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death (unpublished results from "US Burden of Disease and Injury Study," a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.
• 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.