Rogers Frederick B, Osler Turner, Shackford Steven R, Healey Mark A, Wells Susannah K
Department of Surgery, University of Vermont, 111 Colchester Avenue, FL 466, Burlington, VT 05401, USA.
J Trauma. 2003 Jan;54(1):9-14; discussion 14-5. doi: 10.1097/00005373-200301000-00002.
A Level I trauma center must provide immediate availability general (trauma) surgical expertise. In the current practice few patients require a general surgical procedure. The expertise of subspecialists may also be required and frequently these patients will require subspecialty operative care. We hypothesized that trauma surgeons would receive less reimbursement than their subspecialty colleagues despite a greater commitment of time and effort in taking care of the multiply-injured patient.
Three fellowship trained trauma surgeons were specifically hired to cover the trauma service for the year 2000. Professional billings, contribution to margin (reimbursement minus direct costs) of the trauma surgeons and subspecialists were obtained from the hospital financial information system. A surrogate for effort was assessed by the number of attending notes in the chart. A surrogate for complexity of care was assessed by the length of notes in the chart. Weekly time sheets assessed the percentage of time involved in the care of trauma patients.
There were 344 patients cared for exclusively on the trauma service for the year 2000. The billing generated per patient was $1005 for the trauma surgeon, $5904 for the subspecialists, and $27,554 for the hospital. Orthopedics and radiology generated more professional billing on the trauma patients than the trauma surgeons. The trauma surgeons spent 52% of their weekly clinical activity in the care of trauma patients, yet this activity accounted for only 16% of their billings (the rest came from general surgery and ICU care). The effort and complexity of care provided by the trauma surgeons was significantly greater than the subspecialists.
The Level I trauma service is a conduit for patients coming into the hospital that provides a significant remuneration to the subspecialty services. Trauma surgeons are able to bill much less than many of their subspecialty colleagues despite expending significantly greater amounts of time and effort in the care of these patients. Strategies for improved reimbursement for trauma surgeons must be devised or trauma surgery will suffer the same fate as other areas of surgery, losing our brightest and best to more financially sound subspecialty services such as radiology and orthopedics.
一级创伤中心必须随时提供普通（创伤）外科专业知识。在当前的实践中，很少有患者需要进行普通外科手术。可能还需要专科医生的专业知识，而且这些患者通常需要专科手术治疗。我们推测，尽管创伤外科医生在照顾多发伤患者时投入了更多的时间和精力，但他们获得的报销费用会比专科同事少。
专门聘请了三名接受过专科培训的创伤外科医生负责2000年的创伤服务。从医院财务信息系统获取创伤外科医生和专科医生的专业计费、对利润的贡献（报销费用减去直接成本）。通过病历中的主治医师记录数量来评估工作量的一个替代指标。通过病历记录的长度来评估护理复杂性的一个替代指标。每周的时间表评估用于创伤患者护理的时间百分比。
2000年，创伤服务部门共护理了344名患者。创伤外科医生为每位患者开具的账单为1005美元，专科医生为5904美元，医院为27554美元。骨科和放射科在创伤患者方面产生的专业计费比创伤外科医生更多。创伤外科医生将其每周临床活动的52%用于创伤患者的护理，但这项活动仅占他们账单的16%（其余来自普通外科和重症监护病房护理）。创伤外科医生提供的护理工作和复杂性明显高于专科医生。
一级创伤服务是患者进入医院的一个渠道，为专科服务带来了可观的报酬。尽管创伤外科医生在护理这些患者时花费了大量更多的时间和精力，但他们能够开具账单的金额却比许多专科同事少得多。必须制定提高创伤外科医生报销费用的策略，否则创伤外科将遭受与其他外科领域相同的命运，把最优秀的人才流失到经济上更稳定的专科服务领域，如放射科和骨科。
