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Dr. Jeff Guy, director of the Vanderbilt Burn Center (right) and Dr. Rick Miller, director of the Vanderbilt Trauma Center, talked to Tennessee lawmakers on Tuesday, Feb. 20 as they toured Vanderbilt's trauma facilities as part of an education effort to s

What if the entity established to deal with crisis finds itself in critical condition?
For Tennessee's trauma specialists, this uncertainty is quickly moving from hypothetical question to stark reality.
Dr. Julie A. Dunn knows firsthand the forces combining to threaten the system in Tennessee and across the nation. Dunn is chair of the state's Trauma Care Advisory Council and also serves as chair for the Tennessee Committee on Trauma through the American College of Surgeons.
"In Tennessee, we've lost 11 (centers) in the last decade … mostly Level 2s," said Dunn, whose day job is medical director of trauma care services at Johnson City Medical Center (JCMC) … one of the state's six Level 1 centers. "It's not just in Tennessee — trauma centers across the nation are in crisis."
Despite the loss of centers, today every Tennessean is still within 100 miles of a Level 1 Trauma Center. In addition to JCMC, the other Level 1 centers are Erlanger Medical Center in Chattanooga, Holston Valley Medical Center in Kingsport, Regional Medical Center in Memphis, UT Medical Center in Knoxville and Vanderbilt University Medical Center in Nashville.
In an effort to make the public, other providers and the legislators who control funding options more aware of the extraordinary services provided by the state's trauma network and the looming funding crisis that threatens the system, the state's trauma centers recently launched an education campaign.
Annually, about 18,000 patients receive care in state trauma centers. Of that group, nearly 15,000 receive definitive care in one of the six Level 1 centers with remaining cases handled at the state's only Level 2 or one of three Level 3 centers.
However, the state's trauma centers receive no direct funding. Finding some type of recurring funding source is high among the network's priorities. Dr. Corydon Siffring, director of trauma at Holston Valley Medical Center, said the annual readiness cost … the cost just to open the doors each year exclusive of seeing a single patient … is estimated at $14 million for each of the Level 1 centers.
"People have come to depend on the trauma system. They assume like policemen and firemen we'll always be there. Yet unlike policemen and firemen whose services are paid for, there's no guarantee (for the trauma system)," Siffring said. "We're about at the tipping point all across the country."
Dr. John A. Morris Jr., director of the division of trauma and surgical critical care at Vanderbilt University Medical Center, concurred, saying, "It's a tremendous investment in time and money and the value of that investment accrues to all citizens regardless of their ability to pay."
The "perfect storm" that has been brewing for the last several years combines the skyrocketing costs of new technology with higher overall costs of care, decreased reimbursements and an increasing number of uninsured.
"We're seeing a growing segment of the population between 18 and 45 … who used to always carry coverage through their jobs … who don't have insurance now," Dunn said of the demographic most heavily impacted by trauma.
As a matter of fact, trauma is the number one killer of all people between birth and age 45. According to Dunn, it vies with heart disease for the title of "costliest medical condition." She added that on top of the hard costs, there is a huge cost to society in terms of lost productivity since trauma tends to affect people in the prime productive years of their lives.
Taking the brunt of the burden for uncompensated care are the hospitals — typically teaching hospitals at the Level 1 stage — which must have a cadre of specialists on staff and on call at all times to deal with the myriad of injuries that fall into the category of "trauma."
The cost of care is enormous as trauma victims often require an immediate team of specialists followed by days or weeks in the hospital and then months of rehabilitation and follow-up.
"When a lot of people think of trauma, they think of the emergency department," said Siffring. "Yet less than 2 percent of my time is spent in the emergency department … my time is spent in the ICU."
While Dunn, Siffring and Morris were quick to assure that Level 1 centers in Tennessee are stable, all three said the six main centers need to be shored up and that the state would benefit from more Level 2 and Level 3 centers.
Morris pointed out trauma care, which is notoriously complex and expensive, was most efficient when handled by specialty centers.
"Trauma patients make hospitals inefficient," Morris said, noting these cases disrupt flow, bump scheduled surgeries and require additional resources. "The way to make this population of inefficient patients efficient again is to centralize them."
"We really do serve as a safety net," Dunn agreed, adding that the Level 1 centers serve every county in the state and benefit not only those who are injured … regardless of ability to pay … but also clearly help smaller hospitals by offloading the burden.
Morris and others are hoping to get other providers behind their quest for funding. He said it was important for doctors and administrators to understand that if the Level 1 trauma system were to collapse, their patients would have to be managed in local hospitals.
"It will disrupt their practice and transfer the burden of that indigent care to their facility," he said. For many hospitals already on the verge of a financial breaking point, the addition of trauma patients could be disastrous.
Since motor vehicle accidents account for roughly half of all trauma cases in Tennessee, Dunn said one funding option would be to take a broad-based approach such as a small fee added to vehicle registrations that would be specifically designated for trauma care funding. Another option used in some states is a heftier fine attached to moving violations. Dunn noted that Florida has raised about $30 million alone on its red light running fee.
With the increasing number of charity care cases, DSH funds — if restored in Tennessee — might be another option. No matter what the mechanism, the crux of the matter is finding a recurring funding source that will offer some budget stability. As Dunn pointed out, it's the kind of service that might not be top-of-mind, "but by golly you want it there if you ever need it!"
For now, those involved in the state's trauma system can only hope the awareness campaign will help them secure life support before it becomes necessary to pull the plug.

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