HMN 2026: How Crash victims are 70% less likely to be transferred between hospitals in no-fault states

Patients with severe injuries from car crashes are about 70% less likely to be transferred to another hospital in states with no-fault insurance laws than in states with more common at-fault policies, reports a new study led by Northwestern Medicine. The findings suggest that policies such as no-fault laws—which guarantee reimbursement for trauma care—may incentivize hospitals to keep and treat seriously injured patients. The work is published in the journal Injury.

In the U.S., drivers in 12 states are required to buy personal injury protection, also known as no-fault insurance, so that car insurance companies automatically reimburse drivers and the hospital for the cost of injury care. This tends to increase car insurance premiums. In all other states, drivers are not required to buy this protection. As a result, hospitals may not receive reimbursement from insurers unless fault for the crash is established, which is time-consuming and can be difficult to prove.

“We found that states that have no-fault laws have broader participation of hospitals in caring for injured patients, which results in fewer re-triages or transfers to another hospital,” said study senior author Dr. Anne Stey, assistant professor of surgery in the division of trauma and critical care and a Northwestern Medicine trauma surgeon. “That allows patients to get trauma care closer to home.”

Re-triage—the emergency transfer of a patient from one hospital to another—happens when the first hospital determines it cannot provide the needed level of trauma care. These transfers can mean additional costs and time during a critical time window for severely injured patients. According to Stey, the rates of hospital transfers have been going up over the last decade, and a growing proportion of these transfers may not be necessary.

“The re-triage process is challenging because finding another hospital that agrees to provide care, finding an ambulance and the time-sensitive nature of injury care can all be cumbersome. Unfortunately, unexpected problems can arise,” Stey explained.

Stey and colleagues analyzed hospital records from nearly 6,500 Medicare patients who suffered severe injuries in car crashes between 2016 and 2021. The patients were treated in four states: Florida and New York, which have no-fault laws, and Maryland and Wisconsin, which have at-fault policies.

The research team found that:

• Severely injured crash victims on Medicare in no-fault states were re-triaged at a rate of 2.3%, compared with 8.1% in at-fault states.
• After adjusting for patient and hospital differences, no-fault states had 69% lower odds of re-triage than at-fault states.

To make sure the results were not due to differences in trauma systems between states, the scientists compared re-triage rates in the same four states for severe fall injuries. Unlike with car crash injuries, the cost of treating fall injuries is not reimbursed through car insurance companies.

This time, the research team found no significant difference in re-triage rates between no-fault and at-fault states. Stey says this strengthens the case that car insurance policies do influence whether crash victims are re-triaged.

Funding trauma care

Stey said the findings raise broader questions about how taxpayers and policymakers want to fund emergency care at a time when many trauma centers face financial strain. “Ultimately, it is up to the private citizens and state policymakers if they value access to trauma care more highly, or the choice to have lower car insurance premiums,” she said.

Stey added that no-fault laws are just one mechanism that can be used to finance health care costs.

“Other laws that could ensure seriously injured patients get timely high-quality care are state laws that earmark funds from cigarette sales or speeding and parking tickets to finance trauma and emergency care systems,” Stey said. “Another option would be expanding health insurance coverage so that every person living in the U.S. would be able to have their costs of care reimbursed.”

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