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Multiple Issues with Multiple Trauma Albert E. Holt, IV, MD, MBA Chief Medical Officer.

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Presentation on theme: "Multiple Issues with Multiple Trauma Albert E. Holt, IV, MD, MBA Chief Medical Officer."— Presentation transcript:

1 Multiple Issues with Multiple Trauma Albert E. Holt, IV, MD, MBA Chief Medical Officer

2 2 The Golden Triangle Research has found that despite cost containment efforts, a subset of complex, legacy cases typically persist in driving costs: The “Golden Triangle”. 6.2% % Claim Count 100% 13.8% % Claim Dollars 100% 49.9% 67.3% 0% Current industry cost containment tools barely address “the golden triangle” Source: Lipton, et.al. “Medical Services by Size of Claim”, NCCI, 2009

3 3 Complexity Creates Volatility What makes claims within the golden triangle so volatile is their complexity. Multiple locations Multiple providers with many handoffs Higher rate of medical errors Lack of provider expertise depth in non-Center of Excellence locations Fragile medical condition with higher level of known risks Higher interplay of co-morbid conditions Long term compromise Escalation of morphine equivalent doses Increased drug dependency

4 4 Golden Triangle Claim Types There are three main types of claims that dominate the golden triangle. Paradigm Product Offerings Catastrophic – Outcome Plans TBI ● Burn ● Multiple Trauma SCI ● Amputation Chronic (Post-Catastrophic) – CLL Complex medical condition post catastrophic injury Care system changes ● Recurrent hospitalizations Chronic wounds ● etc. Pain Management Fibromyalgia ● Failed back syndrome CRPS ● etc. – 30+ other diagnoses

5 ■ Motor vehicle accidents ■ Falls ■ Explosions ■ Common denominator – high energy! Today’s Focus: Multiple Trauma Today, we will focus on multiple trauma which is defined as an injury that causes simultaneous damage to multiple organ systems. Primary Causes of Multiple Trauma Injuries 5 © Paradigm Management Services, LLC

6 Incidence Statistics for Trauma In the US, trauma is the leading cause of death under the age of 44 and a major cause of death across all age groups. Trauma Case Distribution by Severity 627,664 Cases Source: ACS-NTDB 2009 Annual Report; US DHHS, Agency for Health Research and Quality ■ 12% of all in-patients are trauma (higher in trauma centers) ■ 25,731 deaths annually ■ Second only to heart conditions as a percent of total health expenditures ■ $75 billion loss in income annually 6 © Paradigm Management Services, LLC

7 Multiple Trauma Statistics The cases that are classified as “multiple trauma” represent one-fifth of all trauma cases and are significantly more severe in nature than discrete traumas. Trauma vs. Multiple Trauma Comparisons 7 © Paradigm Management Services, LLC ■ 61% of all deaths from trauma are due to multiple trauma injuries ■ Medical treatment for multiple trauma involves 2-3 times longer: –ventilator days –intensive care unit days –overall (length of stay) hospital days Multiple Trauma Case Distribution by Severity 128,613 Cases Source: ACS-NTDB 2009 Annual Report

8 Clinical Indicators Within the medical field, we use two key trauma severity scoring tools. 8 © Paradigm Management Services, LLC ScoreCalculationCategory X = 1 if Minor 2 if Moderate 3 if Serious 4 if Severe 5 if Critical 6 if Maximum/ Currently Untreatable X2X2 Head and neck, including cervical spine X2X2 Face, including the facial skeleton, nose, mouth, eyes and ears X2X2 Thorax, thoracic spine and diaphragm X2X2 Abdomen, abdominal organs and lumbar spine X2X2 Extremities including pelvic skeleton X2X2 External soft tissue injury TotalSum of Top three from this column X 2 + X 2 + X 2 = ISS Score Injury Severity Score (ISS) 1-75 (Lower Better) Glasgow Coma Scale (Higher Better) Anatomic Physiologic

9 Individual Characteristics Multiple trauma injuries can present with many common features. 9 © Paradigm Management Services, LLC ■ High energy injury ■ Hemodynamic instability ■ Closed Head Injuries (GCS < 9 severe) ■ Blunt or penetrating chest/ abdominal injury ■ Multiple long bone/pelvic fractures ■ Injury Severity Score >16

10 Multiple trauma injuries require extensive treatment. Key Phases of Treatment Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab Management / Treatment 10

