Chapter 3 – Rehabilitation Costs and Payment Sources for
Traumatic Brain Injury

Abstract
This chapter provides data for traumatic brain injury rehabilitation patients on source of payment, length of stay, charges, and outcome measures such as changes in residence, marital status, and employment for four categories of injury cause: Motorcycle, Other Motor Vehicle, Violence (Self or Other) and Other Unintended. Special emphasis is placed on motorcycle injuries in this chapter, as TBI is of particular interest in motorcycle injuries.

Introduction
The TBIMS collects injury, charge, and outcome data from 17 medical centers. We analyzed These data to compare source of payment, charges, and outcome measures such as changes in residence, marital status, and employment for four categories of injury cause: Motorcycle, Other Motor Vehicle, Violence (Self or Other) and Other Unintended, which includes items not included in the former categories, such as falls, cuts, or poisoning.

Methods

Subjects
All subjects were participants in the National Institute on Disability and Rehabilitation Research (NIDRR) funded TBIMS program, a collaborative effort between 17 medical centers initiated in 1987. (Harrison-Felix, Newton, Hall, and Kreutzer, 1996); (Dahmer et al., 1993). Each center includes emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services. All patients were admitted to an acute care hospital within 24 hours of injury. Individuals with a history of prior brain injury, preexisting neurological condition, or substance abuse, are included in the TBIMS program. Informed consent was obtained from the patient or responsible family member.

Of the 3,762 TBI cases available in the TBI Model Systems National Database, 2,266 (60.2%) contained one-year post-injury follow-up data and were included in this analysis.

Procedure
Data collected at 17 model systems rehabilitation centers were analyzed. An individualized, comprehensive program of inpatient rehabilitation had been provided to each patient including nursing care; occupational therapy; physiatry; physical therapy; psychology and neuropsychology; therapeutic recreation; social services; and speech and language therapy. Each program’s admission and discharge criteria were based on Rehabilitation Accreditation Commission (CARF) standards. Rehabilitation charges were available. These did not include physician fees. Cases were analyzed by cause of injury, using codes developed by the Traumatic Brain Injury Model System. The Motorcycle category includes motorcycles and motorized vehicles including mopeds and motorized dirt bikes, and did not distinguish between crashes occurring on-road or off-road. Incidents involving 3-wheeled and 4-wheeled recreational vehicles, dune buggies and go-carts were included in the “other unintended” category, which also includes falls, cuts or poisoning.

Every effort was made to ensure the reliability of the model systems data. The data entry program for the model systems database restricts the ranges for data entered. In addition, error reports are generated by the National Data Center’s database software, highlighting suspect entries. The National Data Center also provides summaries of the data, which are reviewed by the project directors for their respective centers as well as for the database as a whole.

An annual follow-up interview was attempted with every individual entered in the database in prioritized order of (a) an in-person interview, (b) a telephone interview, or (c) a mailed questionnaire and/or interview with a “significant other” or family member.

Results
This section presents demographic data on people in rehabilitation due to motorcycle crashes. It describes the charges incurred in treating these patients, sources of payment for those charges, and the longer-term consequences of TBI for these patients. Except for tables probing details of TBI in motorcycle crashes, we generally present all-victim data with breakdowns comparing motorcyclists with other victims.

Length of Stay (LOS) and Charges
As Table 1 shows, length of stay (LOS) for TBI rehabilitation patients averaged 20.9 days in acute care and 29.4 days in inpatient rehabilitation. Per diem charges were much lower in the rehabilitation than the acute care stage (averaging $1,452 versus $5,360 in 2000 dollars). One caveat in reading Table 1 and subsequent tables is that the ratio of per diem charges was not computed by dividing the mean per diem charge for rehabilitation by the mean per diem charge for acute care; rather the ratio is calculated for each patient, then averaged. The two sets of numbers differ, and the ones reported are the conceptually appropriate numbers. These ratios and the similarly computed ratio of charges per stay provide a means for estimating rehabilitation charges (and possibly costs) when only more readily obtainable hospital charges and costs are available. As expected, the standard deviations in Table 1 were high due to wide case-to-case variation.

