Variation in Trauma Team Response Fees in United States Trauma Centers: An Additional Undisclosed Variable Cost in Trauma Care

doi:10.21203/rs.3.rs-777486/v1

Background: The rising costs associated with trauma care in the United States is an important topic in today’s healthcare environment. Factors such as innovations in technology, increasing governmental and organizational regulations, and the specialization of care have led to increasing costs to the patient. A component of trauma cost is the one-time trauma team response fee (TTRF). The determination process of TTRF’s dollar amount is elusive as no apparent standardized process exists and the literature is scant regarding this aspect of trauma care.

Methods: A nationwide cross-sectional convenience sample was conducted using Survey Monkey. Surveys were sent to 525 trauma centers in the continental U.S, including Alaska and Hawaii. Responses obtained from October 8, 2019 through March 11, 2020

Results: Only 46 out of 525 trauma centers, or 18.2% of those surveyed shared their scheduled fees. Comparisons of TTRF’s among different trauma centers, activation levels, and geographical locations were not statistically significant.

Conclusions: Understanding the true costs of trauma care and fees for patients in the U.S remains elusive due to inadequate data and low response rates. Trauma centers struggle to maintain financial viability as regulatory agencies and the public push for transparency of TTRF’s. Collaboration between TC’s and regulatory agencies is needed to ensure a balance between providing quality trauma care with justified associated charges and financial sustainability.

Health Policy

Health Economics & Outcomes Research

trauma cost

trauma care

trauma centers

activation fees

medical bankruptcy

Trauma is one of the leading causes of death and trauma care is consistently ranked as one of the largest contributors to total healthcare costs in the United States.^1,2 The formalization of trauma centers in the 1980’s added to the cost with 24-hour staffing of various medical specialists, equipment and affiliated educational programs.³ Although many hospitals accepted the added costs when choosing to become a trauma center, institutions could only use standard ED billing codes while rendering care for more complex trauma patients. As a result, many trauma centers could not sustain the rising associated costs of providing trauma care and opted out. ³

In 2002, Potter and her colleagues helped create the trauma activation fee (TAF) code (UB-04 revenue code 68X) that received legislative approval.⁴ The TAF provided much needed financial support for trauma centers through patient reimbursement.⁵Unfortunately, this additional billing code can only be used for trauma patients arriving by ambulance.⁶The TAF billing code entails the initial and one-time trauma team response fees (TTRF) and is based on tiered trauma team response criteria. ^7,8(Figure 1) Since not all trauma patients arrive by ambulance, it is suggested that a discrepancy in billing practices may have resulted in the compulsive billing to offset costs of non-ambulance trauma patients.^9,10However, no additional financial support by state or federal entities to offset costs have been implemented.

The overall TTRF determination may consist of many variables ranging from local and national trauma designation to human and infrastructure costs.^10,11 Sparse national data is available on the process of how TTRFs are determined. Moreover, no standardized process on justified billing practices appears to be in place.¹² The following two cases provide an example of the disparity of TTRF’s within one trauma center. The first case was an 18-month old child who fell three feet off a bed with minimal injuries and was observed for about three hours without any radiographic studies. The second case was an adult patient who fell off a rock wall in a gym, requiring ankle surgery. The TTRF was $15,666 for both cases.¹² Both cases made the news and the backlash was swift as the public was enlightened on the astronomical costs of trauma care.

Increasing healthcare costs along with high numbers of uninsured and underinsured resulted in medical care costs as the number one cause of bankruptcy in the U.S. ^13,14 Public awareness of exorbitant trauma care costs has further supported demands for transparency in trauma billing practices. Legislative efforts in Connecticut and Florida have begun requiring disclosure of TTRF’s. As part of consumer protection and reduction of healthcare expenditures, Connecticut is required to disclose TTRF.^15,16As disclosures become more common, additional regulations from state and federal agencies for TTRF’s may be anticipated.¹⁷ This study aimed to investigate the variation of TTRF among all levels of trauma centers (Level I-IV) in different geographic regions in the U.S. (Midwest, West, South, Northeast U.S.).

