A recent raft of whistleblower lawsuits against the Naplesbased, for-profit Health Management Associates hospital chain (recently acquired by Community Health Systems) alleges that administrators coerced doctors to provide unnecessary care and push admissions for emergency room patients who should've gone home. Meanwhile, the federal government, which has joined the HMA suits, also is investigating billing procedures and practices at other hospitals, including some run by the Nashville-based HCA chain.

If true, the hospitals' manipulation of admissions and billing codes reflects dishonesty, greed and malpractice. But it also reflects the pressure that all hospitals face in maintaining revenue amid trends that are pushing them toward treating sicker people, admitting fewer and providing more care in an outpatient setting rather than in the hospital itself.

Those trends — and that same pressure — will be very much in evidence as the controversy plays out over how many trauma centers Florida should have. For years, the state has had a network of 22 certified, well-regarded trauma centers — hospitals like Bayfront in St. Petersburg, Shands in Gainesville and Jackson in Miami that meet strict criteria for maintaining a range of technology, specialists (neurosurgeons, orthopedists, etc.) and support personnel on call around the clock.

Maintaining those resources is expensive. And because some chunk of trauma care involves patients without insurance, many local governments subsidize them. In 2012, for example, the Palm Beach County Health Care District paid more than $5 million to two trauma care centers in that county.

Florida has grown and will continue to grow. A few years ago, the HCA hospital chain, in partnership with USF Health, moved to open trauma centers at four of its Florida hospitals. The state approved, provisionally, the new HCA centers in 2011, but several of the older trauma centers sued the state to try to block the expansion.

The older trauma centers have couched their arguments against new centers in terms of quality of care. The best trauma teams are those that handle the most cases, the older centers maintain. New trauma centers will simply spread trauma cases around among more facilities and dilute the quality of care, since all trauma personnel will be handling fewer cases. In addition, more trauma facilities means more competition for staff, and higher costs, the older facilities say.

HCA couches its argument in traditional competitive terms and the need for proximity of care, raising the specter of trauma patients in heavily populated suburbs dying before they can reach a trauma center. The requirements for trauma care certification necessarily mean that the HCA facilities will be as qualified to handle trauma cases as anyone, HCA says. In addition, HCA says its trauma units won't need to be subsidized by the public.

In resolving the dispute, the state will have to decide how many trauma centers HCA should be allowed to open and is likely to set some rules to guide future trauma center growth.

Behind the two sides' superficial arguments, however, lurks the bureaucracy of trauma care and billing — and that ongoing pressure to cut costs while maintaining revenue. If an injured patient meets a set of criteria, a trauma center can charge what's called a "trauma activation fee." One major requirement for charging the fee is advance notice and consultation between the trauma center and a third-party medical professional — an EMT at a traffic accident, for example, or physician at another hospital. EMTs must use protocols established by local and state government to assess injuries on the scene, but there's wiggle room about whether to classify a patient as a trauma case as the EMT consults with the trauma center doc.

The ability to charge the trauma care fee — reimbursed by Medicare and Medicaid and also by many private insurance plans — has been around since 2001. But institutions have grown much more aggressive and inventive in charging it. The internet is littered with PowerPoint presentations and studies with titles like "Survey of national usage of trauma response charge codes: an opportunity for enhanced trauma center revenue." Not surprisingly, more than 200 new trauma centers have opened in 20 states since 2009.

The trauma fees are considerable. According to a report by Kaiser Health, HCA's Orange Park trauma center charged a $20,000 trauma activation fee in 2012; its Lawnwood Regional Medical Center in Fort Pierce charged $29,000. Because they're subsidized, fees at the older trauma centers tend to be lower. The same report showed Shands Jacksonville's trauma activation fee was $7,000 in 2012.

There's nothing inherently wrong with a fee that can help offset the costs associated with maintaining round-the-clock trauma teams. But pressure will only grow, on both nonprofit and for-profit institutions, to exploit that fee so their trauma centers pay for themselves. How quickly, after new trauma centers open, can we expect to read about a hospital that's manipulating the trauma bureaucracy — colluding with local EMTs, for example, or overriding the EMTs' evaluation — in order to boost the number of trauma patients and keep the fees flowing?

The ultimate problem, of course, is that in our medical system, no one knows what anything costs — certainly not the consumer or the taxpayer. Until there's more transparency about both quality and price, we're all left to wonder if we're getting what we're paying for.