Table 1. Length of Stay (LOS) and Charges for Acute Care and Rehabilitation of TBI Rehabilitation Patients by Cause of Injury (Including Only Live Discharges from
Rehabilitation Hospitals)

 

Motorcycle (Including Dirt Bike)

Other Motor Vehicle

Violence (Self Or Other)

Other Unintended

All TBI

All Patients

227

2,071

636

828

3,762

LOS Acute Care (Mean, Standard Deviation)

21.93
(16.58)

22.26
(16.92)

19.53
(16.74)

18.29
(16.19)

20.90
(16.79)

LOS Rehab
(Mean, SD)

31.01
(25.27)

30.44
(25.57)

28.79
(24.48)

26.86
(22.89)

29.41
(24.84)

Charges Per Day - Acute Care (Mean, SD)

$5,561.07
(3,208.93)

$5,569.54
(2,887.81)

$4,744.34
(2,792.68)

$5,260.27
(3,368.78)

$5,360.41
(3,017.01)

Charges Per Day-Rehab (Mean, SD)

$1,394.57
(435.82)

$1,469.75
(489.54)

$1,449.26
(445.33)

$1,425.90
(437.99)

$1,452.09
(468.52)

Ratio of Charges Per Day Rehab/Charges Per Day Acute Care (Mean, SD)

.3091
(.1667)

.3322
(.2794)

.4064
(.3009)

.3612
(.2613)

.3499
(.2755)

Ratio of Charges Per Patient Rehab/ Charges Per Patient Acute Care
(Mean, SD)

.5259
(.5449)

.5521
(.5732)

.7537
(.7518)

.7092
(.8608)

.6195
(.6819)


Additional Information on Motorcycle Crash Rehabilitation Cases
Additional analysis was conducted on the demographic characteristics of motorcycle crash rehabilitation cases and costs of these cases. These data are included in appendix C.

Payer Distribution
For rehabilitation services, Table 2 shows the most commonly reported payer for people receiving traumatic brain injuries as a result of Other Motor Vehicle crashes was private insurance (60.9%), followed by public funding (Medicaid or Medicare) (25.2 %), no-fault automobile insurance (11.2%), free care (5.5%), and self-pay, workers’ compensation, other or unknown sources (8.3%). For the motorcycle crash category, payers were private insurance (62.3%), followed by Medicaid (23.2%). This distribution is quite similar to the distribution for TBI in motor vehicle crashes, but quite dissimilar from violence-related TBIs, which burden public pockets much more heavily. Importantly, the payer distributions for acute care and rehab were quite similar.

Table 2. Payer Distribution for Acute Care and Rehabilitation by Cause of Injury

Payer Distribution

Motorcycle (Including Dirt Bike)

Other Motor Vehicle

Violence (Self Or Other)

Other Unintended

All TBI

All Patients

227

2,071

636

828

3,762

Acute Care

Public Funding
(Medicare or Medicaid)

23.9%

24.4%

59.9%

38.5%

33.3%

Workers' Comp

0.4%

2.9%

1.9%

14.4%

5.3%

Private Insurance
(BC/BS, Private, HMO, PPO)

60.0%

57.5%

24.2%

37.3%

47.6%

No-Fault Auto

2.7%

13.6%

0.3%

1.6%

8.1%

Free Care (Charity)

4.4%

3.8%

4.4%

1.8%

3.5%

Self-Pay

3.6%

4.8%

5.5%

3.4%

4.6%

Other/Unknown

7.5%

6.6%

4.0%

4.6%

5.7%

TOTAL

102.50%

113.60%

100.20%

101.60%

108.10%

Rehabilitation

Public Funding
(Medicare or Medicaid)

25.8%

25.2%

62.5%

38.9%

34.6%

Workers' Comp

0.0%

3.0%

1.6%

15.0%

5.2%

Private Insurance
(BC/BS, Private, HMO, PPO)

65.9%

60.9%

24.1%

39.1%

50.4%

No-Fault Auto

3.6%

11.2%

0.3%

1.0%

6.7%

Free Care (Charity)

5.3%

5.5%

5.9%

2.9%

5.0%

Self-Pay

1.8%

3.1%

4.3%

2.2%

3.0%

Other/Unknown

1.3%

2.2%

1.6%

1.8%

1.9%

TOTAL

103.70%

111.10%

100.30%

100.90%

106.80%


Blood Alcohol Concentration (BAC)

Of the TBI cases in rehab, 81 percent were tested for BAC, including 85 percent of motorcyclists (Table 3). The proportion of injured motorcycle riders who tested positive for alcohol was 48.1 percent. By comparison, an analysis of 2001 FARS data found that 37 percent of motorcycle riders killed in crashes were positive for alcohol (Shankar, 2003a). The percentage of BAC-positive was virtually identical for TBI victims injured in motorcycle and other motor vehicle crashes. More violence victims and less victims of unintentional injury were BAC-positive. BAC-positive cases had alcohol in their bloodstreams, although not necessarily at concentrations above the legal limit for intoxication (.08 or .10 grams per deciliter).

