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    Bleeding money

    A paper trail of hospital bills - mostly unpaid - shows how Bayfront's trauma center walks the line between providing an invaluable community asset and staying solvent.

    By KRIS HUNDLEY, Times Staff Writer
    © St. Petersburg Times
    published February 24, 2002


    The summer morning was gray and the pavement slick when the elderly couple's car spun off the road in Hernando County and smashed into a tree.

    The husband, with only minor injuries, was taken by ambulance to the nearby community hospital. His 80-year-old wife was conscious but complaining of severe stomach pain. She was taken by helicopter on the 30-minute flight to Bayfront Medical Center in St. Petersburg.

    Emergency personnel dubbed her Zulu, to protect her privacy. She became one of the nearly 60,000 patients treated each year at the hospital's emergency department, including 3,000 with life-threatening traumatic injuries.

    Bayfront, one of three trauma centers in the region, sees more critically injured patients than any other local hospital. The community desperately needs specialized trauma services, but they're a financial drain on the hospitals.

    The trauma center requires around-the-clock surgeons, expensive imaging equipment and a fleet of four helicopters ready to shuttle accident victims from as far as Spring Hill to the north and Venice to the south.

    It bills patients thousands of dollars for the care, but Bayfront's trauma unit generates reimbursements of just 32 cents for every dollar charged. The reason: low payments by insurers and the high volume of uninsured patients, including a growing population of illegal immigrants. In 2000, the hospital wrote off $13.8-million for patients not covered by government programs. Neither Florida nor Pinellas County provides any funds to cover the difference.

    Dr. Steven Epstein, who has been with Bayfront's trauma unit since it was started 15 years ago, said he gets frustrated by low reimbursements for the care he gives during frenzied 24-hour shifts.

    "I can always get another job," he said. "But if the system goes down, everyone will suffer."

    To measure Bayfront trauma center's balancing act of providing care and staying solvent, the St. Petersburg Times tracked Epstein and his colleagues' care for several patients over a two-day period last summer, then followed the months of paper trail to see what bills were actually paid. Some highlights:

    Of four trauma patients transported by Bayflite, only one bill has been paid and that one only partly. Charges for the four patients totaled $21,563; only $4,600 has been received as reimbursement.

    Medicaid and Medicare, major sources of payment in the Tampa Bay area, often pay less than one-tenth of a hospital's charges. Unless the patient has supplemental insurance, the hospital has no choice but to write off the rest of the charges.

    Uninsured patients make up about one-third of Bayfront's trauma caseload; the hospital is seldom able to collect a penny on those bills.

    For the seven patients whose cases were tracked, the hospital bills totaled more than $314,000. Reimbursements totaled about $41,000. All but one had some form of insurance.

    Consider Zulu, the 80-year-old accident victim from Hernando County. Epstein, the trauma surgeon on call, saw her within minutes of Bayflite landing on the hospital's roof. She was given a CT scan and within a half-hour diagnosed as having a fractured left hip bone and broken wrist.

    Five days later, Zulu was discharged to a nursing home with a pin in her hip and a splint on her wrist. The total bill for her hospital care was $25,229.

    Her car insurance paid $4,129 and Medicare paid Bayfront an additional $2,407, leaving the hospital with a writeoff of nearly $19,000. Bayflite billed $6,950 for its services; no payment has been received.

    While a nurse and a paramedic were putting a weight on Zulu's leg to alleviate pressure on her broken pelvis, another Bayflite crew delivered the second trauma patient of that summer morning.

    Yankee was a nursing home patient in her 90s who had fallen and was flown to Bayfront from north Pinellas County. Barely coherent, her tiny frame topped with a swirl of white hair, Yankee was immediately given the standard trauma care: five X-rays, a CT scan and comprehensive blood tests.

    A transparent mask covered her face, pumping oxygen into her frail body. X-rays showed her leg had been fractured in the fall, but that wasn't Yankee's biggest problem. Blood tests showed that her oxygen and potassium levels were critically low. The lab was called, blood was warmed and transfusions begun.

