Introduction and Data Sources
Although the immediate hospitalization costs of motor vehicle and motorcycle crash-related injuries have been examined, the longer-term costs of injury rehabilitation have not been fully addressed. Cost analyses are often conducted before adopting injury prevention programs or laws, and the rehabilitation costs are a potentially important but often overlooked element of the total cost. No one database provides the information needed to estimate the national costs of inpatient rehabilitation for motor vehicle crash injuries. Motor vehicles were defined according to the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), and included any mechanically or electrically powered device, not operated on rails, upon which any person or property may be transported or drawn upon a highway. In this report we estimate costs and explore cost-related rehabilitation outcomes such as changes in employment and living status, using data from six different sources. Secondary data were collected on the frequency, duration, and costs of motor vehicle injury from six sources: American Medical Rehabilitation Provider’s Association (AMRPA), Uniform Data System for Medical Rehabilitation (UDSMR), Traumatic Brain Injury (TBI) Model System National Database, pooled 1997 or 1998 Hospital Discharge Survey census data from 21 states, the Health Care Utilization Program 2000 National Inpatient Sample (HCUP-NIS), and the Colorado Traumatic Brain Injury Registry and Follow-Up System. When it was available, we collected demographic data, employment data, and functional outcome data. Data in this analysis includes only crashes that occurred on public roadways, except in chapter four where the traumatic brain injury data includes data on motorcycle crashes occurring both on-road and off-road.

We developed a model that estimates the cost of inpatient rehabilitation for motor vehicle and motorcycle-related injuries. The model combines prospective payment system (PPS) rates for inpatient rehabilitation with UDSMR data on the severity of injuries requiring rehabilitation and multi-State data on the probability of requiring rehabilitation. It estimates average costs per inpatient rehabilitation. When applied to Year 2000 HCUP-NIS data on hospital discharges by cause, the model estimates total cost of inpatient rehabilitation for motor vehicle and motorcycle injuries in 2000.

To better understand the costs of motor vehicle and motorcycle-related injuries, comparisons were made with three other injury causes: assault, attempted suicide, and other unintentional injuries.

Inpatient rehabilitation costs for motor vehicle injuries average $11,265 per patient (in 2002 dollars, and excluding motorcycle injuries) and $13,200 for motorcycle injuries. Throughout this report we refer to “other motor vehicles,” a term that contains motor vehicles but excludes motorcycles, which are considered in a separate category. For motor vehicle injuries, the costs for single-problem cases range from $9,052 for fractures to $26,656 for spinal cord injuries (SCIs). Under the Prospective Payment System, net of labor market price adjustments, these figures are flat-rate total payments for inpatient rehabilitation of a patient on Medicare or Medicaid. Analysis of the AMRPA data shows they are roughly comparable to all-payer average payments in 1999, three years before PPS implementation.

Overall, HCUP-NIS suggests 243,000 patients were admitted for motor vehicle injuries and 24,000 patients were admitted for motorcycling injuries in 2000. Five percent of these patients had an inpatient rehabilitation stay separate from their acute care stay. Spinal cord injury victims had the highest probability of a separate stay, with 30 percent of acute admissions subsequently admitted to rehabilitation facilities. Next came lower-extremity amputations at 11 percent, TBIs with fractures or amputations at 9 percent, lower-extremity fractures at 6 percent, and isolated TBIs at 5 percent.
In 2000, we estimate that $127.5 million was spent for inpatient rehabilitation of injuries in motor vehicle crashes and $16.3 million was spent for inpatient rehabilitation of injuries in motorcycle crashes (in 2002 dollars)

Public funds paid for 26.1 percent of the motor vehicle crash injury costs and19.5 percent of the motorcycle crash injury costs. By comparison, including professional fees, we estimate the acute care hospitalization costs for motor vehicle injuries were $3.665 billion in 2000 and $422 million for motorcycle injuries. These acute care bills included some bundled rehabilitation costs. Separately billed inpatient rehabilitation accounted for an estimated 3 percent of the total inpatient care costs for motor vehicle injuries and 4 percent for motorcycle injuries. The methods used provide a model that can readily be applied to HCUP-NIS data to update the national cost estimate in the future.

Other findings from the study are as follows:

Other Motor Vehicle and Motorcycle injuries generate other costs related to functional losses and the resulting impacts on social and role functions. Although this study did not estimate those costs, it showed the losses for some injuries can be quite significant. UDSMR data shows that across all injury categories, more than 50 percent of patients in the workforce changed their vocational status to nonworking or disabled at the time of rehabilitation discharge. Of the previously employed people injured in Other Motor Vehicle crashes, 64 percent were not working or disabled at the time of discharge and (54.1% and 9.9% respectively) for motorcycle crashes, 62 percent were not working or disabled, (51.1% and 10.6% respectively).

Five categories of impairment are the most common causes of inpatient rehabilitation: TBI; “other” multiple trauma; TBI with fracture and amputation; “other” orthopedic; and hip/knee replacement. These categories account for 81 percent of the motorcycle cases and 79 percent of the Other Motor Vehicle cases. Employment drops among TBI patients were notable. Employment status changed dramatically one-year post-injury. Overall, the proportion of employed patients fell 34.2 percent, 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 percent 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.

Our analysis of the Colorado Traumatic Brain Injury Registry and Follow-Up System, which tracked a large sample of Colorado TBI cases for four years, yielded a similar finding. Although considerable numbers of TBI victims return to work after an injury, permanent or temporary disability or extended medical care prevents many individuals from returning to a productive life. The TBI Model System National Database analysis revealed that of the TBI cases in rehabilitation, 85 percent were tested for BAC in the emergency department (table 8 in Chapter 3). Of those tested, 48 percent of both motor vehicle and motorcycle cases tested positive for alcohol. By comparison, an analysis of 2001 FARS data found that 37 percent of motorcycle riders killed in crashes were positive for alcohol (Shankar, 2003a). An analysis of AMRPA data provides rehabilitation hospital costs for 1999 for specific diagnoses, (see tables in appendix A) ranging from $7,613 for the replacement of a lower-extremity joint to $29,495 for a traumatic spinal cord injury. Average cost per day ranged from $716 for a hip fracture to $991 for burns. Traumatic spinal cord injuries required the longest length of stay – on average 34.3 days, while replacement of a lower extremity joint had the shortest – on average 10.5 days. These finding are relatively consistent among age groups.

The PPS appears to have contained inpatient rehabilitation costs, holding 2002 costs to the levels in the 1999 AMRPA data.