11 Acute: Primary Survey The acute primary survey takes place during the lifesaving first minutes. 11 © Paradigm Management Services, LLC A - Airway Maintenance with Cervical Spine Protection B - Breathing and Ventilation C - Circulation with Hemorrhage Control D - Disability (Neurologic Evaluation) E - Exposure / Environmental control Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

12 Acute: Resuscitation Additionally, resuscitation takes place during the lifesaving first minutes. ■ Monitor –BP –Urine Output –CVP ■ Direct control hemorrhage ■ Life support initiated ■ Fluid replacement –IVF –Blood replacement Graphic images ahead! 12 © Paradigm Management Services, LLC Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

13 Acute: Secondary Survey The secondary survey is performed within the first hour. 13 © Paradigm Management Services, LLC ■ Comprehensive survey ■ Skull/C-Spine (50% of trauma deaths) ■ Neuro – Pupils/GCS ■ Chest (25% of trauma deaths) ■ Abdomen ■ Spine/Pelvis ■ Rectal/GU ■ Extremity Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

14 Acute: Emergency Management Emergency management takes place in the first hours. 14 © Paradigm Management Services, LLC ■ Intracranial Hemorrhage ■ Vascular Hemorrhage (e.g., Arch) ■ Exploratory Laparotomy ■ Rectal/GU injuries ■ Fracture Fixation Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

15 Acute: Tertiary Survey After 24 hours a tertiary survey is performed. 15 © Paradigm Management Services, LLC ■ Injury Sequelae ■ Additional / follow-up studies ■ Missed Fractures (6-8%) ■ Ongoing Neurovascular Exams ■ missed peripheral nerve injuries ~30% ■ Occult Bleeding (Abdomen) Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

16 Definitive Acute Management During the days and weeks after the injury definitive acute management begins. 16 © Paradigm Management Services, LLC ■ Acute medical stabilization ■ Fracture Management (multiple surgeries) ■ Wound Management ■ Complications and co-morbid management Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

17 Acute Inpatient Rehabilitation Acute Inpatient rehabilitation takes place in the weeks and months afterwards. 17 © Paradigm Management Services, LLC ■ Functional restoration and maximization ■ Pulmonary ■ Therapy (PT/OT) ■ Diet ■ Neuropsychology ■ Transfers/Ambulation ■ Self Care Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

18 Outpatient Rehabilitation In the months and years after the injury Outpatient Rehabilitation takes place. 18 © Paradigm Management Services, LLC ■ Maximize community function and re- integration ■ ADLs/Psych ■ Residential integration ■ Community Integration ■ Return to work Acute Emergency Management Primary Survey Resuscitation Secondary Survey Emergency Management Tertiary Survey Definitive Acute Mgmt Acute Inpatient Rehab Outpatient Rehab

19 Multiple Trauma Anticipating and managing complications are key to curtailing medical issues and their financial implications. 19 Source: Paradigm mean values for medical costs years 2002-2008 adjusted for inflation (methodology likely understates risk exposure) * Complexity is a Paradigm Management Services proprietary scale assigned after a multivariate analysis containing more than 800 variables.Level 1: Minimal treatment, 2: Routine treatment, 3: Low-intensity treatment, 4: High-intensity treatment, 5: Severe, 6: Extremely severe. Average Cost $$ $10MM Complexity* $192,497 $335,907 $509,146 $971,899 3456 Multiple Trauma Vascular (DVT)Delayed HealingPressure UlcersInfection/SepsisMulti-Organ Failure

20 Delayed Healing Acute Complications For example, delayed wound healing can have serious financial implications. 20 Typically adds $200,000+ Nursing Visits Physician Visits Laboratory Tests Medication Customized Wound Treatment Hospitalization with Surgical Intervention Specialized DME IV Antibiotics

21 21 Systematic Care Management SM The best way to avoid complications is by coordinating and guiding care delivery. By doing the right thing for the patient, the financial results follow. Review and pay medical bills Review pharmacy utilization Provide network oversight Ensure regulatory compliance Inform provider selection Evaluate provider performance Identify and mitigate potential risks Coordinate care Provide education and assistance Support emotional needs of family Inform family decision making Attend key appointments Advocate for patients Provide independent expert guidance Consult physician-to-physician Provide onsite medical support Clarify diagnoses Ensure medical continuity Medical Guidance Family Support Admin Support Care Path Direction