This was a cross-sectional convenience sample survey study utilizing the online survey development cloud-based software, Survey Monkey. The list of trauma centers was obtained from the Society of Trauma Nurses (STN). The Survey Monkey link was emailed to the following positions: Trauma Program Director, Trauma Program Manager, Trauma Nurse Coordinator, Director of Emergency Services, Director of Trauma, Director, Trauma Service Line, Pediatric Trauma Coordinator, and Trauma Operations Manager. Surveys were sent to 525 trauma centers in the continental U.S, including Alaska and Hawaii. Responses obtained from October 8, 2019 through March 11, 2020 were included in this study. Trauma centers not responding to the questionnaire were ultimately excluded from the final analysis.

Trauma centers included in the study were classified by region, trauma designation level, presence of academic program, and verification status by American College of Surgeons Committee on Trauma (ACS-COT). Questions were created by the investigators to capture the costs of a full or partial trauma team response, patient volume, and knowledge of the dollar amount of TTRF’s by the Trauma and Hospital Medical Directors. (Figure2) For this study, we classified trauma team response levels using highest tier level, second tier level and third tier level.¹⁷(Figure 2)

This study was approved by the Institutional Review Board (IRB) at Arrowhead Regional Medical Center (ARMC). ARMC is a 456-bed acute care teaching facility and ACS-COT verified level II trauma center located in San Bernardino County, California, USA. The ARMC ED is one of the busiest in the state of California with more than 100, 000 visits and over 3000 adult traumas annually.¹⁸

All statistical analyses were conducted using the statistical software SAS for Windows version 9.3. Descriptive statistics were presented as frequencies and proportions for categorical variables, along with medians and interquartile for continuous variables. Kruskal-Wallis Tests were conducted to assess if there was a statistical difference among various trauma levels. All statistical analyses were conducted with a two-sided. P-value ≤ 0.05 was considered to be statistically significant.

A total of 46 responses were received and included in the final analysis with a response rate of 8.8%. More than half (n=26, 56.5%) had academic training program, and 71.7% (n=33) were ACS-COT verified trauma centers. The geographic locations were mostly from the South region of the United States (37%, n=17). 56.5%, (n=26) of trauma medical directors and 41.3% (n=19) of hospital medical directors were aware of the TTRF. (see Table 1)

Within each trauma level, the TTRF was compared among the four different regions of the U.S. Table 2 presented the analysis results. Overall, there is no statistically significant difference among the four regions on the highest level response cost (all p-value>0.05), and second tier level response cost (all p-values>0.05).

Understanding the true cost of trauma care and fees for patients in the U.S remains elusive due to inadequate data and poor transparency is available. Historically, transparency in trauma costs was not common practice. This study’s response rate was 18.2%. According to Survey Monkey, external surveys with no previous contact with the receivers, response rates can be as high as 20-30%.¹⁹Similarly, a reported study by The National Foundation for Trauma Care (NFTC) and Trauma Center Association of America (TCAA) in 2009 which reported a response rate of 26.3%.²⁰

From the data obtained from previously published studies, TTRF’s differ vastly among the states.²¹ In Texas, TTRF from 1998-2004 were reported to be $53 (Level 1), $177 (level II), $119 (level III), and $258 (Level IV).²²On the other hand, In Florida, TTRF between 2012-2014 ranged from $197 to $66,000, with the average charge of $10,131 (n= 62, 974 patients).²¹ A national study on the 2012 Medicare Cost reported median TTRF ranged from $1,689 for Level I and II centers and $450 (2014 dollars) for level III and IV centers.^23,24In the Fakhry et al. study, an interesting finding was Level II trauma centers had higher TTRF than Level I trauma centers.²⁰ This study findings also found higher TTRF’s in level II trauma centers in the West compared to Level I. In 2009, the highest level trauma response fees ranged from $837-$24,964 compared to this study’s findings of TTRF’s ranging from $3,300-12,000.²⁰ Overall, this study found no statistically significant difference in TTRF’s despite geographical differences. ²⁵

