Title: Andrew N. Pollak, MD
1Andrew 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
2Maryland 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
3The 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)
4The Golden HourThe Probability of Survival
100
80
Survival Is Related To Severity and Duration
60
Survival
40
20
0
30
60
90
Minutes
5The First Trauma Center
- Center for the Study of Trauma was opened by
Dr. Cowley at the University of Maryland
Hospital in 1969.
6Maryland 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
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8R 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)
9Division of Orthopaedic TraumaResearch
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
10Division of Orthopaedic TraumaResidency 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
11Continuum of Care
Emergency Incident
Citizen Access 911
Dispatch
Dispatch Units
Information
Pre-arrival Information
Fire BLS ALS Specialty Unit
Patient Assessment
Medical Consultation
Transport
Ambulance Medic Helicopter
Hospital Emergency Department or Specialty Center
Rehabilitation
Return to Society
12Maryland EMS System
3
159
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2
H
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A
A
23
51
Baltimore City
H
7
A
A
H
H
H
H
A
H
H
H
H
A
H
A
H
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A
H
H
H
H
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160
13
116
H
A
Areawide Trauma Centers Specialty Referral
Centers Hospitals Central Alarms EMSTel Telephone
Network Medical Command Consultation Centers
A
H
H
13PARC
Burn
Level I
Eye
Trauma Centers
Marylands Trauma System
Specialty Referral Centers
Hand
Level II
Head and Spine
Level III
Hyperbaric
H
Pediatric
H
H
H
Perinatal
Local Emergency Departments
14Maryland 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)
15Maryland 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
16Maryland 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)
17Trauma 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 Georges Hospital Center, Cheverly
- Sinai Hospital of Baltimore
- Suburban Hospital, Bethesda
- Washington County Hospital Association,
Hagerstown - Pediatric
- Johns Hopkins Childrens Center Pediatric Trauma
Center. - Childrens National Medical Center Em. Trauma
Ser.
18Fire Department 911 Center and Dispatch Records
911 Call
Coordinator Gathers Data
4
EMRC
2
Data Coordinator Paged
Randomization Request and Protocol Assignment
1
MIEMSS
5
Data Submitted to MIEMSS
3
4
Patient Transported
Coordinator Gathers Data
MAIS Runsheet
5
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20Maryland EMS and TraumaSources of Funding
- EMS/Fire/911
- Trauma Centers Hospitals
- Trauma Physicians
21Funding 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
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23Funding of Trauma Center Costs
- Hospitals in Maryland are rate regulated
- DRG Waiver since mid-80s
- 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
24Maryland 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
25Context
- 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
(under-insured) populations
26Maryland 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
27Trauma 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
28Maryland 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
29Maryland 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
30Trauma Physician Payment
- PIP - 2500
- Commercial variable
- PPO Variable
- HMO 140 RBRVS
- Work Comp 144 RBRVS
- Uninsured/Medicaid 100 RBRVS
31Ongoing 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 on-call
stipends does not guarantee that on-call
physicians will actually care for patients
32Summary
- 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
33THANK YOU
"Americans do the right thing after they've tried
everything else" Winston Churchill
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