Trauma System Agenda for the Future
 

Index

What is Trauma

What is Trauma Systems

The Vision

Executive Summary

Introduction

Comprehensive Trauma Care System: Fundamental Components of Trauma Care

Comprehensive Trauma Care System: Key Infrastructure Elements

Conclusion

Glossary

References

Appendices

Finances

Current Status

For the past three decades, the cost of trauma system development has been a shared responsibility of Federal and state governments. Although new funding sources have been identified to support the initial implementation of trauma system development in many communities, there is a lack of appreciation by the public and policy makers for the costs associated with the continual "level of readiness" necessary to provide trauma care services for all injured patients. In addition, there are few data to document the cost effectiveness of establishing such systems or to support advocacy for continued financial resources.

In 1996, road traffic crashes, homicide, violence, and unintentional injuries, taken together, accounted for more "Disability Adjusted Life Years" (DALY's) for men than did ischemic heart disease. DALY's equal years of healthy life lost to disability plus years of life lost to premature death (unpublished results from "US Burden of Disease and Injury Study," a joint project of the US Centers for Disease Control and Harvard University).

Costs related to trauma care are incurred by multiple organizations within a trauma system such as public agencies, pre-hospital providers, acute care providers, and rehabilitation providers. Funding for trauma care, as for health care in general, is currently based on payment for services delivered (i.e., fee-for-service structure). However, reimbursement by governmental payers (Medicare, Medicaid) does not fully cover the cost of trauma care for their beneficiaries. The resulting shortfall, added to the cost of uncompensated care provided to nearly 50 million uninsured Americans, has shifted the financial burden of trauma care to nongovernmental payers (insurers, both for-profit and not-for-profit). This cost shifting makes the purchase of insurance by employers and others more expensive and less attractive, which increases the number of uninsured and causes the cost of uncompensated care to spiral upward, especially in rural and inner city areas.

Emergency services in many rural regions today still depend on a "wing and a prayer" of grassroots organizations supported by volunteers and vintage equipment. Studies of rural EMS conducted since 1985 repeatedly point out the same problems. 26 Because of the low annual volume of calls and thin tax base, it is difficult to finance the universally high fixed cost of an ambulance operation. Yet, the need and demand for EMS in rural areas-where distance is critical and rates of occupational injury are high-is as great or greater than in urban areas. However, one call per day can't finance the operation.

The Vision

•  Trauma systems will be recognized as a public good and therefore valued and adequately funded not only for the clinical care they actually deliver, but also for the level of readiness required to meet the needs of all injured persons. A public supported funding source specifically designated for trauma care will be established and administered at the state level.

•  The appropriate level of readiness in a community will be determined by a broad-based group of community members, including citizens, local employers, trauma and health care providers, and payers. Although the level of readiness will vary by community, components of the trauma system that are related to this readiness-such as prevention programs and system assessment and analysis-will be directly reimbursed.

•  There will be a "rural modifier" to the Medicare fee schedule for rural EMS providers. This modifier will be analagous to the payment enhancements made for rural clinics and the Critical Access Hospitals system.

•  There will be dedicated funding for trauma system infrastructure costs.

•  An open dialogue with managed care organizations, public and private, and other payers will facilitate greater mutual understanding of the costs of providing health care, ultimately leading to equitable payment mechanisms, which may include "carve outs" or risk sharing.

•  There will be ongoing dialogue and review regarding the cost-effectiveness of trauma care systems.

•  A system will be created for reimbursing providers for uncompensated trauma care without cost shifting to non-governmental payers .

•  The public will be encouraged to obtain long-term care coverage to augment other forms of payment for post-hospital care.

•  Alternative payment mechanisms will be examined, tested, and piloted, especially in rural areas.

•  Additional funding sources, such as seized drug money, will be explored.