Andrew N. Pollak, MD
Program Director and Head
Division of Orthopaedic Trauma
University of Maryland School of Medicine
Associate Director of Trauma
R Adams Cowley Shock Trauma Center
Medical Director
Baltimore County Fire Department
Special Deputy United States Marshal
Commissioner – Maryland Health Care Commission
Maryland vs. Georgia
 Maryland
–
–
–
–
5.6 million people
12,500 sq miles
$68,000 median income
Density – 5th in US
 Georgia
–
–
–
–
9.6 million people
60,000 sq miles
$43,000 medial income
Density – 18th in US
The Vision
The Maryland System was created
by the vision and leadership of
Dr. R Adams Cowley
Accidental Death and Disability:
The Neglected
Disease of Modern Society (1966)
The Golden Hour
The Probability of Survival
100
% Survival
80
Survival Is Related To
Severity and Duration
60
40
20
0
30
60
Minutes
90
The First Trauma Center
Center for the Study of Trauma was opened
by Dr. Cowley at the University of
Maryland Hospital
in 1969.
Maryland EMS History
 Golden Hour
 Development of
trauma center network
 Development of
helicopter network
 Development of EMS
Network
"Politics is not a spectator sport" John F. Kennedy
R Adams Cowley Shock Trauma
Center
 7500 Admissions per
year
 Approx 40% by air &
60% by ground
 Primary trauma
referral center for 1.5
million people
 Secondary trauma
referral center for 6
million people
 4200 Surgical Cases
 ALOS 4.65 days
– ALOS for isolated femur
fracture less than 48
hours
 90 total overnight beds
(36 critical care)
Division of Orthopaedic Trauma
Research – Education – Clinical Care
 7 Full time faculty members
 10 Orthopaedic residents
 4 Orthopaedic trauma fellows
– Expanding to 5




3000 orthopaedic trauma cases annually
400 pelvis and acetabulum cases annually
$500,000 per year research funding
20-30 Academic peer reviewed publications
per year
Division of Orthopaedic Trauma
Residency Programs
 University of Maryland
 Columbia University
 New York University –
Hospital for Joint
Diseases
 Lenox Hill Hospital
 Union Memorial
Hospital
 Walter Reed Army
Medical Center
 Bethesda – National
Naval Medical Center
 Tripler Army Medical
Center
 Johns Hopkins
University
Educational Mission
Continuum of Care
Emergency Incident
Citizen Access “911”
Dispatch
Dispatch Units
Information Pre-arrival Information
Medical Consultation
Fire BLS ALS Specialty Uni
Patient Assessment
Transport
Ambulance Medic Helicopter
Hospital Emergency Department or Specialty Center
Rehabilitation
Return to Society
Maryland EMS System
3
32
159
2
H
H
A
A
23
51
Baltimore City
H
7
A
A
H
H
H
H
H
H
H
A
H
H
H
A
H
H
H
H
A
H
H H
H
A
H
H
160
13
116
H
A
A
H
H
Areawide Trauma Centers
Specialty Referral Centers
Hospitals
Central Alarms
EMSTel Telephone Network
Medical Command Consultation Centers
PARC
Burn
Trauma Level I Maryland’s Eye
Specialty
Centers
Trauma
Referral
System
Hand Centers
Level II
Head and Spine
Level III
Hyperbaric
H
Pediatric
H
H
H
Perinatal
Local Emergency Departments
Maryland EMS
• System highlights
– 5 regions
– 24 jurisdictions (23 counties and the city of
Baltimore) plus statewide EMS agencies
– 31 commercial ambulance services
– Statewide EMS Advisory Council (SEMSAC)
– EMS Board appointed by Governor
– EMS and trauma funding through $13.50
surcharge on vehicle registration
– Majority of EMS providers are volunteer with a
strong state association (MSFA)
Maryland EMS
• System highlights
– Statewide EMS communications system operated
by MIEMSS
– Statewide protocols for EMS providers
– Statewide data system
– Uniform QI and medical oversight requirements
– ALS available in all jurisdictions
– MSP Med-Evac program with 8 bases across the
state transporting more the 3000 patients/year
– Trauma, EMSC and EMS systems are integrated
Maryland EMS
• System highlights
– R A Cowley Shock Trauma Center is a statewide
trauma resource by statute
– 8 additional adult trauma centers and 2 pediatric
trauma centers
– MFRI provides EMT-B training and EMS CME
– ALS training provided by jurisdictions,
community colleges and UMBC (up to masters
degree)
Trauma Centers
• Primary Adult
– R Adams Cowley Shock Trauma Center,
University of Maryland Medical Center
• Areawide
– Johns Hopkins Bayview Medical Center
– Memorial Hospital and Medical Center of
Cumberland
– Peninsula Regional Medical Center, Salisbury
– Prince George’s Hospital Center, Cheverly
– Sinai Hospital of Baltimore
– Suburban Hospital, Bethesda
– Washington County Hospital Association, Hagerstown
• Pediatric
– Johns Hopkins Children’s Center :Pediatric Trauma
Center.
