A dozen years ago, I wanted to give hospitals the ability to charge trauma center response fees because the highly specialized medicine that saves lives can be extremely expensive. I expected that charges would be based on actual costs. I never imagined that this would lead some Florida trauma centers to charge patients more than $30,000 simply for coming through the door.
This trend is just one symptom of how unregulated proliferation, politicizing and profiteering of trauma care is threatening to dismantle Florida's entire trauma system and undermine a vital pipeline for training surgeons. Floridians need to understand the consequences of such high-profit trauma care — and put an end to it.
Tallahassee's hands-off stance has allowed lower-level trauma centers to encroach on established Level 1 centers, which handle the hardest cases and need enough patients to remain well-trained. The beholden Legislature has overridden judicial decisions favoring the existing system without conducting a needs assessment or system planning. Rules that govern trauma care have been usurped by for-profit practices such as lateral transfers: the self-dealing movement of patients from one hospital to a same-level "sister" trauma center. This practice runs counter to national standards that favor moving patients to the highest appropriate level of care, transporting patients directly to the highest level center within 30 minutes, and using triage criteria as a tool for determining the optimal destination.
In three spots in Florida, new Level 2 centers located in profitable ZIP codes and less than 30 miles from academic centers threaten the Level 1's viability — Ocala and Gainesville, Bayonet Point and Blake surrounding Tampa, and Kendall crowding Ryder in Miami. That proximity means patients may never reach a Level 1 trauma center or pediatric trauma center because medics must transport to the nearest trauma center regardless of injury severity.
Already in Florida, at three key Level 1 centers, the volume of severely injured patients needed for Level 1 proficiency has dropped by 26 to 30 percent. This affects the Level 1's teaching and research mission — which taxpayers have supported for decades — and reduces patient volume needed to build and maintain skills of surgeons and physicians-in-training. The barrage of public relations from Level 2 centers may lead the public to believe that 1 and 2 centers are basically the same. That simply is not true. Level 1 centers have the breadth and depth of capacity and resources to treat every injury; Level 2s simply do not compare.
The Tampa Bay Times has uncovered how this can translate to the equivalent of state-endorsed financial exploitation of helpless injured patients. Trauma patients are given no choice about their destination. The facility not only profits from patients' inability to designate where they want to go, but when patients are unable to pay the full inflated charges, the hospital can file liens against them, then takes a huge deduction on federal and state corporate income tax, leaving the public to subsidize extraordinary "losses."
It was my application to the National Uniform Billing Committee of the American Hospital Association, approved in 2002, that gave hospitals the ability to charge trauma center response fees. Charging full trauma response fees when the patient met only minimal trauma triage criteria, and was discharged within 24 hours, was rare and usually downcoded — an acknowledgement that emergency medical technicians' field determinations of a trauma alert were not reliable. Yet, it's now clear this has become a back-door way for some hospitals to profiteer.
To prevent further exploitation of trauma victims, the medical community must retake control and create legitimate fees. Evidence-based triage criteria is the first place to start, followed by a protocol for a tiered trauma response with proportionate charges.
But Florida also needs to reject the laissez-faire approach to trauma system design and hospital finance that caused this turbulence. The state should take the advice it has from the American College of Surgeons, the highest authority on trauma systems planning in the nation. The moratorium on trauma center applications should extend until an updated plan is completed, triage criteria are developed consistent with those studied by national organizations, and an updated assessment is done to determine where trauma centers are actually needed. Level 2s should not be allowed within 30-plus miles of a Level 1, and those already in place should have triage criteria that routes those critically injured to the Level 1, with few exceptions. Triage criteria must assure all seriously injured children reach a designated pediatric trauma center when appropriate. Only then will Floridians have access to the finest, most appropriate trauma care at a reasonable cost.
Connie J. Potter, a registered nurse with an MBA in health care administration, is an expert in trauma economics, has run two Level 1 trauma centers and is former Oregon trauma systems manager. She resides in Las Cruces, N.M. She wrote this exclusively for the Tampa Bay Times.