Mississippi’s statewide trauma care system is designed to create a network of hospitals capable of treating high-need emergency care patients. But two Jackson hospitals instead pay millions of dollars every year for choosing not to treat serious trauma patients.

The Mississippi State Department of Health annually assess hospitals’ trauma care capacity, ranking hospitals on 1 to 4 scale based on how well-equipped facilities are to handle serious trauma patients. 

A Level 1 designation applies, according to health department information, to “comprehensive facilities, capable of treating the entire range of traumatic injuries,” while Level 2 hospitals “generally have the same clinical services as Level 1 Trauma Centers but lack the surgical residency and research capabilities.” 

Hospitals designated Level 3 “have the capabilities to resuscitate and treat the majority of trauma injuries but lack dedicated neurosurgical services.” Level 4 hospitals, which make up the majority of hospitals in Mississippi, can stabilize and transfer trauma patients to higher level trauma centers.

Although the state of Mississippi says that Jackson-based Baptist Medical Center and St. Dominic Hospital can provide care at a Level 2, each pays $1.5 million annually in what the state calls a non-participation fee for opting out of accepting Level 2 trauma patients. Both hospitals choose to operate as Level 4 facilities instead. Together, the hospitals paid the state more than $26 million since 2008 to avoid treating certain trauma patients as Level 2 facilities, according to state health department records Mississippi Today obtained.  

These payments plus traffic fines from certain recreational vehicles and vanity tag fees  fund about a $20 million yearly payout. That sum is split between trauma hospitals with a small portion going to ambulance services across the state to subsidize high-cost, uncompensated trauma care at hospitals that participate in the program.

Unintentional injury is the largest cause of death for Mississippians aged 1 to 44. Since the trauma system’s inception, overall trauma injuries have increased — mostly vehicle crashes — but trauma deaths have decreased overall, which the state health department credits to the trauma system’s functionality.  

Mississippi was the first state to mandate participation in a statewide trauma care system — a network of regional hospitals each designated to give a specific level of care, from basic stabilization all the way up to complex surgery — to triage high-need emergency patients across the state. 

The system aims to get patients to the appropriate hospital for their injuries the first time, rather than using overburdened emergency medical resources to get them there later as a transfer. UMMC is the only Level 1 hospital in the state, supported by three Level 2 hospitals triangulated around Jackson to bolster regional care in Gulfport, Hattiesburg and Tupelo. 

Baptist and St. Dominic give different reasons for their decisions not to accept more serious trauma patients. 

“To avoid duplication of trauma services, St. Dominic Hospital defers to (University of Mississippi Medical Center), which is already well equipped to handle these cases,” Andy North, director of marketing and communications for the hospital, said in an email, referring to higher level trauma patients. “It is more cost effective and provides better patient outcomes for St. Dominic’s to support the state’s trauma fund through payment of the fee.” 

A volunteer and a first responder jog toward other ambulances gathering outside the Winston Medical Center in Louisville, Miss., April 28, 2014 after a tornado hit the small hospital, a nursing home next door and numerous houses. Credit: Rogelio V. Solis, AP

St. Dominic, which houses 33 emergency slots in a 571-bed capacity hospital, added that improving efficiency and reducing congestion is a priority and part of the impetus for recent upgrades. They are currently undergoing a 25,000-square-foot renovation to add 20 rooms to their emergency department.

Bobby Ware, chief executive officer and administrator of Jackson’s Baptist Medical Center, said the hospital disagrees with their designated Level 2 status. 

“We participate at a level that we feel we have the availability of specialists to support that trauma level. And so that’s why we choose a specific level in the trauma system. It does not preclude us from taking trauma patients, we average over 100 trauma patients a year that we provide care for,” she said. 

Despite operating as a Level 4, it’s possible that both Baptist and St. Dominic might still get some trauma patients who walk through the door or that they accept from another hospital, but the trauma system that coordinates most emergency care across the state through on-scene ambulance crews usually sends high-need patients to facilities operated Level 2 or Level 1.

But because trauma patients can only be transferred to hospitals with higher trauma care designations, St. Dominic and Baptist can send trauma patients to other hospitals, but do not have to receive them. 

Of the 85 hospitals participating in the state trauma care system, there is one in-state hospital and three out-of-state hospitals operating as a Level 1. Three hospitals are operating as a Level 2. There are 17 hospitals operating as a Level 3 and 61 hospitals that are Level 4.

