Health care is one of the largest sources of debt in the United States with over 140 billion dollars due in medical bills.1 Approaches to address this issue thus far have focused on increasing price transparency. For example, Centers for Medicare and Medicaid Services began requiring hospitals to publish comprehensive data on the cost of services in 2021. The recently implemented No Surprises Act uses transparency to protect patients from unpredictable out-of-network costs. While these policies represent critical advances in the fight against unaffordable care, they assume that consumers (ie, patients) have the ability to choose where, when, and for what they receive care. Beyond the fact that price transparency measures have been largely ineffective, trauma patients specifically are unlikely to benefit given the urgency and perceived lack of choice unique to these clinical scenarios. Injuries account for 35 million emergency department visits annually. Out-of-pocket costs for these patients average over $4000 per person, and are rising particularly for those with high-deductible plans and private insurance.2–4 Approximately 70%–80% of patients without insurance are at risk for financial toxicity after trauma.2 Policies focused on transparency alone do not comprehensively account for distinct sources of potential out-of-pocket costs these patients encounter.

Financial toxicity, defined as the negative consequences of unaffordable health care costs, can be evaluated by stratifying sources of cost into direct medical, direct nonmedical, and indirect costs.5 Financial toxicity also includes the psychological distress or subjective burden that accompanies cost strain, and can be measured in the form of patient-reported outcomes and changes in social determinants of health. When considered in the context after trauma, hospital bills are the biggest contributor to direct medical costs, incremental expenses for transportation and food contribute to direct nonmedical costs, and lost wages and impaired productivity are indirect costs.2,5,6 In this perspective, we identify solutions that account for these distinct, but common, sources of financial toxicity accounting for the specific needs of trauma patients (Table 1).

TABLE 1 - Framework to Address Sources of Financial Toxicity in Trauma Patients Source of cost Direct medical costs: hospital bills Direct nonmedical costs: incremental costs of transportation and food Indirect costs:
lost wages and productivity Potential solutions Removal of cost-sharing for trauma patients through incentive programs and targeted risk reduction Inclusion of emergency transportation services in balanced billing reforms
Subsidizing the cost and accessibility of proper nutrition Integration of job training programs with health systems through community-based organizations Short-term benefits Decreases largest source of medical debt for trauma patients Addresses concerns of patients with high-deductible private insurance plans
Addresses growing rates of food insecurity and downstream complications Facilitates debt repayment by restoring income and employment Long-term benefits Cost-savings to insurance companies and health systems
Incentivized structure to decrease the burden of chronic, noncommunicable diseases Fosters uniformity in balanced billing reforms
May incrementally increase savings to facilitate earlier debt repayment Restores identity and agency to patients
May decrease financial burden of long-term disability and unemployment programs
HOSPITAL BILLS

Hospital bills are an example of direct medical costs, and a common source of financial toxicity for patients requiring procedures. Removing cost-sharing has been suggested as a potential solution. While this is inherently logical, buy in is required from insurers and employers shouldering this cost. One way to entice support is to link removal of cost-sharing for trauma patients to enrollment in programs already promoted by payors to reduce the burden of chronic, noncommunicable diseases. The Michigan Surgical Home and Optimization Program at Michigan Medicine and the Preoperative Anesthesia and Surgical Screening program at Duke Health are examples where surgical patients are linked to programs addressing chronic health conditions.7 The increased likelihood of success is founded on the principle that major life events are unique points of opportunity that promote compliance.7 Using trauma-specific encounters in a similar manner that includes an incentivized link to cost-sharing is an approach that can add value to health systems.

For example, ∼25% to 40% of patients presenting with emergencies smoke, compared with 10% to 15% of the general population. Few insurance-based incentive programs exist to reward smoking cessation. Currently, insurers use punitive measures, like higher insurance premiums, to discourage smoking. Using smoking cessation as a stipulation to decrease cost-sharing when patients present for emergencies may provide immediate benefit to patients and long-term gains for patients and payors. Smoking abstinence is measurable, and patients’ and payors’ motivations are aligned. Other measurable metrics for chronic disease management include glycemic control and weight management. These risk factors indisputably impact morbidity and mortality, but are challenging for patients to control in the absence of immediate benefit.

