title: Payer status: the unspoken triage criterion.
abstract: BACKGROUND
  The cost of uncompensated trauma care is a significant barrier to trauma system development. Trauma center designation may burden an institution with an unprofitable mix of underinsured, severely injured patients. Concerns about inadequate reimbursement may motivate interhospital transfers on the basis of insurance status rather than medical necessity, potentially undermining the effectiveness of the system. We set out to explore whether this phenomenon exists in a mature trauma system.
  
  
  METHODS
  Trauma patients receiving definitive care at Level III or IV trauma centers were compared with patients transferred from these centers to the only Level I regional center. Insurance status was classified as either commercial or noncommercial. Logistic regression was used to determine the independent predictors of transfer after adjusting for differences in injury severity.
  
  
  RESULTS
  Only 12% of 2,008 patients initially evaluated at Level III/IV centers were transferred to the Level I center, an indicator of the effectiveness 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 an independent predictor of transfer: patients without commercial insurance were 2.4 (95% confidence interval, 1.6-3.6) times more likely to be transferred to a Level I facility than patients with commercial insurance after adjusting for differences in injury severity.
  
  
  CONCLUSIONS
  Insurance status influences the decision to transfer to higher levels of care. These findings suggest that the financial burden of a trauma 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.
authors.affiliation: Division of General and Trauma Surgery, Department of Surgery, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98104-2499, USA. anathans@u.washington.edu
authors.forename: A B
authors.initials: AB
authors.lastname: Nathens
authors.forename: R V
authors.initials: RV
authors.lastname: Maier
authors.forename: M K
authors.initials: MK
authors.lastname: Copass
authors.forename: G J
authors.initials: GJ
authors.lastname: Jurkovich
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D019458:Insurance Coverage / Q000145:classification*; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured; D008875:Middle Aged; D010360:Patient Transfer / Q000191:economics* / Q000706:statistics & numerical data; D014193:Trauma Centers / Q000191:economics* / Q000706:statistics & numerical data; D014218:Triage / Q000191:economics*; D017664:Uncompensated Care; D014861:Washington