over the past sev­eral years, open­ing Level 2 trauma units at some of its Florida hos­pi­tals. “They have a na­tional ini­tia­tive and now have trauma per­son­nel at the di­vi­sion level help­ing their hos­pi­tals de­velop trauma cen­ters,” Bishop said.

In a pre­pared state­ment, HCA said: “In many of our com­mu­ni­ties, there has been a sig­nif­i­cant need for trauma care. Pa­tients in th­ese cir­cum­stances have a much bet­ter chance of sur­vival when they are given care in a des­ig­nated trauma cen­ter within an hour of in­jury (the Golden Hour), and we are proud that our scale and ef­fi­cien­cies, which sup­port care­givers in our af­fil­i­ated trauma pro­grams, help en­able us to of­fer th­ese life­sav­ing ser­vices.”

Stud­ies have shown that the faster a se­ri­ously in­jured trauma pa­tient gets care, the bet­ter their chances of sur­vival. UH’s An­der­son said bet­ter clin­i­cal out­comes were the ba­sis for its de­ci­sion.

But it re­mains an open ques­tion, es­pe­cially when new trauma cen­ters open in slow-grow­ing mar­kets. The Amer­i­can Col­lege of Sur­geons rec­om­mends a Level 1 trauma cen­ter should see a min­i­mum of about 1,200 pa­tients a year to avoid neg­a­tively af­fect­ing the qual­ity of its care. UH would have to treat 40% of MetroHealth’s trauma pa­tients to reach that level.

MetroHealth han­dles more than 3,000 in­juries a year, in­clud­ing gun­shots, stab­bings, falls and mo­tor-ve­hi­cle ac­ci­dents.

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