Previous analysis of TTRF found little rationale in the billing practices. Patients are left to pay catastrophic medical bills or copayments not covered by their insurance companies. One study suggested the possibility of charging those with private insurance higher TTRF to compensate for the uninsured and underinsured.^{12, 26} Furthermore, there have been growing concerns that trauma centers are using alternative billing practices to increase revenue at the patient’s expense.¹² As discussed earlier, the focus of transparency of TTRF’s has captured the attention of both regulatory agencies and the public. This recent requirement in improving the transparency in medical care cost to the patient, may contribute to educating the public. Furthermore, transparency within each trauma center institution will provide trauma leadership the information needed to monitor for possible over-triaging and over billing. On the other hand, trauma centers' hesitancy for transparent disclosure of billing structures may be related to a dramatic increase in fees to offset the increasing costs of maintaining a variety of sub-specialty physicians, various services, educational programs and equipment costs. Possible future regulation of TTRF’s may have to be combined with widespread support of federal and state governments resulting in reduction of TTRF costs passed on to the patients.

Currently, there are 2,352 designated trauma centers in the continental U.S. including Hawaii. Trauma centers are designated by state or local Emergency Medical Services Agencies and hospitals may be required to pay initial and annual designation fees. These fees vary between counties and states. ^24,27 Furthermore, many counties or states mandate trauma centers to be ACS-COT verified, incurring additional costs. ^{11, 28} for trauma centers that are not mandated but opt to obtain ACS verification, also incur the added expenses. Currently, 540 or 23 % of trauma centers have been verified by the ACS-COT. ²⁹As part of the designation and verification requirements, mandatory minimal triage criteria is used to determine the appropriate patient destination. The triage criteria determine if a partial or full trauma team response are required, ensuring effective trauma resource allocation.³⁰(Figure 2). Many trauma center’s TTRF’s correlate with level of trauma team response with the highest response having the highest dollar amount.³⁰

In addition, trauma centers affiliated with academic institutions have further costs associated with education and maintenance of academic standards. According to the Association of American Medical Colleges, direct training costs for teaching hospitals is approximately $19.2 billion annually of which $3.98 billion is supported by Medicare payment with no increases since 1997.³¹

Attempts to balance responsible financial billing and maintaining viability is an ongoing concern for trauma centers.Although TTRF’s continue to increase each year, it is unclear, who is involved in the process for deciding the dollar amount. ^21,33 Two previous studies reported that only 14% of emergency physicians were able to correctly estimate their hospital’s TTRF’s. ^34,35 This study noted that 41.3% of Hospital Medical Directors (HMD) and 56.5% of Trauma Medical Directors (TMD) are aware of the dollar amounts of the TTRF’s. Providers may better serve their patients through gaining an understanding of the billing practices. ^34,35 Evaluating patients meeting the over-triage criteria is a possible area to reduce healthcare costs. Although, eliminating all over-triage costs is not medically or financially feasible, continuous oversight from the TMD of over-triage costs may aid in reducing some of unnecessary over billing. Unfortunately, many trauma patients arrive to a trauma center other than by ambulance, eliminating the ability to use billing code 68X. This gap in billing capabilities has a negative impact in financial reimbursements. in an effort to maintain the financial viability of trauma centers, the National Uniform Billing Committee is gathering data on the number patients not transported by ambulance presenting to trauma centers. the goal of this data collection is to support a change in the definition and allow a justified level of TTRF applicable for non-ambulance trauma billing code.⁷

The role of trauma centers has evolved since the 1980’s into regionalized trauma networks (RTN). These RTN’s encompass the collaborative effort of trauma centers along with their partner agencies to provide a cost-effective coordinated comprehensive plan that optimizes high-quality care for injured patients.³⁶ Trauma centers are the foundation for the RTN and as a result, their sustained financial viability ensures quality of care and safety throughout the communities in the U.S.