22 22 Relationships with Centers of Excellence ■ Multi-disciplinary approach to injury management ■ Demonstrated superior outcomes ■ Highest level of certification ■ Demonstrated use of evidence based medicine ■ Meets credentialing criteria Peer-to-peer relationships at Centers of Excellence. Shepherd Center Craig Hospital

23 23 Clinical Algorithms: Catastrophic Also, a strong base of data to estimate resource needs and optimal care paths is essential. Clinical Complexity & Outcome Targeting Example of Paradigm Typology/ Nomenclature collect data  Assignment variables from Paradigm Medical Director  500+ variables – Demographic – Procedural – Complications – Psychological – Financial – Etc.  run through proprietary algorithms Data Hub/ Proprietary Algorithm Data Hub/ Proprietary Algorithm Weighted variable formula derived from Paradigm’s nearly 20 years of practice Major Diagnostic Category MT IV Initial Outcome Level Target Outcome Level 6 6 0 0 Clinical Complexity Indicator Routine Treatment 1 1 2 2 4 4 3 3 5 5 6 6 determine clinical complexity The Clinical Complexity Indicator reflects the anticipated resource consumption (cost) required to take an injured worker to a designated Paradigm Outcome Level Minimal Treatment High-Intensity Treatment Low-Intensity Treatment Severe Extremely Severe target outcome level The target outcome level is the best outcome that can be foreseen for the injured worker at the injury outset Physiologic Instability Physiologic Stability Physiologic Maintenance Residential Integration Community Integration Capacity for Return to Work 0 0 I I III II IV V V

24 After the Outcome After achieving the acute outcome monitoring is needed. 24 Outcome Achievement  Acute Medical Stabilization  Pulmonary Management  Musculoskeletal and Orthopedic Trauma Management  Wound Management  Skin Maintenance and Protection  Pain Management  Medication Management  Bladder Management  Bowel Management  Nutritional Program  Communication  Self-Care  Wheelchair Mobility  Transfers independence  Residential Reintegration  Compensatory Cognitive Strategies  Daily Living Competencies  Long-Term Care Support Systems  Community Reintegration  Return to Work - Determination of Potential  Medical Protocols for Long-Term Health Maintenance Extended Monitoring (Not Autopilot) Helps Preserve Recovery

25 Chronic Complications Monitor and anticipate what is on the horizon to prevent its occurrence. 25 © Paradigm Management Services, LLC ■ Chronic pain ■ Multiple medical complications ■ Difficult residential and community reintegration ■ Addiction ■ Psychological

26 26 What Happens if Chronic Pain Develops? Pain is a development that can be anticipated and curbed before it progresses to chronic status. PAINPAIN insomnia atrophy fear of movement PAIN depression atrophy insomnia weight gain medical life roles addiction Acute Pain (0-3 months) Transitional (3-6 months) Chronic Pain Syndrome Greater than 6 months

27 Biopsychosocial Model of Chronic Pain The best model for preventing and unraveling a complex chronic pain condition is the biopsychosocial model. 27 Bio SocialPsycho

28 28 Outcome Plan: Results Confirmed by Milliman Inc., Systematic Care Management SM beat the industry approach by tremendous margins. Industry Benchmark 1 Paradigm Industry Benchmark 1 Paradigm 8% 13% 1.5% 41% 60% 20% Release to Return to Work Returned to Competitive Work Returned to Work Full Duty Medical & Indemnity Costs 1.Based on a an independent comparison by Milliman, the nation’s leading actuarial and consulting firm, of Paradigm cases to their proprietary database of similar Workers’ Compensation claims; Release to Return to Work is determined by the attending physician (not Paradigm) 5x better 5x better 13x better 36% Cost Savings $80 MM $9 MM $21 MM $125 MM $104 MM $71 MM Indemnity Costs Medical Costs

29 29 Medicare Set Aside Findings of a concept study done by Crowe Paradis found a significant decrease in Medicare Set Aside amounts for SCM managed cases. Medicare Set Aside Savings Drivers ■ Lower pharmaceutical expenses ■ Lower diagnostic testing expenses ■ Low physician visit services expenses ■ Higher state of functional independence Note: Comprehensive study currently being scoped Average MSA Amount (Dollars in thousands) $204 $358

30 Questions 30


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