Multiple Issues with
Multiple Trauma
Albert E. Holt, IV, MD, MBA
Chief Medical Officer
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”.
% Claim Count
% Claim Dollars
0%
Current industry
cost containment
tools barely address
“the golden triangle”
0%
6.2%
49.9%
13.8%
67.3%
100%
100%
Source: Lipton, et.al. “Medical Services by Size of Claim”, NCCI, 2009
2
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
3
Golden Triangle Claim Types
There are three main types of claims that dominate the golden triangle.
Paradigm Product Offerings
Catastrophic – Outcome Plans
• TBI
• SCI
● Burn
● Multiple Trauma
● Amputation
Chronic (Post-Catastrophic) – CLL
• Complex medical condition post catastrophic injury
• Care system changes
● Recurrent hospitalizations
• Chronic wounds
● etc.
Pain Management
• Fibromyalgia
• CRPS
● Failed back syndrome
●
etc. – 30+ other diagnoses
4
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
■ Motor vehicle accidents
■ Falls
■ Explosions
■ Common denominator –
high energy!
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5
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
Death
Very 4%
Severe
8%
Severe
12%
Moderate
30%
■ 12% of all in-patients are trauma
(higher in trauma centers)
■ 25,731 deaths annually
Minor
Trauma
46%
■ Second only to heart conditions
as a percent of total health
expenditures
■ $75 billion loss in income annually
Source: ACS-NTDB 2009 Annual Report; US DHHS, Agency for Health Research and Quality
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6
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
Multiple Trauma Case Distribution by Severity
128,613 Cases
Very
Severe
41%
■
61% of all deaths from trauma are
due to multiple trauma injuries
■
Medical treatment for multiple
trauma involves 2-3 times longer:
– ventilator days
Severe
59%
– intensive care unit days
– overall (length of stay) hospital days
Source: ACS-NTDB 2009 Annual Report
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Clinical Indicators
Within the medical field, we use two key trauma severity scoring tools.
Injury Severity Score (ISS)
1-75 (Lower Better)
Anatomic
Score
Calculation
Category
X2
Head and neck, including
cervical spine
X2
Face, including the facial
skeleton, nose, mouth, eyes
and ears
5 if Critical
X2
6 if Maximum/
Currently
Untreatable
Thorax, thoracic spine and
diaphragm
X2
Abdomen, abdominal
organs and lumbar spine
X2
Extremities including pelvic
skeleton
X2
External soft tissue injury
X=
Glasgow Coma Scale
(Higher Better)
Physiologic
1 if Minor
2 if Moderate
3 if Serious
4 if Severe
Total
Sum of Top
three from
this column
X2 + X2 + X2 = ISS Score
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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
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Management / Treatment
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
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Acute: Primary Survey
Acute Emergency Management
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
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
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Acute Emergency Management
Acute: Resuscitation
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
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!
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Acute Emergency Management
Acute: Secondary Survey
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
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
© Paradigm Management Services, LLC
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Acute: Emergency Management
Acute Emergency Management
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
Emergency management takes place in the first hours.
■
Intracranial Hemorrhage
■
Vascular Hemorrhage (e.g., Arch)
■
Exploratory Laparotomy
■
Rectal/GU injuries
■
Fracture Fixation
© Paradigm Management Services, LLC
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Acute Emergency Management
Acute: Tertiary Survey
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
After 24 hours a tertiary survey is performed.
■
Injury Sequelae
■
Additional / follow-up studies
■
■
Ongoing Neurovascular Exams
■
■
© Paradigm Management Services, LLC
Missed Fractures (6-8%)
missed peripheral nerve
injuries ~30%
Occult Bleeding (Abdomen)
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Acute Emergency Management
Definitive Acute Management
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
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
© Paradigm Management Services, LLC
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Acute Emergency Management
Acute Inpatient Rehabilitation
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
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
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Acute Emergency Management
Outpatient Rehabilitation
Primary
Survey
Resuscitation
Secondary
Survey
Emergency
Management
Tertiary
Survey
Definitive
Acute Mgmt
Acute
Inpatient
Rehab
Outpatient
Rehab
In the months and years after the injury Outpatient Rehabilitation takes place.
■
Maximize community function and reintegration
■
ADLs/Psych
■
Residential integration
■
Community Integration
■
Return to work
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Multiple Trauma
Anticipating and managing complications are key to curtailing medical issues and
their financial implications.
