February 1998 Bulletin

Hospital should share cost of trauma care

Orthopaedic surgeons need reasonable reimbursement for treating uninsured, underinsured patients

By Brent L. Norris, MD

Since the advent of Advanced Trauma Life Support (ATLS), management of patients with traumatic musculoskeletal injuries has evolved significantly. Although the incidence of patients with musculoskeletal trauma is unknown, approximately 30 million patients with traumatic injuries will require medical attention annually. Ten percent of these injuries will require hospitalization, often at a Level I trauma center. An estimated 75 to 80 percent of these patients will require musculoskeletal evaluation and treatment.

Since the beginning of medicine, care has been rendered with the expectation of reimbursement. Early on, "gratis" care would be rendered and soon this became accepted by the medical community. Administering medical care without expectation for reimbursement is not without reward. If fact, we have all sworn to the Hippocratic oath and often render care to the sick without regard to reimbursement. As a whole, the medical community believes and adheres to this oath. However, an alarming number of our patients are now either uninsured or underinsured. In addition to this, the younger population has decided to forego purchasing health insurance so they can afford something else that they have prioritized as being more important. This is a concern because trauma is a disease that primarily afflicts the young. From an orthopaedic surgeonís perspective, the typical trauma patient is a young male, often unemployed and uninsured.

Following a traumatic event, the patient is brought to the local hospital emergency room for evaluation and treatment. If the patientís level of acuity is high or the severity of his/her injuries great, then the patient is transferred to a Level I trauma center. The Level I trauma center and its supporting medical staff including the orthopaedic surgeon, then accept the responsibility for rendering medical care. After the trauma team has assessed, resuscitated and stabilized the patient, the orthopaedic surgeon on call must evaluate and treat the musculoskeletal injuries.

Frequently, a single trauma patient will have multiple musculoskeletal injuries, requiring emergent care to be rendered during evening hours. The orthopaedic surgeon initiates the appropriate musculoskeletal care without regard to the patientís ability to pay. After the acute care phase, the orthopaedic surgeon follows the patient until he/she has convalesced. This can be an extended period of time because the typical trauma patient with multiple musculoskeletal injuries may require secondary or even tertiary surgical procedures prior to full recovery.

From the hospitalís perspective, once the trauma patient is admitted and in attendance by the trauma specialist, the focus shifts to insurance and payer issues. If the patient is adequately insured, then both the hospital and the physician usually are paid some fee for services rendered. Uninsured patients, however, must be identified as "uninsurable" or eligible for Medicaid programs in which they have not enrolled. In Tennessee, which is facing budget shortfalls in millions of dollars, the stateís Medicaid program was restructured allowing commercial HMOs to accept responsibility for managing the total health care of the Medicaid recipient in return for a specific capitated amount per patient, per year. Working under the stateís new program, TennCare, these organizations negotiated with health care providers throughout the state to create networks within which the stateís uninsured and uninsurables would receive their health care as mandated by basic benefit plans approved by Medicaid.

Obviously, this precipitated a race for the capitated health care dollar with hospitals receiving, in many cases, reimbursement based on DRGs while most physician specialists were paid on a heavily discounted fee-for-service basis. Hospitals, however, given their information management capabilities, were frequently in a position to retroactively enroll many Medicaid-eligible patients presenting to their facilities who had not yet enrolled in TennCare, and subsequently receive full or partial payment for services rendered. Quite often the orthopaedic surgeons, unaware of the patientís situation, provided care for which reimbursement was not available given the patientís financial status. For orthopaedic surgeons joining the various TennCare networks, fees offered were found in many cases to be substantially less than what had been paid previously for the same Medicaid patient.

This brings us to the question, "Who should be responsible for paying the physicians for services rendered to the uninsured or underinsured trauma patient?" Although I would like to say it is the patientís responsibility, I must wonder: Is the hospital not partially responsible, especially if the hospital is better positioned to bill and collect for these services with respect to governmental and commercial insurers?

The relationship most orthopaedic surgeons have with the hospital is that in return for having privileges at the facility, they agree to cover the emergency room in the event that their services are required. The frequency of their coverage usually relates to the number of orthopaedic surgeons that practice at the facility. At a non-Level I trauma center, the frequency of being on call often is not excessive. However, at a Level I trauma center, the "call" requirements are quite different. The patient volume and level of acuity at a Level I trauma center create more demanding patient management. Assuming limited to no reimbursement for services provided, a surprisingly high percentage of these patients create a significant financial disadvantage for the orthopaedic surgeon. For this reason, orthopaedic surgeons covering a Level I trauma center should encourage the hospital to assist them in establishing a reasonable level of reimbursement for those indigent or uninsured patients managed in their facility.

As everybody knows, in todayís environment of the shrinking health care dollar, orthopaedic surgeons are being increasingly asked by insurers to accept steeply discounted fees for their professional services. In addition, a large percentage of their care at Level I trauma centers is "gratis" for the uninsured or underinsured trauma patients. This system, therefore, creates a substantial economic disparity for the orthopaedic surgeon who actually has no mechanism to control the flow of non-paying patients. Given this environment, health care facilities operating Level I trauma centers must ensure that reasonable compensation is made available to orthopaedic surgeons covering their emergency rooms. Otherwise, trauma centers should expect migration of orthopaedic surgeons to other venues for health care delivery that afford equitable economic and compensation outcomes.


Lyons AS, et al: Medicine, An Illustrated History, New York, NY, Harry N. Abrams, Inc. Publishers, New York, 1878.

American College of Surgeons. Advanced Trauma Life Support Course. 1997.

Brent L. Norris, MD is assistant professor, department of orthopaedic surgery, University of Tennessee College of Medicine, Chattanooga and chief of orthopaedic trauma service, Erlanger Medical Systems, Chattanooga.

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