– Children’s National Medical Center: Em. Trauma Ser.
Fire Department
911 Center and Dispatch
Records
4
Coordinator
Gathers Data
EMRC
2
1
Data
Coordinator
Paged
Randomization
Request
and Protocol
Assignment
MIEMSS
5
Hospital
Data Submitted
to MIEMSS
3
Patient Transported
4
Coordinator
Gathers Data
5
MAIS Runsheet
Maryland EMS and Trauma
Sources of Funding
• EMS/Fire/911
• Trauma Centers – Hospitals
• Trauma Physicians
Funding of Trauma Services
• Emergency Medical Services Operating
Fund (EMSOF)
– Helicopter Services
– MSFA low-interest loan fund for fire/EMS
apparatus for volunteer organizations
– STC Stand-by costs/equipment costs unique
to role as PARC
– MFRI Support
Funding of Trauma Center Costs
• Hospitals in Maryland are rate regulated
– DRG Waiver since mid-80’s
– All-payer system
– Regulated by HSCRC
• Rates established based on allowed costs and
allowed margin
– Traditional allowed costs include costs associated
with provision of services to uninsured patients
• System protects hospitals with regard to
exposure of costs of uninsured patient care
Maryland Trauma Physician
Services Fund – Context - 2002
• Inadequate specialist coverage of trauma
on-call panels was becoming increasingly
common
• Multiple factors contributed to making the
trauma on-call environment unattractive to
surgeons
• Some of them relate to financial issues
Context
• Financial issues themselves are
multifactoral
– Expense related issues
• Perceived increase in liability exposure
• Opportunity cost of lost time in elective practice
– Income related issues
• RBRVS methodology invalidated by creation of
trauma system!
• Burden of care of uninsured and Medicaid (underinsured) populations
Maryland Trauma System
• One model to address one component of
the problem of physician coverage at State
designated trauma centers
– Successful
– Links physician care at trauma centers to
EMS/Fire/Rescue services
– Recognizes trauma care as an essential
public service distinct from remainder of
traditional health care
Trauma Physician Services
• Richly funded statewide trauma EMS
system ultimately dependent on quality of
physician services provided at trauma
centers.
• 2001-2002 Crisis in coverage at
Hagerstown led to recognition of need to
fund trauma physician services to tip
balance back toward facilitation of
participation in on-call panels
Maryland Trauma Physician
Services Fund
• Funded by $2.50 per year surcharge to
state vehicle registration fee
• Administered by Maryland Health Care
Commission
• Provides payment for physician services
for trauma patients in trauma registry at
state designated trauma centers at
Medicare rates
Maryland Trauma Physician
Services Fund
• On-call payments
• Medicare rates for
– Uninsured
– Medicaid
• Broad spectrum of
specialties
• Grants to hospitals for
equipment costs
• Grants to out-of-state
hospitals that provide
trauma specialty care to
Maryland residents
Trauma Physician Payment
•
•
•
•
•
•
PIP - $2500
Commercial – variable
PPO – Variable
HMO – 140% RBRVS
Work Comp – 144% RBRVS
Uninsured/Medicaid – 100% RBRVS
Ongoing Challenges
• 100% of Medicare is better than nothing
but not adequate for complex trauma
cases.
• Maryland Trauma Physician Services
Fund being raided by hospitals
• Payment to hospitals to reimburse for oncall stipends does not guarantee that oncall physicians will actually care for
patients
Summary
• Trauma care must be regarded as an
essential public service like police and fire
• An integrated model for 911/EMS/Trauma
allows for focus on quality and reliability of
delivery
• All components of delivery must be
adequately funded to achieve excellence
"Americans do the right thing after they've tried everything else" Winston Churchill