News stories have raised concerns about level III or IV trauma centers in Florida that upgraded to level II and introduced trauma activation fees for minor injuries.1 These fees support 24-hour capability to treat life-threatening injuries. Texas recently experienced similar trauma center expansion. We analyzed insurance claims for BlueCross BlueShield of Texas to examine whether level I and II trauma center expansion was associated with increased prices or use of trauma activation fees.
This serial cross-sectional study examined BlueCross BlueShield of Texas insurance claims from January 2011 to December 2019 in the Austin, Dallas, and Houston metropolitan statistical areas where a new level II trauma center opened. We selected patients aged 16 to 64 years with a trauma activation revenue code, a trauma-related diagnosis group code, or an urgent or emergent admission with an injury-related International Classification of Diseases, Ninth Revision or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision code. We excluded visits unlikely to reflect acute trauma injuries.2 We calculated the proportion of visits without an inpatient stay, the share of visits with a New Injury Severity Score (NISS)3 of less than 9 (score range, 0-86, with higher scores indicating greater injury severity), and the allowed amount for each visit—the combined amount paid by the insurer and the patient out of pocket. Data on race and ethnicity were not included in the claims. All analyses were conducted using Stata, version 17 (StataCorp, LLC). Because we analyzed deidentified claims, this study was deemed exempt from review and informed consent waived by the Rice University Institutional Review Board. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.
In this study of 38 744 trauma visits, patients’ mean (SD) age was 39.8 (14.9) years, and 22 838 (58.9%) were men and 15 906 (41.1%) were women. The number of level I or II trauma centers in metropolitan statistical areas containing Austin, Dallas, and Houston, Texas, increased from 11 in January 2011 to 21 in 2019 (Table). We counted 2902 level I or II trauma visits in 2011 and 3922 in 2019. The percentage of visits with a trauma activation fee decreased from 71.1% (1689 of 2376 visits) in 2011 to 60.1% (1534 of 2553 visits) in 2019 for existing level I or II centers. No decrease in this fee occurred for visits at newly upgraded centers. Between 2011 and 2019, the percentage of visits without an inpatient admission decreased from 38.0% (1103 of 2902 visits) to 33.4% (1309 of 3922 visits). In the 86.7% of visits (33 601 of 38 744) in which we could categorize injury severity, the percentage with an NISS of less than 9 was 59.8% (1505 of 2517) in 2011 and 53.8% (1826 of 3394) in 2019.
In 2019 dollars, the mean allowed amount for a trauma patient increased from $36 969 in 2011 to $39 773 in 2019. Upgraded trauma centers had lower allowed amounts in 2011 but matched amounts for existing facilities by 2019 (Figure). The allowed amount for visits with trauma activation fees decreased from $32 162 in 2011 to $31 189 in 2019. The 95th percentile for the allowed amount for patients without a hospital admission and an NISS of less than 9 was $20 538 in 2019. Two of 11 level I and II trauma centers open in 2011 had 5 or more outpatients in the 95th percentile in 2019. Another 2 of 9 level II upgraded centers exceeded this limit.
In this serial cross-sectional study, level I and II trauma centers in 3 Texas metropolitan statistical areas almost doubled in number between 2011 and 2019. Simultaneously, the percentage of trauma visits with a trauma activation fee declined for existing facilities but not for upgraded centers. Calculations suggested no decline in case severity. The overall increase in the mean allowed amount for trauma visits paired with the decline in payment for visits with a trauma activation fee meant visits with an activation fee were lower by 13% ($32 162 vs $36 969) in 2011 and 22% ($31 189 vs $39 773) in 2019.
Texas did not experience the growth in trauma fee activations or prices noted in Florida. A limited number of trauma centers in the 3 Texas metropolitan statistical areas included in this study received exceptionally high payments for visits with lower injury severity. A limitation of this study was that we analyzed claims from only 1 large insurer in 3 metropolitan statistical areas.
Unlike surprise billing,4 trauma activation fees may not require government intervention. Insurers’ oversight may sufficiently limit outsize bills submitted by a few hospitals. In fact, Florida Blue recently renegotiated lower trauma rates with HCA Healthcare.5
Accepted for Publication: January 28, 2022.
Published: March 17, 2022. doi:10.1001/jamanetworkopen.2022.2912
Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2022 Ho V et al. JAMA Network Open.
Corresponding Author: Vivian Ho, PhD, Rice University’s Baker Institute for Public Policy, Rice University, 6100 Main St, MS 40, Houston, TX 77005 (vho@rice.edu).
Author Contributions: Dr Ho had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Ho, McClure, Suliburk.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Ho, Suliburk.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Ho, Short, Coughlin.
Obtained funding: Ho, McClure.
Administrative, technical, or material support: Suliburk.
Supervision: Ho, Suliburk.
Conflict of Interest Disclosures: Dr Ho reported serving on the Community Health Choice Board of Directors. No other disclosures were reported.
Funding/Support: The research was supported by a 2019 grant from Health Care Service Corporation’s Affordability Cures initiative (Drs Ho, Coughlin, and Suliburk and Ms Short).
Role of the Funder/Sponsor: Health Care Service Corporation provided the raw claims data for the study and contributed to the concept and design and writing of the report, approval of the manuscript, and the decision to submit the manuscript for publication. Health Care Service Corporation had no role in the collection, management, analysis, and interpretation of the data.
2.Ciesla
DJ, Pracht
EE, Leitz
PT, Spain
DA, Staudenmayer
KL, Tepas
JJ
III. The trauma ecosystem: the impact and economics of new trauma centers on a mature statewide trauma system.
J Trauma Acute Care Surg. 2017;82(6):1014-1022. doi:
10.1097/TA.0000000000001442PubMedGoogle ScholarCrossref 4.Cooper
Z, Scott Morton
F, Shekita
N. Surprise! out-of-network billing for emergency care in the United States.
J Polit Econ. 2020;128(9). doi:
10.1086/708819Google Scholar