Investigation: Hospital trauma centers charge huge fees to treat minor injuries and send people home
The treatments were ordinary. A hospital in Modesto, Calif., Treated a 30-year-old man for shoulder and back pain after a car accident. He got home in less than three hours.
The bill was extraordinary. Sutter Health Memorial Medical Center billed $ 44,914, including a “traumatic alert” fee of $ 8,928, billed to summon the hospital’s top surgical specialists and generally associated with the most seriously injured patients.
The case, buried in the records of a 2017 lawsuit, is a rare example of a court challenge to an element increasingly common in U.S. hospitals, according to billing consultants.
Tens of thousands of times a year, hospitals charge extremely expensive trauma alert fees for injuries so minor that the patient is never admitted.
In Florida alone, where the number of trauma centers has skyrocketed, hospitals billed such fees more than 13,000 times in 2019, even though the patient returned home the same day, according to a KHN analysis of data from the state provided by Etienne Pracht, economist at the University of South Florida. These cases represented more than a quarter of all activations of state trauma teams that year and were more than double the number of similar cases in 2014, according to a database of all payers on claims. of inpatient records maintained by the Florida Agency for Health Care Administration.
While false alarms are to be expected, such frequent charges for little or no treatment suggest that some hospitals see the alerts as much as a tap of money as a clinical emergency tool, the consultants say.
“Some hospitals use it as a source of income,” Tami Rockholt, a registered nurse and medical claims consultant who appeared as an expert witness in Sutter Health’s auto accident lawsuit, said in an interview. “We are taking advantage” and such cases are “much more numerous” than a few years ago, she said.
Hospitals may charge a trauma activation fee when an elite team of doctors and nurses meet after an ambulance team announces they are approaching a patient in need of care trauma. The idea is that life-threatening injuries require immediate attention, and designated trauma centers should be able to recoup the cost of preparing a team – even if they never jump into action.
These fees, which can exceed $ 50,000 per patient, are billed in addition to what hospitals charge for emergency medical care.
“We’re seeing quite a few inappropriate trauma accusations – more than five years ago,” said Pat Palmer, co-founder of Beacon Healthcare Costs Illuminated, which analyzes thousands of bills for insurers and patients. Recently, “we saw a trauma activation charge when the patient entered the emergency room” and was released shortly thereafter, she said.
The share of activation trauma cases in Florida without admission has increased from 22% in 2012 to 27% last year, according to the data. At a Florida facility, Broward Health Medical Center, there were 1,285 cases of trauma activation in 2019 without admission – almost equal to the number that led to admissions.
“Trauma alerts are activated by EMS [first responders with emergency medical services], not hospitals, and we respond accordingly when EMS activates a trauma alert in the field, ”said Jennifer Smith, spokesperson for Broward Health.
Florida regulations allow hospitals themselves to declare a “hospital trauma alert” for “patients not identified as a trauma alert” in the field, according to published standards by the Florida Department of Health.
In some hospitals, few patients whose cases generate traumatic alerts are treated and released the same day.
At Regions Hospital, a Level I trauma center in St. Paul, Minnesota, patients who are not admitted after an alert from the trauma team are “very rare” – 42 of 828 cases last year, or about 5%, said Dr Michael McGonigal, director of the center, who blogs at “The Trauma Pro. “
“If you charge an activation fee for all of these people going home, that will ultimately be a red flag” for Medicare and insurers, he said.
In the Sutter case in Modesto, the patient sued a driver who struck his vehicle, claiming damages from the driver and his insurer. The patient “looks fine,” an emergency doctor wrote in the records, which were part of the trial evidence. He prescribed Tylenol with hydrocodone for the pain.
“If someone isn’t going to bleed, or their heart isn’t going to stop, or if they’re not going to stop breathing in the next 30 minutes, they probably don’t need a trauma team.” Rockholt said in his testimony.
Like other California hospitals designated as trauma centers, Sutter Health Memorial Medical Center follows “county-designated criteria” for calling an activation, said Sutter spokeswoman Liz Madison, “The goal is to remain able to deal with trauma cases at any time – even in events where a patient is determined to be healthy enough to be treated and discharged the same day.