    As she lay on the bed, blood, fluids and oxygen being forced into her body, a nursing home staffer arrived carrying Yankee's living will. There would be no extreme measures taken.

    Yankee died at Bayfront seven days after her fall. Her estate was billed $36,917 for her care, which included five days in the Intensive Care Unit. Medicare paid $2,939. Bayfront took the remaining $33,978 as a writeoff. Bayflite, which billed $5,627, received partial payment from Medicare. It is billing the patient's supplemental insurance for the remaining $1,000.

    'I got thrown in Pillsbury's jail'

    With two Bayflite helicopters stuck on the roof due to heavy fog, ambulances delivered trauma patients to Bayfront. Just after 1 p.m., the Largo Fire Department arrived with a feisty patient who tried to rip off her oxygen mask and climb off the stretcher.

    The ambulance paramedics told Epstein that Alpha, a woman in her 40s, had collapsed in a convenience store. She was unresponsive to emergency workers, who found a sizable bump on the back of her head. "We don't know what came first, the bump or the fall," a paramedic told Epstein. "We got multiple stories."

    A nurse and hospital paramedic removed Alpha's rings, bracelets and earrings while another nurse slid an IV needle into her arm. When the patient began yanking at the needle, a male nurse slipped to her bedside and firmly held her hands across her chest.

    "Let me hold your hands here, love," he said in a soothing voice.

    Two ER staffers inventoried the contents of Alpha's black purse, counting out cash, making a copy of her driver's license, checking pill bottles, then putting everything into a clear plastic bag.

    The nurse in charge entered the room and introduced herself to Alpha, who was becoming more agitated and more vocal.

    What year is it? the nurse asked. "1979," Alpha replied.

    What happened this morning? "I got thrown in Pillsbury's jail," the patient said with conviction. The nurse pushed Alpha's stretcher down the hall for a CT scan.

    Alpha was diagnosed with a concussion and spent eight days at Bayfront, running up a bill of $18,926. Medicare paid $6,673; the hospital took the remaining $12,253 as a writeoff.

    Epstein took advantage of the lull in emergencies to visit patients upstairs in the Intensive Care Unit. Epstein and other trauma surgeons follow patients from the time they enter the ER, through their stay at Bayfront and in followup visits at their private practices. "That's my enjoyment," said Epstein, as he plucked up a chart in the ICU.

    A near drowning victim who had been comatose for a week was stable but not improving. Epstein doubted he would wake up. A paraplegic hit by a car while crossing a busy Pinellas highway at night was in his eighth day in the ICU. He had received two tracheotomies and 20 units of blood and was taking an antibiotic that cost $75 a day.

    "I saved this guy's life on the first night," Epstein said, adding that he figures he'll get paid less than $1,000 by Medicaid on his $5,000 bill for the emergency operation. "Unfortunately, the end is nowhere in sight for this guy."

    Epstein, 54, is a graduate of New York Medical College and spent half of his general surgery residency and trauma fellowship in a hospital in Harlem. He said all five trauma surgeons at Bayfront were trained in busy, big-city emergency rooms. He relishes a fast-paced trauma unit, believing it attracts the best medical talent and helps them keep their edge.

    "You need volume to do this," he said. "You put five traumas in here and it's amazing how well the staff works. They really rise to the occasion."

    'Nobody claims them. From them we get nothing.'

    Over time, Epstein has seen the type of traumas he treats reflect changes in the community outside Bayfront's door.

    After the police made major drug arrests a few years ago, Epstein saw a big decline in gunshot wounds. Now it's predominantly car accidents (65 percent) and falls (30 percent). Forty percent of all injuries he sees are alcohol-related.

    Over the past two years, Epstein has noticed another change in the patient population that has the potential to have a big impact on the unit's bottom line: an increasing number of illegal migrants with traumatic injuries.

