Mississippi Revitalizes the State Trauma Care System

Issue
Unintentional injury is the leading cause of mortality both nationally and for Mississippians aged less than 45 years.  Mississippi ranks third in the nation for unintentional injury deaths.  Research shows formal trauma systems reduce traumatic injury mortality.  Formal trauma systems are also important first lines of defense for reducing deaths caused by natural disasters, terrorism events, and pandemics.  States have actively implemented polices to strengthen formal trauma systems over the past 30 years.   Mississippi began developing a formal trauma system in 1991.  For more information visit the Mississippi State Department of Health trauma web site.

The Mississippi Firefighters Memorial Burn Center, the only burn care specialty facility in the state, closed in 2005.  Two reasons were given for the burn center closure:   uncompensated care and inadequate specialist coverage.  The Governor formed a Burn Care Advisory group to review and make recommendations concerning burn care in Mississippi. In 2006, legislation was passed to transfer the remainder of the burn care funds from the Mississippi Firefighters Memorial Burn Center to the Mississippi State Department of Health.   However, burn trauma is a small fraction of the nearly 18,000 trauma cases occurring in Mississippi annually (Figure 1).   The burn center closure is symptomatic of problems occurring within a “diseased” statewide trauma system. 

Informing The Policy Debate  

The Center for Mississippi Health Policy undertook research during 2006 in order to inform the policy debate regarding the statewide trauma system.  Statewide trauma leaders were interviewed and the trauma system history, operations, legislation, funding, as well as outcomes and best practices of other states were reviewed.  The resulting report titled:  Mississippi Trauma Care System:  Life Saving Care is No Accident, was disseminated to stakeholders and policy makers during 2007.  The Center report found that nationally, trauma systems struggle to meet patient demand and center closures are increasing.  The Institute of Medicine emphasized fragility of state trauma systems in its recent report, Future of Emergency Care.  Mississippi’s trauma system is a mid-maturity (Figure 2), as are the majority of other state systems.  However, Mississippi's trauma system had stalled at mid-level development and was on the verge of collapse if uncompensated care and provider shortages were not addressed expediently. 

Figure 2:  Trauma System Characteristics for Mature Systems & Mississippi

Source:  Man, Mackenzie, Teitelbaum, Wright, and Anderson, 2005.

Mississippi taKES ACTION

During the 2007 Legislative session, Senate Bill 2863 was enacted.  This legislation mandated creation of a Trauma Care Task Force charged with reporting the status of the statewide trauma system and burn care to the Governor and Legislature by December 2007.  The Trauma Care Task Force included:  trauma center administrators, trauma care specialists, as well as Mississippi Legislators from both Senate and House chambers.  Trauma Care Task Force members requested assistance in compiling their report from the Center.  The Trauma Care Task Force Final Report was disseminated to the Governor, Senate & House Public Health Committees, as well as other stakeholders during late 2007 along with an Issue Brief summarizing the report.  The Trauma Care Task Force findings did not change significantly from the Center’s initial trauma report.  They found the statewide trauma system:

• near collapse, with large areas lacking access to specialized trauma care during the “golden hour” (first sixty minutes after sustaining traumatic injury), due to many hospitals halting trauma system participation (Figure 3);  

 Figure 3:  

•  lacking proper funding necessary for statewide trauma system viability;
• declining primarily due to uncompensated trauma care and provider shortages, as with the burn center closure;
• burn victim families struggling with regards to paying for out-of-state travel costs, while the majority of the burn care fund had not been expended since the burn center closure in 2005 ; and
• moving as a leader in trauma system development to having a stalled and deteriorating system. 

The Trauma Care Task Force recommends two funding mechanisms to sustain the statewide trauma system:

• target fees and assessments to have the effect of discouraging risky behaviors resulting in trauma care need; and
• implement a “pay or play” statewide trauma system, where trauma centers capable of providing care that choose not to do so are statutorily assessed a fee transferred to trauma centers participating at capable levels. 

Legislation was introduced during the 2008 legislative session to implement many of the Trauma Care Task Force recommendations via House Bill 1405.  Enactment of House Bill 1405 is projected to add $34 Million to the current trauma system fund of $8 Million.  House Bill 1405 passed both chambers and was signed into law by the Governor on May 10, 2008.  This bill became effective on July 1, 2008, modifying the current trauma statute to include:

• a “pay or play” funding provision;
• a series of mechanisms  to generate additional funds for trauma care from fees and assessments in areas causing trauma;
• a provision for Level I trauma centers from surrounding states caring for Mississippi trauma patients to be eligible to receive trauma care funds for uncompensated care;
• a mandate whereby members of the system oversight council must continue to serve until replacements are named by the Governor; and
• an authorization for the Mississippi Department of Health to reimburse victim families for out-of-state travel expenses from the burn fund.  

The “pay or play” regulations have been promulgated by the Mississippi State Department of Health, whereby licensed acute care facilities are determined by the Department, based on the characteristics of each facility, for what level of trauma care each can contribute to the system.  Levels of trauma center care have historically been based on modifications of the American College of Emergency Physician and American College of Surgeon guidelines (Figure 4), with Level I being the highest tier of trauma care and Level IV being the lowest tier.  A licensed acute care facility, once designated, can choose to participate in the trauma care system and be entitled to reimbursement for uncompensated trauma care.  Otherwise, the facility will be assessed a fee if choosing either to opt out of participation or to participate at a lower level than deemed capable.  These “pay or play” fees will be deposited into the Trauma Care Systems Fund to reimburse properly participating trauma centers for uncompensated trauma care.

Figure 4:  Trauma Center Designation Levels

Source:  Mississippi Department of Health, Bureau of Emergency Medical Services Annual Report, 2005

Other funding will be generated for the trauma care systems fund from:

• increases on moving traffic violation penalties, which specifically targets speeding, reckless, and careless driving;
• increases in fees for motor vehicle license tags and decals;  and
• a point-of-sale fee of $50 on each motorcycle and all terrain vehicles sold statewide.

Funding will also be generated for the emergency medical services operating fund from:

• increases in fines and penalties from moving traffic violations, and
• increases in fines for violations of the Implied Consent Law (driving under the influence of alcohol or illegal substances).

Summary     

An adequate formal trauma care system is a critical to saving lives endangered by traumatic injuries. Policymakers in Mississippi have studied the problem and the policies implemented in other states and have taken action to address the issue. Mississippi recognizes the seriousness of the problem and has taken steps to revitalize the existing system. Mississippi is once again on the forefront on trauma system development.