Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals

Knowlton, Lisa Marie; Morris, Arden M.; Tennakoon, Lakshika; Spain, David A.; Staudenmayer, Kristan

doi:10.1016/j.jamcollsurg.2018.03.043

Cited by 20 publications

(15 citation statements)

References 21 publications

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“…Many level I trauma centers are located within safety net hospitals that deliver a significant proportion of their health care to the uninsured and should be incentivized by programs that will help offset the costs of uncompensated care. 5 Our prior work evaluating the financial impact of HPE programs in the State of California estimated that hospital participation in HPE is associated with an average 9.7% increase in annual net patient Medicaid revenue, suggesting the potential for HPE as a mechanism to increase hospitals' financial stability. 19 It is currently unclear how effectively hospitals are screening patients for HPE and what factors promote or limit successful HPE approval.…”

Section: Discussionmentioning

confidence: 99%

“…3,4 Moreover, nearly 90% of all uninsured trauma survivors are subject to catastrophic health expenditures, and hospitals that emergently treat uninsured trauma patients are strained by uncompensated care. [5][6][7][8] Improving outcomes of uninsured trauma patients is an urgent priority, as the number of uninsured Americans has been on the rise since 2016 and has recently further spiked with unemployment and the loss of employer-based health care coverage because of the COVID-19 pandemic. 9,10 A potential solution, Hospital Presumptive Eligibility (HPE), was enacted as part of the Affordable Care Act of 2014 in all states, regardless of Medicaid expansion status.…”

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confidence: 99%

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Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage

Jaramillo

Arnow

Trickey

et al. 2021

J Trauma Acute Care Surg

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Uninsured trauma patients are at higher risk of mortality, limited access to postdischarge resources, and catastrophic health expenditure. Hospital Presumptive Eligibility (HPE), enacted with the 2014 Affordable Care Act, enables uninsured patients to be screened and acquired emergency Medicaid at the time of hospitalization. We sought to identify factors associated with successful acquisition of HPE insurance at the time of injury, hypothesizing that patients with higher Injury Severity Score (ISS) (ISS >15) would be more likely to be approved for HPE. METHODS:We identified Medicaid and uninsured patients aged 18 to 64 years with a primary trauma diagnosis (International Classification of Diseases, Tenth Revision) in a large level I trauma center between 2015 and 2019. We combined trauma registry data with review of electronic medical records, to determine our primary outcome, HPE acquisition. Descriptive and multivariate analyses were performed. RESULTS:Among 2,320 trauma patients, 1,374 (59%) were already enrolled in Medicaid at the time of hospitalization. Among those uninsured at arrival, 386 (40.8%) acquired HPE before discharge, and 560 (59.2%) remained uninsured. Hospital Presumptive Eligibility patients had higher ISS (ISS >15, 14.8% vs. 5.7%; p < 0.001), longer median length of stay (2 days [interquartile range, 0-5 days] vs. 0 [0-1] days, p < 0.001), were more frequently admitted as inpatients (64.5% vs. 33.6%, p < 0.001), and discharged to postacute services (11.9% vs. 0.9%, p < 0.001). Patient, hospital, and policy factors contributed to HPE nonapproval. In adjusted analyses, Hispanic ethnicity (vs. non-Hispanic Whites: aOR, 1.58; p = 0.02) and increasing ISS (p ≤ 0.001) were associated with increased likelihood of HPE approval. CONCLUSION:The time of hospitalization due to injury is an underused opportunity for intervention, whereby uninsured patients can acquire sustainable insurance coverage. Opportunities to increase HPE acquisition merit further study nationally across trauma centers. As administrative and trauma registries do not capture information to compare HPE and traditional Medicaid patients, prospective insurance data collection would help to identify targets for intervention. (

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage

Jaramillo

Arnow

Trickey

et al. 2021

J Trauma Acute Care Surg

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“…Approximately 40% of US trauma centers operate within safety-net hospitals, which deliver a substantial portion of health care services to uninsured patients or other vulnerable populations regardless of their ability to pay. Knowlton et al 4 reported that operating margins for level I trauma centers within safety-net hospitals ranged from −16.5% to 8.5%. We suggest that a future study should examine how trauma activation fees are calculated and charged by safety-net institutions.…”

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confidence: 99%

Trauma Activation Fees—A Fair Approach to Reimburse Trauma Readiness Costs or a Pathway to Profitability?

Knowlton

Haut

2023

JAMA Netw Open

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“…These hospitals are often located in high population density areas and serve an important role in treating trauma patients. It is estimated that SNHs provide almost 40% of the hospital care for Medicaid and uninsured patients 1 and run up to 85% of Level 1 trauma centers 2 in many states.…”

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confidence: 99%

Treatment of Facial Fractures at Safety-Net Hospitals: A National Analysis of Inpatient Burden and Cost

Musavi

Chin

Pfaff

et al. 2021

Journal of Craniofacial Surgery

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Purpose: Safety-net hospitals (SNHs) are vital in the care of trauma populations, but little is known about the burden of facial trauma presenting to SNHs. The authors sought to characterize the presentation and treatment of facial fractures across SNHs and determine the association between SNH care and healthcare utilization in patients undergoing fracture repair. Methods: Adult patients presenting with a facial fracture as their primary admitting diagnosis from the year 2012 to 2015 were identified in the National Inpatient Sample. The ''safety-net burden'' of each hospital was defined based on the proportion of Medicaid and self-pay discharges. Patient factors analyzed were sex, race, age, income level, insurance status, fracture location, and comorbidities. Hospital factors analyzed were safety-net burden, teaching status, geographic region, bed size, and ownership status. The main outcomes were length of stay (LOS), hospital costs, time to repair, and postoperative complications. Results: Of 78,730 patients, 27,080 (34.4%) were treated at SNHs and 24,844 (31.6%) were treated at non-SNHs. Compared to non-SNHs, patients treated at SNHs were more likely to undergo operative repair at SNHs (65.8% versus 53.9%, P < 0.001). Overall mean LOS was comparable between non-SNH and SNH (3.43 versus 3.38 days, P ¼ 0.611), as was mean hospital cost ($15,487 versus $15,169, P ¼ 0.434). On multivariate linear regression, safety-net status was not a predictor of increased LOS, cost, or complications. However, safety-net status was significantly associated with lower odds of undergoing repair within 48 hours of admission (odds ratio 0.783, 95% confidence interval ¼ 0.680-0.900, P ¼ 0.001). Conclusions: Safety-net hospitals are able to treat facial trauma patients with greater injury burden and lower socioeconomic resources without increased healthcare utilization. Healthcare reform must address the financial challenges that endanger these institutions to ensure timely treatment of all patients.

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Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals

Cited by 20 publications

References 21 publications

Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage

Acquisition of Medicaid at the time of injury: An opportunity for sustainable insurance coverage

Trauma Activation Fees—A Fair Approach to Reimburse Trauma Readiness Costs or a Pathway to Profitability?

Treatment of Facial Fractures at Safety-Net Hospitals: A National Analysis of Inpatient Burden and Cost

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