AAOS Bulletin - October, 2006

Maryland sets example for funding of trauma care

Model includes EMS, hospital and physician services

By Andrew N. Pollak, MD

On a national basis, a major challenge to the development and implementation of effective trauma care systems is how to fund the three essential components of such a system: emergency medical services (EMS), hospital services and physician services. Maryland has one of the most organized and effective trauma care systems in the United States, in part due to funding mechanisms that ensure the fiscal viability of each of these components.

The history of organized trauma care in Maryland dates to 1961 when R Adams Cowley, MD, developed an intensive care unit for the management of complications of postoperative shock at the University of Maryland Hospital. His work underscored the importance of rapid shock correction in preventing acute respiratory distress syndrome and multisystem organ failure. He defined the “Golden Hour” as the time during which correction of shock from any cause (including trauma) could lead to increased survival.

To save the lives of trauma patients, Dr. Cowley convinced the Maryland governor and state legislature of the need for an organized network of trauma centers. The network would be supported by local EMS agencies that would provide on-site rapid assessment. State-wide helicopter availability would ensure expeditious transport of trauma patients to the most appropriate treatment facility.

The Maryland Institute for Emergency Medical Services Systems (MIEMSS), established by the state legislature, was both a designated trauma hospital and a state agency that oversaw EMS operations, including the establishment of a trauma center network with differing levels of care. In 1993, the R Adams Cowley Shock Trauma Center was separated from MIEMSS, incorporated into the University of Maryland Medical Center and designated in statute as the state’s primary adult resource center for trauma.

The current state network consists of eight regional trauma centers. The Cowley Center is the referral center of last resort for head injury, spinal cord injury, multiply injured patients and complex injuries beyond the scope of providers at regional centers. Under law, the helicopter system is part of the state police aviation division, which also conducts search-and-rescue and law enforcement missions. The system also includes local EMS, incorporated into fire departments, and local 911 dispatch centers.

This system includes the three essential components of EMS, hospital services and physician services. Although only a few elements in each component exist solely for the provision of trauma care, the increased stand-by, care delivery and liability costs are substantial. Without adequate funding mechanisms, the ability of any of these components to provide timely and effective trauma care would be significantly compromised.

The Emergency Medical Services Operating Fund (EMSOF) covers hospital costs unique to the provision of trauma services (trauma stand-by costs), helicopter operations, certain EMS services and other emergency services operations. It does not support indigent care or cover the disproportionate share of indigent care realized by trauma centers in general. Vehicle registration fees finance EMSOF.

Support for indigent care is provided under the mechanism of the Health Services Cost Review Commission (HSCRC), which financially regulates all hospitals, including trauma centers. The HSCRC reviews each individual hospital’s costs, payer mix and patient acuity and establishes bed and facility rates that the hospital can charge third-party payers for services provided. The established charge schedules account for the hospital’s costs of providing indigent care. The cost structure is non-negotiable between hospitals and payers and applies to all payers.

Thus, the rate paid by Blue Cross is the same as the rate paid by any other insurer, including Medicare and Medicaid. In this way, the HSCRC guarantees that payments to a hospital are sufficient to generate established margins (and therefore fund capital equipment needs), regardless of the amount of indigent care provided. Maryland is the only state that regulates hospital rates in this way.

Physician reimbursement
When the system was first established, physician reimbursement for trauma services was relatively high and the percentage of uninsured patients treated was relatively low. Volunteer physician participation in trauma center call schedules was financially viable. As reimbursement levels decreased and the numbers of uninsured or underinsured patients increased—along with increasing liability premiums—physician participation in trauma call became less attractive. In some areas, the only physicians who could justify continued participation in trauma center call schedules were those who were otherwise unable to build an elective practice.

In 2001, the legislature recognized the critical role of physician participation in the success of the entire trauma and emergency care system and took steps to improve on-call reimbursement levels for physicians at state-designated trauma centers. They first mandated that HMO reimbursement for trauma services at state-designated trauma centers equal 140 percent of the Medicare fee schedule.

Two years later, the legislature created the Maryland Trauma Physicians Services Fund, with a $2.50 increase in the annual vehicle registration fee. The fund pays Medicare rates to certain trauma specialists (including orthopaedic surgeons) for care to uninsured trauma patients at state-designated trauma centers. It also reimburses hospitals for stipends paid to specialists for taking call at state-designated trauma centers. This past year, due to a substantial surplus in the fund, the legislature expanded the number of specialties eligible for reimbursement for care to the uninsured, increased the reimbursement amount to hospitals for on-call stipends, and extended the eligibility for reimbursement to include follow-up care and surgery directly related to the initial injuries sustained and performed within six months of the initial trauma.

As a result, on-call participation, particularly at smaller peripheral trauma centers, has increased.

A model for others?
The funding model for the Maryland trauma system is unique in its inclusion of all three critical components of emergency care. We were able to educate the legislature about the importance of trauma systems and the way the components of those systems contributed to their overall effectiveness.

Expanding this model to other states may help address at least some of the challenges related to physician participation in trauma center call schedules. Because trauma centers cannot limit death and disability from motor vehicle collisions if physicians are unwilling or unable to take call, the federal government should consider linking federal highway funding to each state’s development of a system that ensures adequate reimbursement to both physicians and hospitals for care delivered to trauma patients at designated trauma centers. The Maryland model stands as an example of just how effective such a system can be.

Andrew N. Pollak, MD, is associate professor and head, division of orthopaedic trauma, associate director of trauma, R Adams Cowley Shock Trauma Center, University of Maryland Baltimore. He also serves as a commissioner on the Maryland Health Care Commission, which administers the Maryland Trauma Physicians Services Fund. He can be reached at apollak@umoa.umm.edu

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