Limitations of this study included a low response rate of 8.8% from trauma centers, incomplete data, and specific charges. Additionally, the survey questions did not include information on who determines the TTRF and the specific factors that influences the billing practices. Future studies should include identification of specific processes and factors like cost of living adjustment that influence how TTRFs are determined.

Trauma centers struggle to maintain financial viability as healthcare costs increases and limited options are available to offset those costs. Regulatory and public awareness of these increasing TTRF’s has resulted in a push for transparency. Improving hospital and trauma leadership knowledge of TTRF’s along with federal and state financial support is needed to aid in the prevention of disparity in patient charges and assuring quality of trauma care for the public. In addition, vigilant efforts are needed in patient advocacy to ensure all patients receive quality trauma care with justified associated charges.

TTRF	Trauma team response fees
TAF	Trauma activation fee
ACS-COT	American College of Surgeons Committee on Trauma
ARMC	Arrowhead Regional Medical Center
NFTC	National Foundation for Trauma Care
TCAA	Trauma Center Association of America
HMD	Hospital Medical Directors
TMD	Trauma Medical Directors
RTN	Regionalized Trauma Networks

Ethics approval and consent to participate

The study was approved by the Institutional Review Board at Arrowhead Regional Medical Center. The study approval number is 19-06. A waiver was obtained for this study as the data collected was from trauma centers and did not involve patients or patient data. The Helsinki Declaration and informed consent was not applicable in this study. All participating trauma centers were de-identified in the study to maintain privacy.

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors have disclosed no financial relationships related to this article

Authors' contributions

MN-

Made substantial contributions for the conception of the study, interpretation of data, substantial participation in drafting and revising of manuscript. Approved final version and agrees to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

JS-

Made substantial contributions for the interpretation of data, drafted the work and substantial revisions. Approved the submitted version and agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

FD-

Made substantial contributions to the conception, analysis and interpretation of data. Substantial contribution in drafting and revising manuscript. Approved the submitted version and agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

MC-

Made substantial contributions for the conception of the study, interpretation of data, substantial participation in drafting and revising manuscript. Approved final version and agrees to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

DF-

Made substantial contributions for the conception of the study, interpretation of data, substantial participation in drafting and revising of manuscript. Approved final version and agrees to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

AN-

Made substantial contributions in drafting and revising of manuscript. Approved final version and agrees to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

RV-

Made substantial contributions for the conception of the study, interpretation of data, substantial participation in drafting and revising of manuscript. Approved final version and agrees to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

DW-

Made substantial contributions for the conception of the study, interpretation of data, substantial participation in drafting and revising of manuscript. Approved final version and agrees to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

LT-

Made substantial contributions for the conception of the study, interpretation of data, substantial participation in drafting and revising of manuscript. Approved final version and agrees to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

All authors read and approved the final manuscript

Acknowledgements

Not applicable

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Table 1: Survey Participants Demographic Summary

Trauma Level
1	22	47.8%
2	12	26.1%
3	12	26.1%
Resident Training Program
No	20	43.5%
Yes	26	56.5%
ACS Verified
No	13	28.3%
Yes	33	71.7%
Region
Midwest	9	19.6%
Northeast	9	19.6%
South	17	37%
West	11	23.9%
Does your Trauma Medical Director know the base trauma cost?
Yes	26	56.5%
No	19	41.3%
Unknown	1	2.2%
Does your Hospital Medical Director know the base trauma cost?
Yes	19	41.3%
No	25	54.4%
Unknown	2	4.4%

Table 2: Reported Trauma Team Response Fees by Region*

Note: *all values were reported as median and corresponding first and third quartiles inside the parenthesis. All units were in US dollars.

**only one or two values was reported in the data. The data were the actual numbers reported by the respondents. Median and corresponding first and third quartiles were not available for computation. These values were not used for the comparison of median cost among the geographic locations.

No competing interests reported.

Variation in Trauma Team Response Fees in United States Trauma Centers: An Additional Undisclosed Variable Cost in Trauma Care

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