As a 35-year veteran in physician recruiting and staffing in the surgical specialties, it seems within the last several years there has been an unprecedented movement within the hospital industry to establish new trauma centers or to upgrade designation status from Level III to Level II—particularly within the for-profit hospital chains.
More than 200 trauma centers in 20 states have opened since 2009, according to Kaiser Health News. In Ohio alone, where there are few investor-owned hospitals, the trauma center count went from 22 American College of Surgeons-verified centers to 42.
Everyone knows that the payer mix for trauma patients is not so hot. But here are a few things hospital executives are looking to gain:
1. Market Positioning-By obtaining or upgrading a trauma designation, a hospital is better positioned to market itself as a full-service hospital that can care for patients with all types of illnesses, including the severely injured trauma patient.
2. Increases in Patient Volume- While the payer mix may not be so great, overall volume will provide increases in revenue. Also, trauma designation sometimes creates a watershed effect for elective, non-trauma surgical cases. Some of the trauma centers that have popped up have not been in under-served areas but in more suburban areas where they can attract paying patients.
3. Trauma Activation Fees- Any time an ambulance crew brings a patient that is believed to be a trauma patient, the hospital can charge a trauma activation fee to help cover the higher overhead it has to be a trauma center. Trauma activation fees are $7,000 to $24,000.
Becoming a trauma center or upgrading status can be expensive and arduous, however. As a hospital executive, you should evaluate the projected costs in time and money before beginning the application process to determine whether the return on investment would justify attaining the new designation.
Start by reviewing the criteria for earning you desired designation, whether it is for a new trauma center or for an upgraded status. A state or local municipality identifies unique criteria in which to categorize trauma centers but they typically require you to evaluate, manage and treat within the guidelines of trauma patient management.
Once you've reviewed the criteria, you must then consider whether or not you have the support of your medical staff, particularly the orthopedic surgeons, neurosurgeons and general surgeons. This support is key and you shouldn't overlook it because 24-hour immediate coverage by general surgeons is a must—as is coverage by the specialties of orthopedic surgery, neurosurgery, anesthesiology, radiology and critical care.
If you don't have the necessary surgeons or lack support among those that you do have, you must determine whether you could recruit the specialist(s) necessary to maintain a trauma center and determine what it would likely cost. Look for a win-win. For example, you may be able to partner with the local orthopedists by working with them to recruit one or two fellowship trained ortho trauma surgeons to their group or bring on an orthopedist who is not fellowship trained but has experience in and enjoys doing complex pelvic fracture work.
Ortho trauma surgeons are especially important in treating the trauma patient because a trauma designation must include the availability of an orthopedic surgeon to provide care within the required time limit for each trauma designation (within 30 minutes for a Level II). But there are not nearly enough of them to go around, whether they are practicing physicians or coming out of fellowship, so it should not be expected that a newly designated or upgraded trauma center would be able to achieve 24/7/365 coverage from fellowship trained orthopaedic traumatologist.
According to the American Medical Association Physician Masterfile, 235 practicing physicians have a self-designated primary specialty of ortho trauma and 287 have ortho trauma as a secondary specialty. There are roughly 50 fellowship training programs, which graduate 75-80 fellows a year.
Orthopaedists right out of ortho trauma fellowship usually have a strong preference to join a large orthopaedic group or to join the faculty of an academic medical center that has Level I designation with residents and teaching and research opportunities. This assures an active and robust practice with the ability to use the skills and experience learned and needed to be performed to maintain qualification for continued orthopaedic trauma care. The benefit of closely working with experienced orthopaedic trauma surgeons is also a benefit of being in a larger center.
It is quite a stretch to rely on orthopedist on the on-call panel to care for trauma patients, particularly when it comes to patients with acetabular/pelvis fractures, which are also frequently accompanied by other high energy fractures and dislocation of other extremity bones and abdominal, spine, and head injuries. Community hospital orthopedist are generally opposed to doing this kind of work due to the nature of the injuries, generally high energy.
An orthopedic surgeon's comfort with dealing with emergency and high energy orthopaedic injuries is the most important factor. If orthopaedic surgeons do not have a history of managing trauma patients, further hands on classes, lectures, or cadaver labs may have to be considered if trauma patients will be expected to be safely managed by inexperienced orthopaedic surgeons.
Furthermore, your facility, hospital, or institution needs to provide trauma prevention and continuing education programs for staff. This includes Continuing Medical Education that insures required number of hours dedicated to trauma management.
All physicians and surgeons covering your hospital must include trauma CME in their ongoing CME portfolio. This CME requirement and demonstration of trauma interest is an element of the program that will be open to evaluation and auditing.
You may also have to prove that you have the resources needed to provide optimum care when seeking a new or upgraded trauma center destination. Opposition most likely would come from the nearest Level I trauma center, which probably would be an academic medical center.
The Trauma Medical Directors or Chiefs of Service in the Level I trauma may claim that your surgeons, for example, lack adequate training and experience. They may also argue that your new designation would create a duplication of services that are not needed in close proximity if both a level I and level II trauma center are available.
The market must provide an adequate amount of trauma facilities in close proximity to insure the number and amount of cases needed in a timely fashion to fulfill requirements needed for trauma center designation. This may be difficult if centers are competing for time, surgical skills and numbers of cases.
Determine what role your hospital can realistically play in the local trauma system. If you pursue and attain your desired trauma center designation, you would likely get your share of trauma patients and the trauma activation fees that would come with them, but you would also have the costs associated with paying the surgeons and having an OR ready 24/7.
The more accurate your assessment of the costs for securing the support of the surgeons you would need in your trauma center development efforts, the better you can determine whether the desired designation would be worth pursuing.
Aaron Risen is a managing partner of Med Link, a St. Augustine, Fla.-based physician staffing agency specializing in trauma and surgical critical care, neurosurgery, neurology, intensivists, hospitalists and emergency medicine. He can be reached at aaron@medlinkstaffing.com.
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