Trauma centers regularly review and revise their rules for activating trauma teams, said Dr. Martin Schreiber, chief of trauma at Oregon Health & Science University and chairman of the board of directors of the Trauma Center Association of America, an industrial group.
“I don’t feel like trauma centers are using activations to make money,” he said. “Activating patients unnecessarily is not considered acceptable in the trauma community. “
Hospitals began charging trauma team fees to insurers of all kinds after Medicare cleared them from 2008 for cases where hospitals are informed of serious injuries before a patient arrives. Instead of leaving trauma team alerts to paramedics, hospitals often call themselves trauma activations based on information from the field, according to trauma surgeons.
The reimbursement of traumatic activations is complicated. Insurers do not always pay the costs of trauma to a hospital. Under rules set by Medicare and a committee of insurers and health care providers, emergency departments must give 30 minutes of intensive care after a trauma alert to be paid for team activation. For inpatients, the trauma team’s fees are sometimes combined with other fees, according to billing consultants.
But, overall, the increase in the size and frequency of activation fees for trauma teams, including those for unadmitted patients, has helped transform trauma operations, often once a financial drain. , in profit centers. In recent years, hundreds of hospitals have applied for the trauma center designation, which is necessary to charge a trauma activation fee.
“There had to be a consultant who went around the country and said, ‘Hey hospitals, why don’t you start charging for this, because you can,'” said Marc Chapman, founder of Chapman Council, which calls into question the large hospital bills of automobile insurers and other payers. “In many of these cases, patients never get admitted. “
The national number of Level I and II trauma centers, capable of treating the most seriously injured patients, increased from 305 in 2008 to 567 last year, according to the American College of Surgeons. Hundreds of other hospitals have Level III or IV trauma centers, which can treat less severe injuries and also charge for trauma team activation, although often at lower rates.
Emergency surgeons say they walk a narrow road between being overly careful and activating a team unnecessarily (called “overtriage”) and endangering patients by failing to call a team when serious injuries are not evident.
Often times, “we don’t know if patients are seriously injured in the field,” said Dr. Craig Newgard, professor of emergency medicine at Oregon Health & Science University. “EMS providers use the best information they have. “
Too many seriously injured patients still do not receive the care they need from trauma centers and teams, Newgard argues.
“We’re trying to do the greatest good for the most people from a system point of view, recognizing that it is fundamentally impossible to get a good triage every time,” he said. “You’re going to take some patients to major trauma centers who don’t really end up with serious injuries. And it’s going to be a bit more expensive. But compromise optimizes survival.
At Oregon Health & Science, 24% of patients treated with trauma alerts over the 12 months ending this spring were not admitted, Schreiber said.
“If that number gets much lower, you could endanger patients who need activation if they are not activated,” he said.
On the other hand, the increasing number of trauma centers and the fees increase the costs of health care. The charges are passed on to higher insurance premiums and expenses paid not only by health insurers, but also by auto insurers, who are often the first to pay for the care of an accident victim.
Audits are rare and the system is often designed to pay claims with little or no review, billing specialists say. Legal challenges like the Sutter case are extremely rare.
“Most of these insurers, especially auto insurance, don’t look at the bill,” said Beth Morgan, CEO of Medical Bill Detectives, a consulting firm that helps insurers dispute hospital costs. “They pay it automatically.”
And the trauma activation fee can also directly affect patients.
“Sometimes the insurance companies won’t pay them. So people could get stuck with this bill, ”Morgan said.
A few years ago, the Zuckerberg San Francisco General Hospital billed a $ 15,666 in trauma intervention costs to the family of a toddler who fell from a hotel bed. He was doing fine. The treatment consisted of a bottle of formula and a nap. The hospital waived the charges after KHN and Vox wrote about it.
Fatigue from trauma alerts can come at a non-financial cost to the trauma team itself, McGonigal said.
“Every time that pager rings, you are pulling a lot of people away from their jobs to see [patients] get home an hour or two later, ”he said.
“Some trauma centers are having problems because they are in tatters. And there is probably an unnecessary expense in all the resources needed to assess and manage these patients. “
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three main operational programs of KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization that provides information on health issues to the nation.
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