Association of Level I and II Trauma Center Expansion With Insurer Payments in Texas From 2011 to 2019.

Introduction

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.

Methods

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.

Results

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.

Table.

Characteristics of Trauma Service Use in Texas Metropolitan Statistical Areas With Upgraded Level I and II Trauma Centers

Year	Market characteristics				Visits to level I or II trauma centers
	Level I or II trauma centers, No.a	Populationb	BCBSTX market share, %c	Trauma visits, No.	No.	Visits without inpatient admission, No. (%)	Visits with NISS <9, No./total No. (%)d	Visits at upgraded centers, No. (%)	Existing		Upgraded
									No.	Visits with activation fee, No. (%)	No.	Visits with activation fee, No. (%)
2011	11	14 347	29.8	3849	2902	1103 (38.0)	1505/2517 (59.8)	526 (18.1)	2376	1689 (71.1)	526	324 (61.6)
2012	12	14 662	32.0	5476	4136	1617 (39.1)	2045/3411 (60.0)	745 (18.0)	3391	2431 (71.7)	745	448 (60.1)
2013	12	14 965	34.2	5748	4266	1562 (36.6)	2210/3690 (59.9)	773 (18.1)	3493	2373 (67.9)	773	412 (53.3)
2014	12	15 332	32.2	6283	4655	1766 (37.9)	2372/4044 (58.7)	888 (19.1)	3767	2601 (69.0)	888	541 (60.9)
2015	12	15 716	29.6	7023	5125	2036 (39.7)	2735/4500 (60.8)	1134 (22.1)	3991	2772 (69.5)	1134	663 (58.5)
2016	12	16 065	27.8	6729	4685	1579 (33.7)	2251/4110 (54.8)	1305 (27.9)	3380	2198 (65.0)	1305	697 (53.4)
2017	14	16 353	26.2	6525	4586	1625 (35.4)	2237/4032 (55.5)	1440 (31.4)	3146	2096 (66.6)	1440	945 (65.6)
2018	19	16 599	28.1	6509	4467	1543 (34.5)	2160/3903 (55.3)	1454 (32.5)	3013	1953 (64.8)	1454	880 (60.5)
2019	21	16 866	32.0	6036e	3922	1309 (33.4)	1826/3394 (53.8)	1369 (34.9)	2553	1534 (60.1)	1369	874 (63.8)

Abbreviations: BCBSTX, Blue Cross and Blue Shield of Texas; NISS, New Injury Severity Score.

Number in January of each year, except for 1 upgrade in April 2019.

Population estimates (in thousands) of the metropolitan statistical areas that include Austin, Dallas, and Houston, Texas, are from the US Census Bureau.

BCBSTX market shares are from Competition in Health Insurance annual reports from the American Medical Association.

Based on the 87% of patients for which New Injury Severity Score (NISS) is defined.

The visit count for 2019 is lower because the sample consisted of claims processed through January 30, 2020.

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.

Figure.

Mean Allowed Amount for Visits to Existing and Upgraded Level I or II Trauma Centers, 2011 to 2019

Payments were adjusted to reflect 2019 dollars using the Consumer Price Index for All Urban Consumers: All Items. Whiskers indicate 95% CIs.

Discussion

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]