Andrew N. Pollak, MDAndrew N. Pollak, MDProgram Director and HeadProgram Director and Head

Division of Orthopaedic TraumaDivision of Orthopaedic TraumaUniversity of Maryland School of MedicineUniversity of Maryland School of Medicine

Associate Director of TraumaAssociate Director of TraumaR Adams Cowley Shock Trauma CenterR Adams Cowley Shock Trauma Center

Medical DirectorMedical DirectorBaltimore County Fire DepartmentBaltimore County Fire Department

Special Deputy United States MarshalSpecial Deputy United States Marshal

Commissioner – Maryland Health Care CommissionCommissioner – Maryland Health Care Commission

Maryland vs. GeorgiaMaryland vs. Georgia

MarylandMaryland– 5.6 million people5.6 million people– 12,500 sq miles12,500 sq miles– $68,000 median income$68,000 median income– Density – 5Density – 5thth in US in US

GeorgiaGeorgia– 9.6 million people9.6 million people– 60,000 sq miles60,000 sq miles– $43,000 medial income$43,000 medial income– Density – 18Density – 18thth in US in US

The VisionThe Vision

The Maryland System was created The Maryland System was created by the vision and leadership of by the vision and leadership of

Dr. R Adams CowleyDr. R Adams Cowley

Accidental Death and Disability: Accidental Death and Disability: The Neglected The Neglected Disease of Modern Society (1966)Disease of Modern Society (1966)

The Golden HourThe Golden HourThe Probability of SurvivalThe Probability of Survival

MinutesMinutes

% S

urv

ival

% S

urv

ival

00

2020

4040

6060

8080

100100

3030 6060 9090

Survival Is Related ToSurvival Is Related ToSeverity and Duration Severity and Duration

The First Trauma CenterThe First Trauma Center

Center for the Study of Trauma was opened Center for the Study of Trauma was opened by Dr. Cowley at the University of by Dr. Cowley at the University of Maryland Hospital Maryland Hospital in 1969.in 1969.

Maryland EMS HistoryMaryland EMS History Golden HourGolden Hour Development of Development of

trauma center networktrauma center network Development of Development of

helicopter networkhelicopter network Development of EMS Development of EMS

NetworkNetwork

"Politics is not a spectator sport" John F. Kennedy

R Adams Cowley Shock Trauma R Adams Cowley Shock Trauma CenterCenter

7500 Admissions per 7500 Admissions per yearyear

Approx 40% by air & Approx 40% by air & 60% by ground60% by ground

Primary trauma Primary trauma referral center for 1.5 referral center for 1.5 million peoplemillion people

Secondary trauma Secondary trauma referral center for 6 referral center for 6 million peoplemillion people

4200 Surgical Cases4200 Surgical Cases ALOS 4.65 daysALOS 4.65 days

– ALOS for isolated femur ALOS for isolated femur fracture less than 48 fracture less than 48 hourshours

90 total overnight beds 90 total overnight beds (36 critical care)(36 critical care)

Division of Orthopaedic TraumaDivision of Orthopaedic TraumaResearch – Education – Clinical CareResearch – Education – Clinical Care

7 Full time faculty members7 Full time faculty members 10 Orthopaedic residents 10 Orthopaedic residents 4 Orthopaedic trauma fellows4 Orthopaedic trauma fellows

– Expanding to 5Expanding to 5 3000 orthopaedic trauma cases annually3000 orthopaedic trauma cases annually 400 pelvis and acetabulum cases annually400 pelvis and acetabulum cases annually $500,000 per year research funding$500,000 per year research funding 20-30 Academic peer reviewed publications 20-30 Academic peer reviewed publications

per yearper year

Division of Orthopaedic TraumaDivision of Orthopaedic TraumaResidency ProgramsResidency Programs

University of MarylandUniversity of Maryland Columbia UniversityColumbia University New York University – New York University –

Hospital for Joint Hospital for Joint DiseasesDiseases

Lenox Hill HospitalLenox Hill Hospital Union Memorial Union Memorial

HospitalHospital

Walter Reed Army Walter Reed Army Medical CenterMedical Center

Bethesda – National Bethesda – National Naval Medical CenterNaval Medical Center

Tripler Army Medical Tripler Army Medical CenterCenter

Johns Hopkins Johns Hopkins UniversityUniversity

Educational Mission

Emergency IncidentEmergency Incident

Citizen Access “911”Citizen Access “911”DispatchDispatch Dispatch UnitsDispatch Units

Patient AssessmentPatient Assessment

TransportTransport

Hospital Emergency Department or Specialty CenterHospital Emergency Department or Specialty Center