Table 3. Percent of Cases Positive for BAC at Time of Injury by Cause of Injury

Cases with BAC information

Motorcycle (Including Dirt Bike)

Other Motor Vehicle

Violence (Self Or Other)

Other Unintended

All TBI

% Tested

85.0%

82.5%

86.5%

71.8%

81.0%

Of those tested, % cases BAC-positive

48.1%

48.2%

56.7%

39.1%

48.0%


Patient Residence at Three Points in Time
Data on patients’ main place of residence was gathered for three points in time: before the injury, at the time of discharge, and at a one-year follow-up. As Table 4 shows, most of the patients lived in private residences prior to the injury, including almost the entire Motorcycle group (99.1%) and the Other Motor Vehicle group (98.6%). Slightly fewer people in the Violence category lived in private residences (93.5%), with 3.3 percent listed as homeless. Upon discharge, the proportion of TBI clients living in private residences fell an average of almost 12 percent. Patients were placed in varied care settings, including nursing homes (5%), adult homes (2.4%), rehabilitation facilities (1.2%), or hospital settings — sub-acute care (2.4%), acute care (1.1%), or other hospital (0.9%). By the one-year follow-up, an average of 91.4 percent of the patients were back in private residences. Most of the others were in nursing homes (3.1%) or adult homes (2.6%). The Motorcycle group was more likely than the other groups to be in private residences after one year (97.1%), followed by the Other Motor Vehicle group (94.1%)

The TBI data set lacks information on rehospitalizations, but other studies find a relatively high rate of rehospitalization in the long term following traumatic brain injury (Kreutzer, Marwitz, High Jr., Englander, and Cifu, 2001) reported that TBI rehospitalization ranged from 22.9 percent at one-year post-injury to 17.0 percent at five-years post-injury. At one-year post-injury, one-third of the rehospitalizations were elective admissions.

Table 4. Patient Residence Prior to Injury, Upon Discharge and at One Year.

Residence
Pre Injury

Motorcycle (Including Dirt Bike)

Other Motor Vehicle

Violence (Self Or Other)

Other Unintended

All TBI

Private

99.1%

98.6%

93.5%

97.3%

97.5%

Adult home

 

.2%

.6%

.4%

.3%

Correctional facility

 

.1%

.2%

.1%

.1%

Hotel

 

.2%

.9%

.1%

.3%

Homeless

 

.6%

3.3%

1.2%

1.2%

Acute care

 

 

.2%

 

.0%

Rehab facility

 

 

 

.1%

.0%

Other hospital

 

 

 

.1%

.0%

Other

.9%

.2%

1.3%

.6%

.5%

At Discharge

Private

89.3%

87.8%

83.0%

81.6%

85.7%

Nursing home

2.7%

3.3%

7.9%

7.6%

5.0%

Adult home

1.3%

2.3%

3.3%

2.2%

2.4%

Correctional facility

 

.1%

.2%

.1%

.1%

Hotel

 

.2%

.3%

 

.2%

Homeless

 

 

.3%

.4%

.1%

Acute care

1.3%

1.0%

1.0%

1.3%

1.1%

Rehab facility

2.2%

1.4%

.3%

1.2%

1.2%

Other hospital

.9%

.7%

.6%

1.7%

.9%

Sub-acute-care facility

1.3%

2.3%

2.5%

2.9%

2.4%

Other

.9%

.9%

.5%

1.0%

.9%

One-Year Follow-up

Private

97.9%

94.1%

84.5%

88.0%

91.4%

Nursing home

 

1.4%

6.8%

5.7%

3.1%

Adult home

.7%

2.1%

4.6%

3.0%

2.6%

Correctional facility

.7%

.3%

2.2%

.6%

.7%

Hotel

 

.1%

 

.4%

.1%

Homeless

 

.3%

 

.4%

.3%

Acute care

 

.2%

 

 

.1%

Rehab

 

.3%

.3%

.2%

.3%

Other hospital

 

.1%

 

.2%

.1%

Sub-acute-care facility

.7%

.6%

.5%

.6%

.6%

Other

 

.6%

1.1%

.8%

.7%


Marital Status
Table 5 reports marital status before the injury and at the one-year follow-up. Pre-injury, 31.0 percent of victims were married, including 28.5 percent of the Other Motor Vehicle group and 32.5 percent of Motorcyclists. The Other Unintended injury victims were more likely to be married than victims in the other categories -- perhaps because this group includes more elderly people. Conversely, those in the Violence category were less likely to be married, and tended to be younger.
The marital status of the TBI patients did not noticeably change from before the injury to the time of one-year follow-up. In the first year post-TBI, families largely stayed together.

