Health
8:33 am
Thu February 20, 2014

Insurance, Not Injuries, May Determine Who Goes To Trauma Centers

Originally published on Thu February 20, 2014 1:00 pm

When private hospitals transfer patients who don't have insurance to public hospitals, it's called "patient dumping." But a study from Stanford University published Wednesday suggests a twist: Hospitals, it seems, are less likely to transfer critically injured patients to trauma centers if the patients have health insurance.

Researchers at Stanford University looked at more than 4,500 trauma cases at 636 hospitals around the country to see what happened to critically injured patients who were brought to emergency rooms that weren't designated trauma centers. They found that non-trauma facilities were much more likely to admit patients who had insurance, whether it was private insurance or Medicaid coverage, than to transfer the patients to more skilled facilities.

"It's the opposite of the overly aggressive transfer of a poor patient," says Dr. Arthur Kellermann, dean of the medical school at Uniformed Services University and a trauma care specialist who was not involved in the study. "This is actually suggesting that patients who have coverage for critical injuries may not be getting transferred as quickly as they should be."

Getting to a designated trauma center matters for patients who are seriously hurt — those with severe injuries are 25 percent less likely to die at a trauma center than in a typical emergency room.

"That's the whole point of trauma centers," Kellermann says. "The expertise, the speed of response, the capacity to manage complex injuries is significantly better at major trauma centers. That's the whole reason certain hospitals are designated trauma centers." It's not just a matter of getting in the door at the closest hospital, he says, but getting in the door at the right hospital.

The study didn't assess how well the patients who were held at non-trauma centers fared. The researchers excluded patients over 65, and those who were discharged from the ER or who died. But Dr. Kit Delgado, the study's lead author and a former Stanford emergency medicine instructor, says critically injured patients "admitted to hospitals that are not trauma centers are at risk for worse outcomes."

It's unclear just who makes that decision to admit or transfer. Emergency physicians and nurses typically don't know whether their patients are insured or not. But Delgado, who is now an emergency care researcher at the University of Pennsylvania, says hospital administrators often weigh in on where uninsured patients end up, and that same dynamic, he says, could help explain why non-trauma centers are reluctant to give up paying customers.

"As an emergency physician," Delgado says, "you may get a tap on the shoulder by a case manager that suggests that you should consider transferring the patient out to a hospital where they can be taken care of and [where] they're willing to accept them without insurance."

The business of medicine too often dictates where patients are cared for, Kellermann says, and that includes whether a hospital admits patients or transfers them away. "That decision should not be influenced by economics one way or the other," he says. "It should be influenced only by what's in the best interest of patients."

It's not the first time researchers have found hospitals holding on to insured patients: Low-birth-weight babies do best at neonatal intensive care units that care for many such infants, but babies covered by insurance are less likely to be transferred.

Still, there could be other reasons why patients aren't transferred to hospitals that have more expertise: Patient preference may play a role.

Delgado is currently researching whether patients prefer to stay at their local community hospital rather than be moved to a trauma center — which might be part of a public hospital or located in an inner-city area. If patient choice is driving these decisions, Delgado says, hospitals need to do a better job of educating patients about where they'll get the best care.

Copyright 2014 Kaiser Health News. To see more, visit http://www.kaiserhealthnews.org/.

Transcript

AUDIE CORNISH, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Audie Cornish.

ROBERT SIEGEL, HOST:

And I'm Robert Siegel. We're going to focus now on a phenomenon in healthcare known as patient dumping. That's when hospitals take patients who don't have insurance and transfer then to public hospitals. Well, a new study from Stanford University turns dumping on its head. Researchers found that hospitals are also less likely to transfer critically-injured patients to trauma centers if they do have insurance.

Reporter Sarah Varney explains.

MICHELLE TRACEY: We're here in the emergency department right now near the trauma bay.

SARAH VARNEY, BYLINE: Michelle Tracey(ph) is a registered nurse and director of emergency services at Marin General, the only designated trauma center in Marin County, north of San Francisco. There's specialized equipment and specialized doctors ready at all times. Neurosurgeons for head injuries from car crashes and, says Tracey...

TRACEY: If we get a gunshot wound, we have cardiothoracic surgeons who can come in and take care of that issue, take them right to surgery.

VARNEY: Getting to a designated trauma center matters for patients with serious injuries. Severely injured patients are 25 percent less likely to die at a trauma center than in a typical emergency room. Dr. Arthur Kellermann, dean of the U.S. military's medical school, says it's not just a matter of getting in the door at the closest hospital, but getting in the door at the right hospital. That's the whole reason certain hospitals are designated trauma centers.

ARTHUR KELLERMANN: The expertise, the speed of response, the capacity to manage complex injuries is significantly better in major trauma centers.

VARNEY: In a study published today in the journal JAMA Surgery, researchers looked at thousands of trauma cases at more than 600 hospitals. They wanted to see what happened to critically injured patients brought to emergency rooms that aren't designated trauma centers. They found that those hospitals were much more likely to admit patients up to age 65 who had insurance than to transfer them to more skilled facilities. That was true whether they had private insurance or Medicaid. The findings did not surprise Kellermann, a trauma care expert, who was not involved in the study.

KELLERMANN: It's the opposite of that overly aggressive transfer of a poor patient. This is actually suggesting that patients who have coverage but critical injuries may not be getting transferred as quickly as they should be.

VARNEY: The study didn't assess how well patients held at non trauma centers faired. The researchers excluded patients over 65 and those who were discharged from the ER or died. But Dr. Kit Delgado, the study's lead author and former Stanford emergency medicine instructor, says critically injured patients admitted to hospitals that aren't specially equipped are at risk for worse outcomes.

It's unclear just who makes that decision to admit or transfer. Emergency physicians and nurses typically don't know whether their patients are insured or not, but Delgado, who is now an emergency care researcher at the University of Pennsylvania, says hospital administrators often weigh in on where uninsured patients end up and that same dynamic, he says, could help explain why non-trauma centers are reluctant to give up paying customers.

KIT DELGADO: As an emergency physician, you may get a tap on the shoulder by a case manager who will suggest to you that, you know, you should consider transferring the patient out to a hospital where they can be taken care of and are willing to accept them without insurance.

VARNEY: The business of medicine too often dictates where patients are cared for, says Kellermann, and that includes whether a hospital admits patients or transfers them away.

KELLERMANN: That decision should not be influenced by economics one way or the other. It should be influenced only by what's in the best interest of patients.

VARNEY: It's not the first time researchers have found hospitals holding on to insured patients. Low birth weight babies do better at high volume neonatal intensive care units, but babies covered by insurance are less likely to be transferred. Still, there may be other reasons why patients aren't transferred to hospitals with more expertise. Delgado is currently researching whether patients prefer to stay at their local community hospital instead of being moved to a trauma center that may be a public hospital or located in an inner city area.

If that's the case, Delgado says hospitals need to do a better job educating patients about where the best care is available. For NPR News, I'm Sarah Varney.

SIEGEL: And that story came to us through a partnership with Kaiser Health News, a nonprofit news service. Transcript provided by NPR, Copyright NPR.