A significant amount of volume coming in to Level I and Level II trauma centers is transferred from other hospitals. Occasionally, concerns are raised that some hospitals “cherry pick” the patients, retaining those who are insured and transferring those who are not. If this is true, it has the potential to undermine the entire trauma transfer system by delaying and impeding patient care and by financially damaging the higher level trauma centers. A few single state or single health care system studies have been performed, and some of them have suggested that the uninsured were more likely to be transferred to high level trauma centers.

The group at Parkland looked at a national sample using the National Trauma Databank, and compared the insurance status of patients transferred to Level I and II centers to those retained at Level III and IV centers. Overall, most patients (83%) were insured. At first glance, transferred patients were significantly more likely to be uninsured (18% vs 14%). However, they were also more seriously injured and more likely to have multiple injuries. When adjusted for these differences, the transferred patients were no more likely to be uninsured than the others.

Bottom line: There does not appear to be any concerted effort nationally to inappropriately transfer uninsured injured patients to high level trauma centers. The perception arises because the uninsured have a tendency toward higher risk behaviors that may result in serious injury.

However, it is possible that cherry picking may occur on occasion at the local level. If you are a trauma director experiencing this phenomenon, the best course of action is to speak directly to the director at the referring hospital. Politely discuss your perceptions and offer to see if there is anything you can do to help with their triage process. Frequently, letting them know you are aware of the pattern causes them to improve their transfer decision making.

Reference: Financial triage in transfer of trauma patients: a myth or a reality. Am J Surg 198(3):e35-e38, 2009.