Play or pay: a financial model for trauma care in a regional trauma system

Trauma systems are threatened from declining reimbursement. To increase trauma system participation in Mississippi, a novel "Play or Pay" (PoP) state trauma funding law went into effect on September 1, 2008. Hospitals were required to participate in the trauma system or pay a fee of up to $1.5 million per year. Funds generated are distributed for uncompensated care to hospitals participating in the trauma system. The purpose of this study was to evaluate the effect of PoP on a bordering state's Level I trauma center.

Patients living in the PoP state at the time of injury who were admitted to a regional Level I trauma center from 2006 to 2009 were eligible. Demographics, payer source, and injury severity were determined. The reimbursement ratio (reimbursement or charges) (REIMBR) was calculated for each patient. Patients admitted before PoP (PRE) were compared with those admitted after (POST).

Trauma system participation increased in the PoP state PRE (70 of 107 [65%]) versus POST (85 of 106 [80%], p < 0.05). Transfers of Mississippi residents from referring hospitals to the regional Level I trauma center increased PRE (30.0%) versus POST (36.8%, p < 0.05). Payer mix was significantly different PRE versus POST with an increase in self-pay (37.4% POST vs. 36.5% PRE, p < 0.05) and a decrease in commercial insurance (36.0% POST vs. 41.0% PRE, p < 0.05). The REIMBR significantly decreased PRE (1.11 ± 1.43) compared with POST (0.91 ± 1.07, p < 0.05). At the same time, there was an increase in funds received from the PoP state. After accounting for increased funds, there was a significant increase in the adjusted REIMBR PRE (1.21 ± 1.53) versus POST (1.49 ± 4.51, p < 0.05).

A PoP policy in a neighboring state was associated with more transfers, a change in payer mix, and a decrease in the REIMBR. However, funds received from the PoP state ameliorated the negative financial impact on bordering state's Level I trauma center. The Mississippi legislature's foresighted PoP policy created a truly regional trauma system, blind to state lines.