    "As the profile of Florida starts to change, I'd not be surprised to see more unfunded migrants," he said. "And if they're working under the table, nobody claims them, not even workers' comp. From them we get zero."

    While Bayfront's charges are irrelevant to most payers, hospital officials say the prices they charge for supplies are based on cost plus a 5 percent markup. The daily rate of $753 per day for a semiprivate room is an aggregate of food, labor and overhead. Charges for procedures, including labor and supplies, are priced competitively with other hospitals in the marketplace.

    Bob Thornton, Bayfront's chief financial officer, said the revenue stream from trauma patients covers the cost of care, but not the overhead of maintaining a trauma department. Bayflite, the helicopter service that is a subsidiary of Bayfront, is breaking even, he said.

    There is some economic spinoff from the trauma unit. When these severely injured patients are admitted to Bayfront, as they are about 75 percent of the time, they may generate additional revenue as inpatients and later through outpatient rehab services.

    The Bayfront system as a whole made a financial turnaround in 2000, posting a surplus of $7.3-million on total revenues of $194-million. Last year, the surplus was $8.7-million. Maternity, cardiac catheterizations and elective surgery are among the moneymaking services that offset the expense of trauma care and keep Bayfront in the black.

    Though Thornton is in charge of hospital finances, he acknowledges there are noneconomic reasons for Bayfront to maintain its trauma services.

    "It enhances the quality of our staff and our image as a center of high-tech, high quality care," he said. "Plus it's our mission to improve the health of the community. And no other hospital in Pinellas County offers these services."

    Shooting hoops, then three hours in surgery

    As Epstein returned to the trauma unit, an ambulance pulled up and wheeled in Jason Biggs. One minute the 16-year-old was shooting hoops with friends in his neighborhood. The next thing the teenager knew, he was lying in Bayfront's emergency room, broken bones in his face, blood in his mouth and a half-dozen strangers hovering around his head.

    The emergency team didn't know it, but Biggs had been the victim of a hit and run.

    Epstein sized up the teen's injuries, then two technicians took chest and pelvis X-rays with a portable machine pulled bedside. A lab tech drew blood from his arm to test for alcohol and drugs, both of which came back negative.

    Biggs, who was vomiting and complaining of pain in his jaw and blurred vision, was moved down the hall for a CT scan of his brain and face. His mother, crying and clutching her purse, trotted to keep up with her son's stretcher.

    Biggs was billed $28,505 by Bayfront and $22,000 by the specialist who rebuilt his face during a three-hour surgery. His mother, who quit her waitressing job to care for her son for the three weeks his jaw was wired, has received additional bills from radiology, the trauma surgeon and ambulance service. Her son is eligible for Medicaid, which will reimburse the hospital $972 per day or $4,860. The remainder will be written off.

    By 11 p.m., the ER was quiet and Epstein slipped home to his condo in Feather Sound. At 1 a.m. his beeper went off. Bayflite was flying from north Pinellas with Bravo, a pedestrian in his late 30s who had been hit by a car.

    He had two broken legs but more critical was what appeared on the CT scan: a blood clot on his brain.

    By 2:30 a.m., a neurosurgeon was operating on Bravo, who had given Bayfront staffers three different names. By 4 a.m., the patient was stabilized and Epstein was able to return home for a quick rest. The trauma surgeon was not optimistic about Bravo's chances. "He's not going to have a full recovery," Epstein said.

    The patient remained in a coma for 18 days until his family decided to withdraw life support. His hospital bill was $170,868; Medicaid paid $17,000 and the remainder was written off. Details of his Bayflite account were not available.

    The following afternoon, under a clear sky, two Bayflite helicopters landed in quick succession on either end of Bayfront's rooftop. In one was Foxtrot, a woman in her late 50s from north Pinellas who had fallen down a flight of steps. In the second was Golf, a man in his late 20s from Manatee County who had slipped at a hotel poolside.

