What’s the difference between an emergency room and a low-level trauma unit?

A $12,000 cover charge, for starters.

That’s how much MountainView Hospital CEO Jeremy Bradshaw says the hospital intends to charge should it win local approval and state designation as a Level III trauma unit.

At Sunrise Hospital in Las Vegas, a visit to the Level II trauma unit triggers an activation fee of $53,153, according to the hospital’s website.

University Medical Center, the state’s only Level I unit, charges between $10,750 and $22,953, depending on the severity of the trauma.

Once an expensive, labor-intensive burden for hospitals, thanks to exorbitant and unregulated “activation fees”, trauma centers are turning into profit centers.

MountainView is one of five Southern Nevada hospitals seeking a trauma unit designation from the state. The others are Centennial Hills Hospital and Spring Valley Hospital, owned by health care giant United Health Services; St. Rose San Martin Hospital, owned by Dignity Health; and Mike O’Callaghan Federal Hospital at Nellis Air Force Base operated by the Veterans Administration.

An effort by three hospitals to do the same in 2016 met with opposition from the Southern Nevada Board of Health, which is the first hurdle to clear for applicants.

A third of all Nevada patients who meet the criteria for trauma were seen in non-trauma hospitals in 2017, according to the Southern Nevada Health District’s annual trauma report.

“The patients are already coming through our door,” says Bradshaw — 600 last year and 500 the year before, who presented with trauma-level injuries at MountainView’s ER.

At $12,000 a pop, that’s $13.2 million missed in trauma activation fees alone for just two years.

MountainView’s parent company, Hospital Corporation of America (HCA), owns Southern Nevada’s only Level II trauma unit at Sunrise Hospital. HCA has been widely criticized nationally for its activation fees, meant to cover the costs of being at the ready for disaster. HCA has fought back in the arena of public perception by treating uninsured trauma patients for free.

St. Rose Siena’s trauma activation fee at its Level III center is $12,000 and would be similar at San Martin, should it receive Level III designation, says Dignity Health spokesman Gordon Absher.

A 2014 story from the Tampa Bay Times found one in five trauma centers in the U.S. charge upwards of $15,000 for trauma activation fees.

“Prices charged for trauma activation should be structured in a way that avoids price gouging patients and health plans. For example: Medicare and Medicaid prohibit these outrageous activation fees,” says Bethany Khan, spokeswoman for the Culinary Union, which along with its health fund, “supports a model that increases capacity if a shortage should occur, but only after a comprehensive needs-assessment, which has not been done in the past.”

Last year, MountainView polled 400 Clark County voters, still shell-shocked from the Las Vegas shooting massacre a year earlier, about the need for more trauma centers.

“What’s their perception of MountainView and others seeking trauma status? We also wanted to try to validate the need and we wanted to see if the community saw it that way, as well,” says Bradshaw, who reports 93 percent of those asked supported MountainView’s application for a trauma unit.

But do voters possess the expertise to gauge the necessity for additional trauma centers?

“I’m not sure about the expertise,” says Bradshaw. “That’s where we come in to pull numbers and look at data.”

MoutainView spokeswoman Jennifer McDonnell added that community support is among the components reviewed in the needs assessment process.

“Being treated in a hospital with a trauma center, any level, reduces patient deaths by 25 percent,” Bradshaw said.

But a New England Journal of Medicine found no difference in death rates between patients treated in emergency rooms and hospitals with Level III trauma units.

Bradshaw cited a 2014 study by the American College of Emergency Physicians that ranks Nevada last when it comes to emergency response.

“The state has a severe shortage of specialists, ranking last or next to last for the number of neurosurgeons (1.1 per 100,000 people); orthopedists and hand surgeons (6.1 per 100,000); and ear, nose, and throat specialists (2.0 per 100,000).”

But wouldn’t more trauma centers, which require having certain specialists on-call, strain medical professionals even more?

