Better funding means trauma center shortage may become a glut

For the past 20 years, MetroHealth Medical Center has been the sole provider of Level 1 adult trauma care for the metropolitan Cleveland area's 2 million residents.

Located on the city's west side, Cuyahoga County-owned MetroHealth operates one of the busiest trauma centers in the country. Its specialized facility and highly trained clinical staff handle more than 3,000 sudden and serious injuries a year, including gunshots, stabbings, falls and motor-vehicle accidents. “Emergencies come first here,” said Dr. Jeffrey Claridge, director of the trauma division at MetroHealth.

But his center is about to face some stiff competition. Next month, Case Western Reserve's University Hospitals (UH), anchored by its massive 1,032-bed tertiary-care hospital on the city's east side, will open the region's second Level 1 trauma center. Its rationale: The largely African-American eastern side of Cleveland has been underserved for years because of the distance to reach MetroHealth.

“When we first started to look at the delivery of adult trauma care, we really looked at it from a public health need,” said Dr. Michael Anderson, UH's chief medical officer. “Cleveland is often thought of as east side and west side, so for those patients on the east side of town, rapid access to trauma care was sorely lacking.”

Such scenarios are playing out in a number of metro areas across the country. More urban hospitals are looking to open trauma-care centers or elevate the designation of an existing facility to Level 2 or Level 1. Experts say the designation upgrade not only steps up the medical services they can provide, but generates substantially higher facility fees from both government and private payers.

Since 2012, 117 Level 1 and Level 2 trauma centers have opened in the U.S., bringing the total of such facilities to more than 520, according to the American Trauma Society. “You have a surge of openings in trauma-care centers right now that has replaced probably the main problem that we have had for decades, (which was) not enough,” said Greg Bishop, president and founder of Bishop and Associates, a healthcare research consulting firm that specializes in trauma-center development and management.

Some say the growth in trauma centers reflects an increase in trauma cases and local population booms. But the financial incentives for trauma-center expansion have clearly been a factor, as a greater share of trauma-care patients are now covered by public and private insurance. If the expansions lead to overcapacity, it could be detrimental for patient care and the bottom lines of those hospitals.

“If somebody opens the spigot, somebody should know how to turn the spigot off,” said Mike Williams, former director of Emergency Medical Services for Orange County, Calif., and president of the Abaris Group, a consulting firm. “These hospitals are learning that there are not a lot of constraints as to whether they can go after trauma or not. At some point, we'll have too many trauma centers and that doesn't help anybody.”

Increased insurance and Medicaid coverage under the Affordable Care Act contributes to the recent expansion. For years, most hospitals saw Level 1 or Level 2 trauma centers as money-losing operations that required substantial investments in equipment, facilities and staffing, including keeping 24-hour, on-call surgical specialists. Before the ACA, a number of trauma centers that served people on Medicaid or the uninsured closed.

Between 1990 and 2005, the number of trauma centers fell from 1,125 to 786, according to a 2011 Health Affairs study co-authored by Dr. Renee Hsia, professor and director of health policy studies at the University of California at San Francisco's Emergency Medicine Department.

But that has turned around over the past few years. “Research shows that, on the whole, trauma centers tend to be expensive. They're not reimbursed appropriately, so hospitals may end up hemorrhaging financially,” Hsia said. “On the other hand, a lot of hospitals want to become trauma centers, so both things are happening.”

In September, the University of Chicago Medical Center announced plans to partner with local safety net provider Sinai Health System to build and run a Level 1 adult trauma center on the city's South Side, an area that has one of the highest rates of violent trauma cases in the nation. UChicago is providing $40 million for the center that will be housed in Sinai's Holy Cross Hospital.

“When we looked at a map of where the trauma was occurring, it became abundantly clear to us that there was a huge amount clustering around the Holy Cross community,” said Karen Teitelbaum, CEO of Sinai Health System. The move comes more than 20 years after the last hospital that provided trauma care on the South Side closed.

But not all new trauma centers are opening in underserved areas. And even when that argument is made, as in Cleveland, it may create problems for existing centers by splitting the available pool of patients.

According to annual reports from the American College of Surgeons' National Trauma Data Bank, the number of cases reported from trauma centers has been on the rise, from 681,000 incidents in 2010 to 860,000 in 2014. But national trends have shown the number of fatalities from firearms and car accidents, two of the major causes of trauma, has been slowly declining over the past decade.

Claridge at MetroHealth worries the addition of a second Level 1 trauma center in Cleveland will spell financial trouble for his institution. UH's plan puts it in direct competition with the already-established Northern Ohio Trauma System, or NOTS. The regional trauma network, led by MetroHealth, in collaboration with the Cleveland Clinic, was designed to coordinate regional trauma care. UH declined to join NOTS.

“Trauma centers shouldn't be brought up for competitive purposes and market share,” Claridge said. “They should work together with an existing system that's already there for what's best for patients.”

Other experts worry that splitting the available patient pool between two trauma centers will worsen outcomes. “The more the number of cases gets diluted because we have too many centers, the less experience any one center has,” said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University.

The biggest factor driving hospital decisions is the availability of insurance coverage, Hsia said. “If you're located in an area where you have a lot of good insurance—private and commercial insurance, as well as Medicare—then a lot of those hospitals tend to want to have Level 1 trauma centers because they can bill for a facility fee, a trauma-activation fee, and a lot of those things are reimbursed at a fairly good rate.”

Pay for Level 1 and Level 2 trauma care increasingly comes from Medicare and Medicaid. The 2015 annual National Data Trauma Bank report from the American College of Surgeons, which verifies designation for more than 740 trauma centers, found that Medicare now accounts for 25.8% of all center payments, up from just 16.6% in 2005, and Medicaid is at 14%, up from 11.2%. Private and commercial insurance is now 26.3% compared with 29% a decade ago, while self-paying patients—many of whom never pay—have fallen from 21.1% to just 12.5% over the past decade.

“It's not popular to say that your emergency room or your trauma center makes money,” Williams said. “But I have looked at the financials of hundreds of these hospitals. They do make money when they're properly constructed.”

Operating a trauma center can bring ancillary benefits to a hospital system, experts say, by acting as a powerful marketing tool that attracts other patients and top specialists. Sometimes called “the halo effect,” many hospitals see an increase in emergency department visits after opening a trauma center, since they become known for handling emergencies.

For-profit HCA, based in Nashville, has actively pursued that strategy over the past several years, opening Level 2 trauma units at some of its Florida hospitals. “They have a national initiative and now have trauma personnel at the division level helping their hospitals develop trauma centers,” Bishop said.

In a prepared statement, HCA said: “In many of our communities, there has been a significant need for trauma care. Patients in these circumstances have a much better chance of survival when they are given care in a designated trauma center within an hour of injury (the Golden Hour), and we are proud that our scale and efficiencies, which support caregivers in our affiliated trauma programs, help enable us to offer these lifesaving services.”

Studies have shown that the faster a seriously injured trauma patient gets care, the better their chances of survival. UH's Anderson said better clinical outcomes were the basis for its decision.

But it remains an open question, especially when new trauma centers open in slow-growing markets. The American College of Surgeons recommends a Level 1 trauma center should see a minimum of about 1,200 patients a year to avoid negatively affecting the quality of its care. UH would have to treat 40% of MetroHealth's trauma patients to reach that level.