Research undertaken thus far indicates that trauma systems and select elements of systems are cost-effective for some groups. Yet far more research must be conducted on the cost-effectiveness of trauma care systems and system characteristics such as organization, configuration, and elements of care (Spaite et al., 1993; NIH, 1994). For example, research is critically needed to determine which elements of prehospital, acute, and rehabilitative care are the most cost-effective in reducing patient morbidity and mortality. Better methods are needed for arriving at true costs, rather than charges, and better methods are needed for capturing outcomes in terms of later productivity (NIH, 1994). There may be some populations, such as the elderly, for whom cost-effectiveness is difficult to establish. For such vulnerable populations, continued public support is likely to be necessary. The key is to devise adequate sources of financing for trauma systems and patient care.

FINANCING OF TRAUMA SYSTEMS

This section covers public and private financing of trauma systems. The first part discusses federal and state funding for system infrastructure, and later sections cover the financing of patient care and the advent of managed care. The availability of financing is a prime determinant of trauma systems development, proliferation, and endurance.

History of Federal and State Support for Trauma Systems

For the past three decades, federal and state governments have assumed much of the responsibility for trauma systems development. A major impetus came from the publication of Accidental Death and Disability: The Neglected Disease of Modern Society (NRC, 1966). Another major factor was awareness of the military's prowess at triage, transport, and field hospital care in Korea and Vietnam. Federal and state support, however, has not been consistent. The record of support has been erratic, shifting over time, depending on the vicissitudes of legislative and public support, competing budget priorities, and health care costs. The history of federal and state support is captured in more detail elsewhere (Boyd, 1983; IOM, 1993; Mustalish and Post, 1994). Nevertheless, a few general observations and legal milestones are worth chronicling (Table 6.1).

Since the passage of the 1966 Highway Safety Act, the federal role traditionally has been to provide leadership, technical assistance, and systemwide models and guidelines for states and regions; to establish curricula for EMS providers; and to offer financial support to states for planning and infrastructure. States have assumed responsibility for dispersing federal and state funds; developing, coordinating, and administering systems; designating trauma centers; and ensuring quality. Yet both federal and state activities historically have concen-



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