“No,” says Bradshaw. “We already contract with those specialists. We’re not taking them from anywhere.”

“Trauma centers in Southern Nevada are seeing well-above the American College of Surgeons minimum threshold of patient volume,” Bradshaw said, making the case for planning now for additional volume in the years ahead.

The state recorded 9,768 trauma patients treated at 38 hospitals throughout Nevada in 2017.

UMC admitted about a third, or 3,222 patients, to its trauma unit. Renown Hospital in Reno, which has a Level II trauma unit, treated 1,415 or 14 percent, and Sunrise Hospital in Las Vegas, a Level II trauma center, treated 1,127, or 11.5 percent.

Perhaps the greatest testament to the strength of Southern Nevada’s existing trauma system is how it functioned under the unimaginable stress of the nation’s largest mass shooting.

“Ian Weston, executive director of the American Trauma Society, said the trauma system worked well in Las Vegas, which is a credit to ambulances and other first responders and their ability to triage patients to hospitals across the city,” reported Kaiser News Service, just days after the October 2017 massacre.

University Medical Center, the valley’s only Level I trauma unit, treated 104 shooting victims, while Sunrise Hospital’s Level II center, received 180 of the wounded.

“In theory, the more centers you have the more people you have to deal with injuries. However, no trauma system is able to handle a tragedy of this magnitude,” Bill Bullard of the hospital consulting firm The Abaris Group, told Kaiser News Service.

Do No Harm

Studies indicate outcomes are improved at trauma centers that see more patients and critics contend additional centers will siphon patients from existing units, possibly to the detriment of patients.

“If you can bring all the patients to one place, then those surgeons become really good at dealing with trauma, instead of spreading it out [around a number of facilities],” Bullard told Kaiser News.

“Smart and strategic growth in the Southern Nevada Trauma System should not, and must not, threaten the viability of the established trauma centers at Saint Rose, Sunrise, and UMC,” said Dr. John Fildes of UMC, speaking on behalf of established trauma centers. “An abrupt oversupply of new and inexperienced trauma centers is likely to cause duplication of services and may threaten the viability of ALL of the established trauma centers.”

“The problem arises when a lead agency passively allows health care organizations and hospital groups to establish new trauma centers in areas that yield an economic advantage, while ignoring areas of true need,” says the website for the American College of Surgeons (ACOS), the organization that sets criteria for assessing the need for additional trauma units. “Such uncontrolled growth of trauma centers—some of which may lack long-term commitment—has the potential to undermine the quality of trauma care within a region, creating areas of oversupply and adverse competition while ignoring underserved areas entirely.”

Among ACOS criterion for determining the need for additional trauma units:

Number of Level I and II centers per 1 million population. The rule of thumb is one Level I unit per one million people (Like Nevada, Washington State has just one Level I trauma unit at Harborview Hospital in Seattle.)

Percentage of population within 60 minutes of a Level I or Level II trauma unit.

EMS transport times. The median transport time in Clark County was 16.7 minutes, according to the Southern Nevada Health District’s Trauma System 2017 report.

Frequency and nature of inter-hospital transfers.

How do the Southern Nevada applicants stack up?

Bradshaw was unable to provide specific data, such as deficiencies in transport times, to back up the need for a trauma unit at MountainView, but pointed to the northwest valley’s growth and an aging population as factors in the hospital’s favor.

“As I said, the trauma patients are already coming through the door,” he said. “That’s the need.”

“Our application is supported by various data points, including population and population growth, median transport times to existing Trauma Centers, type and number of cases being handled by existing Trauma Centers, and other factors outlined by the SNHD, the American College of Surgeons, and other entities,” said Absher of Dignity Health, which owns St. Rose’s San Martin hospital.

UHS, which owns Centennial Hills and Spring Valley, did not respond to our requests for data and comment.

The applicants are scheduled to make their cases to the Southern Nevada Board of Health in mid-April.