    As the two stretchers were rolled into one trauma room, Dr. Tom Wells, the trauma surgeon on call who relieved Epstein, sized up the situation. The woman had been combative on the flight; a breathing tube had been inserted in her throat en route; a deep gash on her head was spurting blood. The male patient was moaning about back pain but had no other apparent injuries.

    Wells ordered X-rays for the man, told the registered nurse at his side, "You know what to do," then began stitching up the woman's head. There were 16 staffers buzzing around the two trauma patients, but the high-ceilinged room was oddly quiet as they went about their work.

    A nurse cut off the woman's bloody shirt while the hospital chaplain dug through her purse, looking for personal information and prescription drugs. A respiratory therapist took the temporary breathing apparatus from the Bayflite nurse, then hooked the woman to a ventilator.

    Two techs took head, neck and spine X-rays of the male patient with a portable machine, then waited for their chance to do the same on the woman. An EKG technician rolled in a machine and prepared to put leads on the woman as a nurse wiped blood off her chest. Another nurse inserted a central IV line just under her collarbone. A housekeeper slipped into the room to pick up bloodied towels, clothes and a blood-stained backboard that had been tossed on the floor.

    Fifteen minutes after arriving at Bayfront, the woman, her eyes barely open and with blood on her pink-painted toenails, was rolled down the corridor for a CT scan. "Take somebody with you," the head nurse told the CT tech. "And if she starts deteriorating, call."

    After a three-day stay, during which she was treated for a concussion, fractured clavicle and sprained ankle, the woman was billed $20,956. Her insurance agreed to pay $973 per day, or $2,919. Bayflite's bill of $4,220 has not been paid.

    Though the man from Manatee County told emergency room staff he had only had three beers before his accident, when the blood alcohol test came back it told a different story.

    "You've had nine or 10 beers in the last two hours," said his nurse, a former medic in the Israeli army. "Don't lie to us because we'll find out anyway."

    The chaplain told the patient he had left a phone message for his father. The nurse prodded the man to raise his knees and move his legs. "Where's your pain?" he asked as the man moaned.

    Diagnosed with a spinal cord concussion, the patient was given high doses of steroids and admitted for observation. Four days later, after the swelling subsided, he was discharged. By October he had filed a lawsuit against the hotel where the accident occurred.

    Bayfront's bill to the patient, who had no insurance, was $12,755. No payment has been received. The hospital hopes it can negotiate a payment with the patient's lawyer if there is any financial settlement with the hotel. Bayflite has received nothing on its bill of $4,766.

    'Society should want to make the investment'

    Everyone agrees that trauma centers are essential. But there's little effort to help cover the costs.

    Dr. Paul Taheri runs the trauma burn center at the University of Michigan Health System. Florida officials hired him to study the cost of providing trauma care in the state.

    Though Florida budgeted $15-million for trauma centers this year -- $500,000 earmarked for Bayfront -- none of the money was allocated because of the state's fiscal crisis.

    Several counties in the state subsidize their trauma units through sales or property taxes. Palm Beach County may be the most generous: Its two trauma centers and helicopter service received about $24-million last year from a special property tax. That worked out to about $22 per resident.

    Taheri said trauma doesn't have to be financially devastating for a hospital, but it can become a crisis if a trauma patient lingers for weeks or months. Even in the best scenario, however, a hospital's trauma department tends to be a shoestring operation, he said.

    "When a hospital has a surplus, it's going to reinvest in those departments like cardiodisease that have political capital and brand awareness," he said. "Trauma gets (cheated) in the end."

    The result, Taheri said, is that almost every week some trauma center in the United States threatens to close. There's a public outcry followed by a trickle of money that keeps the center alive until the next crisis.

    "The perception of trauma is like a secondary citizen, treating less desirables," Taheri said. "But the bulk of trauma patients are insured, employed working people. Society should want to make the investment because it's going to be one of us."

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