Table 5. Marital Status Pre-Injury and at One-Year Follow-Up

Marital Status
Pre-Injury

Motorcycle (Including Dirt Bike)

Other Motor Vehicle

Violence (Self Or Other)

Other Unintended

All TBI

Single

46.4%

55.3%

55.8%

31.0%

49.5%

Married

32.1%

28.5%

16.1%

48.4%

31.0%

Divorced

12.5%

10.1%

15.6%

11.0%

11.4%

Separated

5.8%

3.6%

8.7%

3.0%

4.5%

Widowed

3.1%

2.5%

3.8%

6.5%

3.7%

One-Year Follow-up

Single

41.3%

53.2%

54.4%

31.0%

47.8%

Married

34.3%

28.8%

14.5%

45.3%

30.4%

Divorced

18.2%

12.0%

18.6%

14.1%

13.9%

Separated

2.8%

3.3%

7.7%

3.1%

3.9%

Widowed

3.5%

2.7%

4.9%

6.5%

3.9%


Employment Status
In comparing the four injury categories, Motorcycle TBI patients were most likely to be employed before the injury (80.2%) (see Table 6). The Other Unintended group contains 58 percent employed and 18.8 percent retired. This grouping includes many older people injured in falls. The Violence (Self or Other) category has the largest number of unemployed patients pre-injury (34.6%).

Employment status changed dramatically one-year post-injury. Overall, the proportion of employed patients fell 34.2 percentage points, from 59.8 percent to 25.6 percent. For Other Motor Vehicle injuries, the drop was from 60.7 percent to 26.1 percent and for motorcyclists, the drop was from 80.2 percent to 44.7 percent. Unemployment rose 27.6 percentage points overall (from 17.1% to 44.7%), and nearly tripled among motorcyclists (from 10.8% to 31.9%). Those on disability or in sheltered employment more than quadrupled, rising from 1.3 percent to 5.7 percent.

The drop in employment may be due to some loss of aptitude or changes in personality. It may also be due to patients still being out of work or finding job search difficult after losing jobs during the months they spent recovering from their TBIs.

Although this data set does not address the issue, the employment status of caregivers also may change. A study of 51 caregivers of TBI inpatients (Hall et al. 1994) were interviewed by phone at 12- and 24-months post-injury. Forty-seven percent of caregivers had altered or given up their jobs at one year post-injury and 33 percent at two years post-injury.

Table 6. Employment Status Before and After Injury

Employment Status
Pre-Injury

Motorcycle (Including Dirt Bike)

Other Motor Vehicle

Violence (Self or Other)

Other Unintended

All TBI

Employed

80.2%

60.7%

51.8%

58.0%

59.8%

Special employment

 

.2%

.5%

.7%

.4%

Unemployed

10.8%

14.1%

34.6%

13.0%

17.1%

Student

5.9%

16.2%

6.2%

5.3%

11.5%

Retired

2.3%

4.7%

3.2%

18.8%

7.4%

Homemaker

 

2.0%

.6%

2.0%

1.6%

On disability

 

1.0%

1.0%

1.0%

.9%

Other

.9%

1.1%

2.1%

1.2%

1.3%

One-Year Follow-up

Employed

44.7%

26.1%

15.3%

26.4%

25.6%

Special employment

.7%

.6%

.8%

.6%

.7%

Unemployed

31.9%

43.9%

61.3%

38.0%

44.7%

Student

5.7%

12.9%

5.2%

5.1%

9.5%

Retired

1.4%

4.2%

5.2%

17.4%

7.1%

Homemaker

 

2.7%

1.1%

2.0%

2.1%

On disability

7.8%

4.8%

4.4%

5.3%

5.0%

Other

7.8%

4.8%

6.8%

5.1%

5.4%


Discussion
The data presented comes from a self-selected sample of 17 TBI model systems that chose to pool their data. The charges and duration for care at other rehabilitation providers may vary. So may the outcomes. Nevertheless, this dataset includes follow-ups at one year and is by far the largest case series available. The ratios of rehabilitation charges to acute care charges provide a credible basis for costing rehab care from known acute care hospitalization costs.