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

Multiple Issues with Multiple Trauma

Albert E. Holt, IV, MD, MBA Chief Medical Officer

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%

0%

Current industry cost containmenttools barely address “the golden triangle”

Source: Lipton, et.al. “Medical Services by Size of Claim”, NCCI, 2009

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

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

■ 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

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 Severity627,664 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

Minor Traum

a45%

Moderate30%

Se-vere12%

Very Se-

vere8%

Death4%



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

■ 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

Severe59%

Very Severe41%

Multiple Trauma Case Distribution by Severity128,613 Cases

Source: ACS-NTDB 2009 Annual Report


Clinical Indicators

Within the medical field, we use two key trauma severity scoring tools.

Score Calculation Category

X =

1 if Minor

2 if Moderate

3 if Serious

4 if Severe

5 if Critical

6 if Maximum/ Currently Untreatable

X2 Head and neck, including cervical spine

X2 Face, including the facial skeleton, nose, mouth, eyes and ears

X2 Thorax, thoracic spine and diaphragm

X2 Abdomen, abdominal organs and lumbar spine

X2 Extremities including pelvic skeleton

X2 External soft tissue injury

Total Sum of Top three from this column

X2 + X2 + X2 = ISS Score

Injury Severity Score (ISS)1-75 (Lower Better)

Glasgow Coma Scale(Higher Better)

Anatomic Physiologic


Individual Characteristics

Multiple trauma injuries can present with many common features.

■ 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

Multiple trauma injuries require extensive treatment.

Key Phases of Treatment

Acute Emergency Management

PrimarySurvey Resuscitation Secondary

SurveyEmergency

ManagementTertiary Survey

Definitive Acute Mgmt

Acute Inpatient

Rehab

Outpatient Rehab

Management / Treatment

10


Acute: Primary Survey

The acute primary survey takes place during the lifesaving first minutes.

A - Airway Maintenance with Cervical Spine Protection

B - Breathing and Ventilation

C - Circulation with Hemorrhage Control

D - Disability (Neurologic Evaluation)

E - Exposure / Environmental control



SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab

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!




SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab


Acute: Secondary Survey

The secondary survey is performed within the first hour.

■ Comprehensive survey

■ Skull/C-Spine (50% of trauma deaths)

■ Neuro – Pupils/GCS

■ Chest (25% of trauma deaths)

■ Abdomen

■ Spine/Pelvis

■ Rectal/GU

■ Extremity



SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab


Acute: Emergency Management

Emergency management takes place in the first hours.

■ Intracranial Hemorrhage

■ Vascular Hemorrhage (e.g., Arch)

■ Exploratory Laparotomy

■ Rectal/GU injuries

■ Fracture Fixation



SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab


Acute: Tertiary Survey

After 24 hours a tertiary survey is performed.

■ Injury Sequelae

■ Additional / follow-up studies

■ Missed Fractures (6-8%)

■ Ongoing Neurovascular Exams

■ missed peripheral nerve injuries ~30%

■ Occult Bleeding (Abdomen)



SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab


Definitive Acute Management

During the days and weeks after the injury definitive acute management begins.

■ Acute medical stabilization

■ Fracture Management (multiple surgeries)

■ Wound Management

■ Complications and co-morbid management



SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab


Acute Inpatient Rehabilitation

Acute Inpatient rehabilitation takes place in the weeks and months afterwards.

■ Functional restoration and maximization

■ Pulmonary

■ Therapy (PT/OT)

■ Diet

■ Neuropsychology

■ Transfers/Ambulation

■ Self Care



SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab


Outpatient Rehabilitation

In the months and years after the injury Outpatient Rehabilitation takes place.

■ Maximize community function and re-integration

■ ADLs/Psych

■ Residential integration

■ Community Integration

■ Return to work



SurveyEmergency



Acute Inpatient

Rehab

Outpatient Rehab

Multiple Trauma

Anticipating and managing complications are key to curtailing medical issues and their financial implications.

19Source: 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.

AverageCost $$

$10MM

Complexity*

$192,497 $335,907 $509,146

$971,899

3 4 5 6

Multiple Trauma

Vascular (DVT) Delayed Healing Pressure Ulcers Infection/Sepsis Multi-Organ Failure

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Delayed Healing

Acute Complications

For example, delayed wound healing can have serious financial implications.

Typically adds $200,000+

Nursing Visits Physician Visits Laboratory Tests Medication Customized Wound Treatment Hospitalization with Surgical Intervention Specialized DME IV Antibiotics

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

AdminSupport

Care Path Direction

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

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

Weighted variable formula derived from Paradigm’s nearly 20 years of practice

Major Diagnostic Category

MT

IV

Initial Outcome Level

Target Outcome Level

6

0

Clinical Complexity Indicator

Routine Treatment

1

2

4

3

5

6

determine clinicalcomplexity

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

I

III

II

IV

V

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


Chronic Complications

Monitor and anticipate what is on the horizon to prevent its occurrence.

■ Chronic pain

■ Multiple medical complications

■ Difficult residential and community reintegration

■ Addiction

■ Psychological

26

What Happens if Chronic Pain Develops?

Pain is a development that can be anticipated and curbed before it progresses to chronic status.

PAIN PAIN

insomnia

atrophy

fear of movement

PAIN

depressionatrophy

insomnia

weight gain

medical

life rolesaddiction

Acute Pain(0-3 months)

Transitional(3-6 months)

Chronic Pain SyndromeGreater than 6 months

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

Outcome Plan: Results

Confirmed by Milliman Inc., Systematic Care Management SM beat the industry approach by tremendous margins.

Industry Benchmark1

Industry Benchmark1

Industry Benchmark1

Paradigm Paradigm Industry Benchmark1

Paradigm 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)

5xbetter

5xbetter

13xbetter

36% Cost Savings

$80 MM

$9 MM

$21 MM

$125 MM

$104 MM

$71 MM

Indemnity Costs

Medical Costs

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 MSAAmount

(Dollars in thousands)

$204

$358

Questions

30

Documents

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