RehabilitationRehabilitation Return to SocietyReturn to Society

Information Pre-arrival Information

Medical Consultation

Ambulance Medic Helicopter

Fire BLS ALS Specialty Unit

Continuum of CareContinuum of Care

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Maryland EMS SystemMaryland EMS System

Baltimore CityBaltimore City

Areawide Trauma CentersSpecialty Referral CentersHospitalsCentral AlarmsEMSTel Telephone NetworkMedical Command Consultation Centers

TraumaTraumaCentersCenters

SpecialtySpecialtyReferralReferralCentersCenters

PARCPARC

Level ILevel I

Level IILevel II

Level IIILevel III

Local Emergency DepartmentsLocal Emergency Departments

BurnBurn

EyeEye

HyperbaricHyperbaric

PerinatalPerinatal

Head and SpineHead and Spine

PediatricPediatricH

H

HH

Maryland’sMaryland’sTraumaTraumaSystemSystem HandHand

Maryland EMSMaryland EMS• System highlightsSystem highlights

– 5 regions5 regions– 24 jurisdictions (23 counties and the city of 24 jurisdictions (23 counties and the city of

Baltimore) plus statewide EMS agenciesBaltimore) plus statewide EMS agencies– 31 commercial ambulance services31 commercial ambulance services– Statewide EMS Advisory Council (SEMSAC)Statewide EMS Advisory Council (SEMSAC)– EMS Board appointed by GovernorEMS Board appointed by Governor– EMS and trauma funding through $13.50 EMS and trauma funding through $13.50

surcharge on vehicle registrationsurcharge on vehicle registration– Majority of EMS providers are volunteer with a Majority of EMS providers are volunteer with a

strong state association (MSFA)strong state association (MSFA)

Maryland EMSMaryland EMS• System highlightsSystem highlights

– Statewide EMS communications system operated Statewide EMS communications system operated by MIEMSSby MIEMSS

– Statewide protocols for EMS providersStatewide protocols for EMS providers– Statewide data systemStatewide data system– Uniform QI and medical oversight requirementsUniform QI and medical oversight requirements– ALS available in all jurisdictionsALS available in all jurisdictions– MSP Med-Evac program with 8 bases across the MSP Med-Evac program with 8 bases across the

state transporting more the 3000 patients/yearstate transporting more the 3000 patients/year– Trauma, EMSC and EMS systems are integratedTrauma, EMSC and EMS systems are integrated

Maryland EMSMaryland EMS

• System highlightsSystem highlights– R A Cowley Shock Trauma Center is a statewide R A Cowley Shock Trauma Center is a statewide

trauma resource by statutetrauma resource by statute

– 8 additional adult trauma centers and 2 pediatric 8 additional adult trauma centers and 2 pediatric trauma centerstrauma centers

– MFRI provides EMT-B training and EMS CMEMFRI provides EMT-B training and EMS CME

– ALS training provided by jurisdictions, ALS training provided by jurisdictions, community colleges and UMBC (up to masters community colleges and UMBC (up to masters degree) degree)

• Primary AdultPrimary Adult– R Adams Cowley Shock Trauma Center, R Adams Cowley Shock Trauma Center,

University of Maryland Medical CenterUniversity of Maryland Medical Center• AreawideAreawide

– Johns Hopkins Bayview Medical CenterJohns Hopkins Bayview Medical Center– Memorial Hospital and Medical Center of CumberlandMemorial Hospital and Medical Center of Cumberland– Peninsula Regional Medical Center, SalisburyPeninsula Regional Medical Center, Salisbury– Prince George’s Hospital Center, CheverlyPrince George’s Hospital Center, Cheverly– Sinai Hospital of BaltimoreSinai Hospital of Baltimore– Suburban Hospital, BethesdaSuburban Hospital, Bethesda– Washington County Hospital Association, HagerstownWashington County Hospital Association, Hagerstown

• PediatricPediatric– Johns Hopkins Children’s Center :Pediatric Trauma Johns Hopkins Children’s Center :Pediatric Trauma

Center.Center.– Children’s National Medical Center: Em. Trauma Ser.Children’s National Medical Center: Em. Trauma Ser.

Trauma CentersTrauma Centers

EMRCEMRCFD

Station1Station1

Fire Department911 Center and Dispatch

Records

MIEMSS

Hospital

Patient Transported

DataCoordinator

Paged

Randomization Request

and Protocol Assignment

Data Submitted to MIEMSS

Coordinator Gathers Data

MAIS Runsheet

Coordinator Gathers Data

1

2

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4

5

5

Maryland EMS and TraumaSources 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 (under-

insured) 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 on-call stipends does not guarantee that on-call 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