The decision by the Jackson hospitals to opt out of accepting the most critical trauma patients came into focus recently when emergency medical services personnel complained that the practice leads to prolonged periods before patients are admitted to emergency departments. This is known as wall time in the emergency medical services field. Paramedic complaints about wall time recently escalated to the point that the health department’s trauma council asked the Attorney General’s office to intervene.

According to a memo, Mississippi code is so clear that patient liability falls to hospitals, the AG did not opine and instead pointed to statute reiterating wall time burden falls on hospitals, not paramedics. But it’s still ambulance crews who pay the price. 

AG opinion on wall time (Text)

According to health department data, Baptist and St. Dominic saw the fewest patient transfers last year — around 1,300 each — among high-volume hospitals. But the two also had the highest average wall times. By comparison, UMMC’s wall time is comparable, at around an hour, but their 47-bed emergency department sees more than double the number of patient transfers as Baptist and St. Dominic combined — 3,500 last year. 

Ware, Baptist’s CEO, notes that wall time is not a standard metric. States, medics and hospitals across the nation have been grappling with wall time, which sees a median of 48 minutes for transfers across the state, but have not figured out a consistent measure to count the amount of time medics are stuck on the wall. The health department used standardized time stamps from ambulances — when they arrive at the hospital and when they go back in service — as the best estimate of the time it takes to offload a patient and move on to the next emergency call.

“Wall time is not really a standardized measure, so it’s hard for me to comment on that. It’s not something that we track. We don’t monitor it. I have no basic calculation that says this is what makes up wall time and how you calculate it,” Ware said. 

“We really base our times on the (U.S. Centers for Medicare and Medicaid) standard reporting criteria,” she added. “From everything we are seeing from a (CMS) statistic standpoint it looks like we are performing very well. There’s always room for improvement — we always try to find ways that we can be more efficient.”

Notably, the federal government does not track wall time either. When asked what the health care system could do to try to alleviate wall time and keep emergency medical services from being pulled out of their home counties for long amounts of time when stuck in Jackson, Ware said: “I understand their (paramedics) frustration. I don’t know if there are options for them to go to a hospital that’s closer to them that doesn’t take them away from their home base as long, so that might be a possibility.”

North, the St. Dominic spokesman, said local emergency medical services have worked with the hospital on temporary initiatives when the hospital is at capacity by routing ambulances carrying patients with less acute injuries to other areas of the hospital to reduce congestion. 

Jim Craig, who directs health protection for the state and coordinates emergency preparedness, including the trauma fund, said choosing to participate at a lower level boils down to an economic decision for hospitals, but added that the penalty fee helps the system overall.

“Three million dollars is a good amount of money. It helps support the trauma care system, so it is part of our funding formula right now to have that revenue to be able to take care of trauma patients in Mississippi,” he told WLBT as a part of an ongoing emergency medical care series. “It would need to come from there or from another source.”

“What the system contemplates is that if you have the resources to participate as … a Level 1, 2, or 3 you either have to participate or you have to pay a non-participation fee so that those that are taking your burden — your community obligation to take care of trauma patients — they’re taking that burden for you, (they) can then use that funding,” he said.

“We keep it very simple. Level 2 hospitals are those that in addition to Level 3 requirements have neurosurgical coverage. If you are a hospital that has sufficient physicians to provide 24/7 neurosurgical coverage, advertise 24/7 neurosurgical coverage to the public or have a call schedule that shows that you are accomplishing 24/7 neurosurgical coverage then you’ll be assessed to be a Level 2,” he added.

“It’s that easy … it’s really a business decision for the facility and we respect that.”

C.J. LeMaster, WLBT-TV’s chief investigative reporter, contributed to this story

Editor’s note: Due to an editing error, in a quote attributed to Andy North, marketing and communications director for St. Dominic Hospital, he referred to the hospital as St. Dominic’s not St. Dominic. The original story also referred to St. Dominic Hospital’s sending patients with less-acute injuries to different hospitals when at capacity, but has been corrected to say different areas of the hospital.

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Erica Hensley, a native of Atlanta, has been working as an investigative reporter focusing on public health for Mississippi Today since May 2018. She is a Knight Foundation fellow for our newsroom’s collaboration with local TV station WLBT and curates The Inform[H]er, our monthly women and girls’ newsletter. She is the 2019 recipient of the Doris O'Donnell Innovations in Investigative Journalism Fellowship. Erica received a bachelor’s in print journalism and political science from the University of Southern California Annenberg School for Communication and Journalism and a master’s in health and medical journalism from the University of Georgia Grady College for Journalism and Mass Communication.