News & Events

Nov 16 09 Boston Children’s Hospital research shows uninsured trauma victimes die at a rate 89% higher than insured

Andrew Schneider

Study: Uninsured Trauma Victims Face Sky-High Death Rate

Posted: 11/16/09

(Nov. 16) — It’s federal law: All seriously injured emergency and trauma patients must be given equal lifesaving care, whether or not they can pay for it. But that’s not happening, according to a new report. The study, conducted by Children’s Hospital Boston research fellow Dr. Heather Rosen and colleagues from three other hospitals, found that uninsured trauma victims ages 18 to 30 are dying at an annual rate 89 percent higher than insured victims with identically severe injuries.

As the health reform tornado continues to swirl on Capitol Hill, the data could provide fresh ammunition for those pushing for expanded health insurance coverage.

The study, published today in the Archives of Surgery, examines the survival rates for patients brought to about 900 U.S. trauma centers between 2002 and 2006, analyzing some 690,000 patients who had suffered penetrating trauma — such as wounds inflicted by a gun or knife — or blunt trauma from vehicle crashes and falls. Earlier research found 18,000 extra deaths a year among uninsured victims of such injuries. Rosen and the other researchers chose to focus on the 18-to-30-year-old subset because they had fewer existing conditions — comorbidity — that muddy the evaluation of the cause of death.

Courtesy of Heather Rosen
Dr. Heather Rosen, a research fellow at Children’s Hospital Boston who authored the study.

The study concludes that there is "pervasive evidence of disparities in screening, hospital admission, treatment and outcome due to insurance status." Overall, uninsured patients had the highest rate of death, even after controlling for age, sex, race, and severity and mechanism of injury.

In an e-mail interview, Rosen puts it more plainly: "Uninsured patients in the United States have a higher risk of dying after trauma, even though there is universal access to emergency care."

That the absence of insurance leads to preventable deaths of patients with cancer, diabetes, respiratory and other chronic diseases is by now accepted wisdom among medical professionals. But existing policy is supposed to protect victims of trauma and other acute medical events, for whom instant medical intervention makes the difference between survival and death. In 1986, in response to widespread dumping of uninsured critically injured or ill patients onto the street or on lesser hospitals, Congress passed the Emergency Medical Treatment and Active Labor Act. It mandated that hospitals and ambulance services provide care to anyone who needs emergency treatment, regardless of citizenship, legal status or ability to pay.

But if the law is not preventing uninsured trauma patients from receiving substandard care, as Rosen’s study indicates, the question becomes why.

Trauma is well-studied, and the specific steps that must be taken to keep the lethal dominoes from falling are well-established. Dr. R Adam Cowley, one of the fathers of the field, sermonized on the importance of the "Golden Hour" that exists between an injury and getting the patient definitive treatment. "Who’s paying the bill is the last thing we have time to worry about," he liked to say. Trauma doctors and nurses insist that mentality continues to govern today, even as the high cost of trauma care and ICU follow-up — which can run to hundreds of thousands of dollars for a single patient — have brought trauma centers in Los Angeles, Miami and other urban areas to the edge of bankruptcy and created pressure to cut costs.

Interviewed over the weekend, nine members of five different trauma units who had read the study all had the same message: "Not in my shop." "They will tell you they don’t even know the funding status of most of their patients until after they’ve been hospitalized for some time," says Dr. Harold Sherman, a retired trauma surgeon in Pittsburgh. "They take and treat all comers equally as required by their ethics and the law, and certainly don’t actively discriminate on the basis of insurance status."

Some trauma specialists I spoke with recall representatives from the hospital billing departments sometimes hovering at the fringes of the bloody ballet to save a life. But as a trauma social worker from Washington, D.C. — who declined to allowed her name to be used because she isn’t authorized to speak to reporters — puts it: "They would never be foolish enough to tell a trauma surgeon to not order this or that test, or cancel a scan or expensive lab work because they found no insurance card in the patient’s wallet."

"What surgeon, ER doc or nurse would risk their license and violate federal law to keep the billing office happy?" the social worker adds.

The problems, Sherman explains, creep in after patients leave trauma care. "Post-discharge care certainly does vary with insurance status. It is a constant irritant to trauma surgeons."

Dr. Gregory Jurkovich, chief of trauma for Seattle’s Harborview Medical Center, claims his hospital had not seen the disparity in treatment described in Rosen’s report, but he too says that follow-up efforts are falling short. For the underinsured, he says, "there is decreased access to rehabilitation and chronic care services."

Such anecdotal evidence squares with another finding of Rosen’s study: Even when everything else was equal, "uninsured patients received significantly fewer radiographic studies and were less likely to be admitted compared with insured patients with similar diagnoses."

In a comment published with the journal article, Dr. Brent Eastman, a trauma and vascular surgeon from Scripps Memorial Hospital in San Diego who was just elected chairman of the Board of Regents of the American College of Surgeons, noted that emergency rooms and trauma centers "are the safety net for many communities." He called for Rosen’s conclusions to be taken seriously.

Rosen cautions that the definitive cause for the higher death rate for uninsured people remains to be determined. Still, the hard number — the nearly 90 percent jump in mortality rates for uninsured accident victims — speaks loudly on its own. "Although the lack of insurance may not be the only explanation," she says, "the accidental costs of being uninsured in the United States today may be too high to continue to overlook."