Andrew N. Pollak, MD - PowerPoint PPT Presentation

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Andrew N. Pollak, MD

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Title: Andrew N. Pollak, MD


1
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

2
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

3
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)
4
The Golden HourThe Probability of Survival
100
80
Survival Is Related To Severity and Duration
60
Survival
40
20
0
30
60
90
Minutes
5
The First Trauma Center
  • Center for the Study of Trauma was opened by
    Dr. Cowley at the University of Maryland
    Hospital in 1969.

6
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
7
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8
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)

9
Division 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

10
Division 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
11
Continuum 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
12
Maryland EMS System
3
159
32
2
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23
51
Baltimore City
H
7
A
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A
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A
H
A
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A
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
13
PARC
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
14
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)

15
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

16
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)

17
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 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.

18
Fire 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
19
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20
Maryland EMS and TraumaSources of Funding
  • EMS/Fire/911
  • Trauma Centers Hospitals
  • Trauma Physicians

21
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

22
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23
Funding 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

24
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

25
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
    (under-insured) populations

26
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

27
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

28
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

29
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

30
Trauma Physician Payment
  • PIP - 2500
  • Commercial variable
  • PPO Variable
  • HMO 140 RBRVS
  • Work Comp 144 RBRVS
  • Uninsured/Medicaid 100 RBRVS

31
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 on-call
    stipends does not guarantee that on-call
    physicians will actually care for patients

32
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

33
THANK YOU
"Americans do the right thing after they've tried
everything else" Winston Churchill
34
(No Transcript)
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