Leveraging the point-of emergency care receipt as a time to incentivize chronic disease management can offset immediate out-of-pocket costs to patients from the emergency hospitalization, and save money for insurers long term. Such interventions must be carried out while accounting for known challenges regarding compliance and follow-up after trauma. Follow-up can be resource intensive, and physically demanding for patients after trauma, particularly for those experiencing disability. In addition, few institutions are able to offer long-term follow-up through structured clinics focused on survivorship.8 To address these challenges, researchers must work towards designing point-of-care risk stratification systems to identify patients at risk for financial toxicity before discharge. Identifying high-risk patients proactively enables more efficient inpatient resource utilization, including targeted consultation with social workers and case managers, closer outpatient follow-up for high-risk patients, and integration with community-based organizations specialized in addressing housing instability, food insecurity, and employment considerations common to those struggling with financial toxicity. As the Centers for Medicare and Medicaid Services and the Joint Commission have already rolled out requirements for hospitals to screen for social determinants of health, risk stratification systems can build on these screening mandates. Using data-driven approaches, it is possible to direct social worker and case worker expertise to high-risk cases instead of engaging in uniform consultation practices for high and low-risk patients alike. In addition, collaborating with community-based organizations can connect patients with resources closer to their communities and effectively address patients’ needs without straining hospital resources.

INCREMENTAL COSTS FROM TRANSPORTATION AND FOOD

Out-of-pocket costs from ambulance services are an example of direct nonmedical costs. These costs can be exceptionally high and unpredictable for trauma patients. While patients with Medicaid and Medicare have coverage for ambulance services, many with private insurance lack reliable in-network coverage. Consequently, over 50% of emergency ambulance rides include out-of-network charges.9 Integrating coverage of these services within surprise billing reforms for patients presenting or being transferred emergently, as is being done in Ohio, could reduce financial toxicity.

Incremental costs from food are another source of financial toxicity. Trauma patients are 1.8 times more likely to experience food insecurity after discharge compared with an uninjured cohort.10 Food insecurity has important clinical implications. Poor nutrition increases postoperative complications including length of stay, readmission, and mortality; this increases out-of-pocket costs. The extent of this relationship has led to the implementation of quality improvement programs for inpatient nutrition. Subsidizing the cost of proper nutrition for trauma patients in a time-specific manner after discharge may mitigate spillover effects associated with poor nutrition and clinical complications. Feasible first steps include routine screening for financial toxicity and food insecurity in emergency settings and training social workers to apply for Supplemental Nutrition Assistance Program benefits during hospitalization. Connecting patients to community-based resources including meal delivery services and prescription food pantries has also proven beneficial.

LOST WAGES AND PRODUCTIVITY

Lost wages and productivity, or indirect costs, exacerbate acute and chronic financial toxicity. Medical debts unpaid within 1 year negatively affect credit scores; only one third of patients anticipate they will be able to pay debt off within this period. This may be because over 40% of individuals who were employed before hospitalization for trauma were unemployed 3 months after discharge. Early debt recovery interventions are critical to mitigate spillover effects and prevent long-term financial toxicity.

Integrating job training programs with care of trauma patients may help patients afford hospital bills while also restoring a sense of identity and agency. A program that could broaden its application into health care is the Trade Adjustment Assistance (TAA) program. Implemented in 2015 to support unemployed individuals, this program functions at the community level, provides individualized training, and supplies funding for housing. An analogous design could apply to patients in trauma rehabilitation programs. While this program has not been applied to health care, such a program could connect case managers with community-based networks to help patients rejoin the workforce.

In the midst of emerging policies designed to improve transparency to address the growing problem of medical debt, we must consider whether these policies go far enough to ensure that all patients are able to receive trauma care without experiencing financial toxicity. Understanding which patient populations fall into the watershed zone of these initiatives is critical. While transparency data is an important first step, we must concomitantly address the needs of populations unlikely to benefit from simply increasing access to data.

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