Payer status: The unspoken triage criterion

Background: The cost of uncompensated trauma care is a significant barrier to trauma system development, Trauma center designation may burden an insti tution with an unprofitable mix of underinsured, severely injured patients. Concerns about inadequate reimbursement may motivate interhospital transfe rs on the basis;of insurance status rather than medical necessity, potentia lly undermining the effectiveness of the system. We set out to explore whet her this phenomenon exists in a mature trauma system. Methods: Trauma patients receiving definitive care at Level III or IV traum a centers were compared with patients transferred from these centers to the only Level I regional center. Insurance status was classified as either co mmercial or noncommercial, Logistic regression was used to determine the in dependent predictors of transfer after adjusting for differences in injury severity. Results: Only 12% of 2,008 patients initially evaluated at Level III/IV cen ters were transferred to the Level I center, an indicator of the effectiven ess of prehospital triage protocols in the region. The presence of specific complex injuries, younger age, male gender, and insurance status were all associated with an increased likelihood of transfer, Insurance status was a n independent predictor of transfer: patients without commercial insurance were 2.3 (95% confidence interval, 1.6-3.6) times more likely to be transfe rred to a Level I facility than patients with commercial insurance after ad justing for differences in injury severity. Conclusion: Insurance status influences the decision to transfer to higher levels of care. These findings suggest that the financial burden of a traum a system may be inequitably distributed. This inequitable distribution may be necessary for trauma system sustainability and calls for the development of disproportionate reimbursement strategies to support regional referral centers.