Trauma Activation Fees Among For-profit and Nonprofit Trauma Centers: Hierarchical Spatial Clustering Analysis of Regional Market Competition, and Socioeconomic Characteristics of Neighboring Residents.

Abstract

Compare trauma activation fees (TAFs) between for-profit and nonprofit trauma centers within granular geographic clusters, accounting for regional market competition and socioeconomic factors. TAFs remain unregulated, and evidence suggests higher fees among for-profit centers. Evaluating whether these differences are justified requires examining trauma centers within geographic clusters alongside market and socioeconomic characteristics. This cross-sectional study analyzed TAFs at American College of Surgeons Committee-on-Trauma-verified level 1-3 trauma centers. Clusters were identified using hierarchical density-based spatial clustering. We obtained market competition and socioeconomic data of residents within one-hour driving distance. Mixed-effects regression assessed associations between TAFs and ownership status. Among 55 clusters of trauma centers (N=546), 26 included both for-profit and nonprofit centers. Within these, median (IQR) tier 1 TAFs were higher in for-profit centers ($29,000[20,000-38,000] vs. $11,000[7,800-15,000]; P<0.001). Residents near for-profit centers had greater socioeconomic disadvantage (Area-Deprivation-Index: 42.3[27.3] vs. 33.9[28.0], SMD=-0.30) and higher exposure to concentrated markets (Herfindahl-Hirschman Index >2500: 29.4% vs. 14.9%, SMD= 0.56). We found no significant association between TAFs and for-profit status alone (β=870[-2,830-4,580]; P=0.64), but a significant interaction between for-profit status and level 1/2 centers (β=15,300[15,100-15,600]; P<0.001). Among level 1/2 trauma centers, for-profit status was associated with higher TAFs after accounting for clustering, socioeconomic, and market factors. Negotiated payor fees or cash prices remain unclear, yet higher TAFs among for-profit centers warrant further investigation. Until the drivers of TAF differences are clarified, higher fees at for-profit centers and the need for regulation warrant further investigation.