[ST-21] Statement on Managed Care and the Trauma System
[by the American College of Surgeons]
Congress passed Public Law 101-590, the Trauma Care Systems
Planning and Development Act, in 1990. The value of implementing
trauma systems through statewide planning has been recognized
and has already demonstrated that these organized regional systems
result in dramatic improvements in patient outcomes. These systems
are designed so that patients with catastrophic injuries will
have the quickest possible access to an established trauma center
or a hospital that has the capabilities to provide comprehensive
emergency medical care. These systems ensure that the severely
injured patient can be rapidly cared for in the facility that
is most appropriately prepared to treat the severity of injury.
Unfortunately, in some situations, managed care systems or
insurers have interfered with and defeated the purpose of trauma
system networks because:
(A) The managed care system or insurer may not authorize treatment
for a severely injured patient unless there is prior authorization.
On many nights and weekends, prompt prior authorization is almost
impossible to obtain. Trauma is by definition an emergency condition,
and treatment cannot wait for such delays.
(B) The managed care system or insurer may deny coverage unless
the patient is transferred either to a hospital with which there
is an existing contract or to a hospital where specific doctors
who are already contracted to the health care entity have privileges
and practice medicine. This forced triage may not be appropriate
for the severity of the patient's injury and, therefore, may
not be in the injured patient's best medical interests.
(C) In many instances in which care has been provided at a
trauma center, reimbursement from the managed care system or
insurer has been denied or severely limited.
Trauma systems have been designed to provide the most rapid,
coordinated medical services to injured patients. The American
College of Surgeons believes that managed care plans and insurers
should be required to allow their patients to be treated in trauma
centers or emergency facilities when true medical emergencies
arise. Delaying or denying approval in such circumstances, or
requiring transfer to another facility as a condition of payment,
may seriously compromise the effective medical treatment of a
severely injured patient.
Agreement upon the following principles should ensure that
any patient brought to a trauma center will receive the best
possible medical care:
1. No impediment to prompt acute trauma care as determined
by the regional trauma system should be permitted.
2. Approval for treatment should be automatic when
admissions or transfers are deemed necessary by the physician
or surgeon at the trauma facility.
3. Prompt reimbursement for all trauma care at trauma
centers that have been verified by the American College of Surgeons
and/or verified by the state should be the norm.
4. Managed care systems and trauma centers should establish
agreements to ensure that transfer does not interrupt continuity
of vital medical care for injured patients and result in avoidable
complications.
5. There should be no barriers to the exchange of data
allowing for procedures to monitor the quality of performance
and verification of the outcome of the care of trauma patients.
6. A mechanism for the rapid and appropriate resolution
of conflicts should be in place.
Trauma centers and managed care agencies should coordinate
their efforts to obtain long-term outcome and cost data in order
to promote optimal patient management. All decisions to transfer
a patient should require a physician-to-physician request and
should be based on the patient's condition and the appropriateness
of the receiving facility's resources relative to the patient's
needs. The final decision to transfer the patient should remain
with the trauma surgeon, who, as attending physician, has the
best information regarding the patient's injuries, condition,
and needs.
These types of patient care guarantees should be incorporated
in licensing requirements for managed care health systems and
insurers in all states.
Statements
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Reprinted from Bulletin of the American College
of Surgeons
Vol. 80, No. 1, Pages 86-87, January 1995
