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Multiple Issues with Multiple Trauma
Albert E. Holt, IV, MD, MBA Chief Medical Officer
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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
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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
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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
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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%
6© Paradigm Management Services, LLC
7© Paradigm Management Services, LLC
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
8© Paradigm Management Services, LLC
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
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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
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
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11© Paradigm Management Services, LLC
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
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
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!
12© Paradigm Management Services, LLC
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
Acute Inpatient
Rehab
Outpatient Rehab
13© Paradigm Management Services, LLC
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
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
Acute Inpatient
Rehab
Outpatient Rehab
14© Paradigm Management Services, LLC
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
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
Acute Inpatient
Rehab
Outpatient Rehab
15© Paradigm Management Services, LLC
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)
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
Acute Inpatient
Rehab
Outpatient Rehab
16© Paradigm Management Services, LLC
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
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
Acute Inpatient
Rehab
Outpatient Rehab
17© Paradigm Management Services, LLC
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
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
Acute Inpatient
Rehab
Outpatient Rehab
18© Paradigm Management Services, LLC
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
Acute Emergency Management
PrimarySurvey Resuscitation Secondary
SurveyEmergency
ManagementTertiary Survey
Definitive Acute Mgmt
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
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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
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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
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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.
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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© Paradigm Management Services, LLC
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
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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.
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.
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Bio
SocialPsycho
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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
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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
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