As lawmakers in Washington try to control the swirling tornado know as health care reform, a study has been released showing that thousands die each year because they have no health insurance.
What makes the fate of this group of patients even more puzzling is that they are victims of trauma and thought to be protected by federal law that demands that people with this level of life-threatening injuries must receive equal treatment regardless of their ability to pay.
Every year, uninsured trauma victims – aged 18 to 30 – die at a rate 89 percent greater than victims with equally severe injuries, but who have health insurance, said Dr. Heather Rosen, a research fellow at Children’s Hospital Boston and her colleagues from three other hospitals.
In the study, published today in the Archives of Surgery, the researchers examined who survived and who didn’t out of 2.7 million patients brought to about 900 U.S. trauma centers between 2002 and 2006.
The researchers analyzed patients suffering from penetrating trauma, such as knife-and-gun-club injuries, or blunt trauma from vehicle crashes and falls. Earlier studies found that there were 18,000 extra deaths a year among the uninsured trauma victims.
Rosen and the other researchers chose to examine those younger patients, 18 to 30, because they had fewer other diseases – comorbidity – to muddy the evaluation of the cause of death.
There is “pervasive evidence of disparities in screening, hospital admission, treatment and outcome due to insurance status,” the study concluded.
It is common knowledge backed by numerous peer-reviewed studies that the absence of insurance has led to preventable deaths of patients with cancer, diabetes, respiratory and other chronic diseases.
But with victims of trauma and other acute medical events, where instant medical intervention or the withholding of it means survival or death, this isn’t suppose to happen because it’s illegal.
The relationship between trauma deaths and lack of health insurance has also been studied at length, but Rosen said this study is different because they used a national trauma database and included about 690,000 patients. She says this “makes it one of the largest studies of its kind.”
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.
The law demanded that hospitals and ambulance services provide care to anyone who needed emergency treatment regardless of citizenship, legal status or ability to pay.
“The main point of the study is that uninsured patients in the United States have a higher risk of dying after trauma even though there is universal access to emergency care,” Rosen told me in an email interview Sunday.
Overall, uninsured patients had the highest rate of death following admission for trauma, even after controlling for age, sex, race and severity and mechanism of injury, the surgeon said.
The study also discussed that non-white patients had a higher chance of death than white patients with the same injuries. That older had higher death rates than young, and that penetrating injuries were more lethal than blunt trauma.
Rosen and her colleagues also concluded that 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.”
Trauma is well studied and the mechanism of death among those gravely injured is well known, as are the specific steps that must be taken to keep the lethal dominoes from falling.
Dr. R Adam Cowley, acknowledged by most as the father of trauma medicine, told me years ago, right after he opened the nation’s first trauma center in Baltimore, that teams trying to stall “the cascade of death” that accompanies almost all serious trauma don’t have time to wait while hospital bean-counters and insurance companies debate over who’s going to pay to save the patient’s life.
He sermonized on the “Golden Hour’’ that exists between the injury and the receiving of definitive trauma care and often said “who’s paying the bill is the last thing we have time to worry about.”
Cowley told all who would listen and hundreds who wouldn’t that “If you are critically injured – be it a car wreck, gunshots or falls – and you want to survive, you have, at the most, 60 minutes to be in the hands of people with the right skills, the right equipment and the right motivation to save you – a trauma center.”
The model for a trauma center that Cowley established 40 years ago has been honed and refined across the country.
For level I trauma centers – the top of the four categories of programs – there is a collection of highly trained specialists in the hospital or immediately available, including nurses, emergency physicians, surgeons of all specialties, anesthesiologists, radiologists, infectious disease experts, intensivists, technicians and social workers.
These teams fight life-and-death battles one after another and often develop a camaraderie usually found only on a battlefield. I have spent hundreds of days reporting from trauma centers across the country and I’m convinced that the survival of the patient comes way before hospital payment policies.
The cost of trauma care and the intensive-care unit follow up can easily cost hundreds of thousands of dollars for a single patient. Trauma centers in Los Angeles, Miami and other urban areas have been brought to the edge of bankruptcy, so the pressure to cut costs is enormous.
I interviewed members of five trauma teams this weekend who had read the study and to a person, they all said “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. 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,” said Dr. Harold Sherman, who retired as a trauma surgeon after 15 years in Pittsburgh.
He said that all the surgeon’s claims are probably true, and then added, “Post-discharge care certainly does vary with insurance status. It is a constant irritant to trauma surgeons and does lead to disparities.”
Some that I spoke with this weekend recalled representatives from the hospital billing departments sometimes hovering at the fringes of the bloody ballet to save a life.
“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,” said a trauma social worker from Washington, DC, who declined to allowed her name to be used because she wasn’t authorized to speak to reporters.
“What surgeon, ER doc or nurse would risk their license and violate federal law to keep the billing office happy?” the social worker added.
On the other coast, Seattle’s Harborview Medical Center says it’s the only level one trauma center serving Washington, Idaho, Montana and Alaska.
Dr. Gregory Jurkovich, Harborview’s chief of trauma said, “We have not seen this disparity (described in Rosen’s report) in the Pacific Northwest.
“We find no difference between any strata of insurance status with regards to care, types of testing, amount or number of procedures,” Jurkovick said Friday. “However, there is decreased access to rehabilitation and chronic care services in the underinsured.”
He says that each of the possibilities Rosen and her colleagues raise for the difference in mortality “will need to be more carefully examined.”
Rosen cautions that the definitive cause for the higher death rate for uninsured 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.”
For another version of this story here is a link to AOL’s sphere.com