$10MM
Multiple
Trauma
$971,899
Complexity*
Vascular (DVT)
$192,497
$335,907
3
4
Delayed Healing
Average
Cost $$
$509,146
5
Pressure Ulcers
6
Infection/Sepsis
Multi-Organ Failure
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.
19
Acute Complications
For example, delayed wound healing can have serious financial implications.
Typically adds $200,000+
Delayed Healing








Nursing Visits
Physician Visits
Laboratory Tests
Medication
Customized Wound Treatment
Hospitalization with Surgical Intervention
Specialized DME
IV Antibiotics
20
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.
•
•
•
•
•
•
•
•
•
Provide independent expert guidance
Consult physician-to-physician
Provide onsite medical support
Clarify diagnoses
Ensure medical continuity
Inform provider selection
Evaluate provider performance
Identify and mitigate potential risks
Coordinate care
Medical
Guidance
Family
Support
Care Path
Direction
Admin
Support
•
•
•
•
•
Provide education and assistance
Support emotional needs of family
Inform family decision making
Attend key appointments
Advocate for patients
•
•
•
•
Review and pay medical bills
Review pharmacy utilization
Provide network oversight
Ensure regulatory compliance
21
Relationships with Centers of Excellence
Peer-to-peer relationships at Centers of Excellence.
Shepherd Center
Craig Hospital
■ Multi-disciplinary approach to injury
management
■ Demonstrated superior outcomes
■ Highest level of certification
■ Demonstrated use of evidence based
medicine
■ Meets credentialing criteria
22
Clinical Algorithms: Catastrophic
Also, a strong base of data to estimate resource needs and optimal care paths is
essential.
Clinical Complexity & Outcome Targeting
collect
data



Assignment
variables
from Paradigm
Medical Director
500+ variables
– Demographic
– Procedural
– Complications
– Psychological
– Financial
– Etc.
target
outcome level
run through
proprietary
algorithms
The target outcome level is the
best outcome that can be foreseen
for the injured worker at the
injury outset
0
Physiologic
Instability
I
Physiologic
Stability
II
Physiologic
Maintenance
III
Residential
Integration
IV
Community
Integration
V
Capacity for Return
to Work
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
Data Hub/
Proprietary
Algorithm
Weighted variable
formula derived from
Paradigm’s nearly 20
years of practice
1
Minimal
Treatment
2
Routine
Treatment
3
Low-Intensity
Treatment
4
High-Intensity
Treatment
5
Severe
6
Extremely
Severe
Example of
Paradigm
Typology/
Nomenclature
MT
Major
Diagnostic
Category
6
Clinical
Complexity
Indicator
0
Initial
Outcome
Level
IV
Target
Outcome
Level
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After the Outcome
After achieving the acute outcome monitoring is needed.
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
24
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
© Paradigm Management Services, LLC
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What Happens if Chronic Pain Develops?
Pain is a development that can be anticipated and curbed before it progresses to
chronic status.
atrophy
depression
atrophy
insomnia
insomnia
PAIN
PAIN
PAIN
weight gain
fear of movement
medical
addiction
life roles
Acute Pain
(0-3 months)
Transitional
(3-6 months)
Chronic Pain Syndrome
Greater than 6 months
26
Biopsychosocial Model of Chronic Pain
The best model for preventing and unraveling a complex chronic pain condition is
the biopsychosocial model.
Bio
Psycho
Social
27
Outcome Plan: Results
Confirmed by Milliman Inc., Systematic Care Management SM beat the industry
approach by tremendous margins.
Release to
Return to Work
Returned to
Competitive Work
Returned to
Work Full Duty
Medical &
Indemnity Costs
$125 MM
60%
Indemnity
Costs
5x
better
5x
better
13x
better
41%
Medical
Costs
$21 MM
$104 MM
36% Cost Savings
$80 MM
$9 MM
$71 MM
20%
13%
8%
1.5%
Industry
Benchmark1
1.
Paradigm
Industry
Benchmark1
Paradigm
Industry
Benchmark1
Paradigm
Industry
Benchmark1
Paradigm
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)
28
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.
Average MSA
Amount
(Dollars in thousands)
Medicare Set Aside Savings Drivers
$358
$204
■
Lower pharmaceutical expenses
■
Lower diagnostic testing expenses
■
Low physician visit services expenses
■
Higher state of functional independence
Note: Comprehensive study currently being scoped
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Questions
30