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					     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

              80
                               Survival Is Related To
% Survival




              60               Severity and Duration

              40

              20

              0
                          30           60        90
                                Minutes
     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        4200 Surgical Cases
  year                       ALOS 4.65 days
 Approx 40% by air &         – ALOS for isolated femur
  60% by ground                 fracture less than 48
 Primary trauma                hours
  referral center for 1.5    90 total overnight beds
  million people
                              (36 critical care)
 Secondary trauma
  referral center for 6
  million people
      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    Walter Reed Army
 Columbia University        Medical Center
 New York University –     Bethesda – National
  Hospital for Joint         Naval Medical Center
  Diseases                  Tripler Army Medical
 Lenox Hill Hospital        Center
 Union Memorial            Johns Hopkins
  Hospital                   University


          Educational Mission
                            Continuum of Care
                            Emergency Incident
                             Citizen Access “911”
        Dispatch                                              Dispatch Units
Information Pre-arrival Information                        Fire BLS ALS Specialty Uni

  Medical Consultation        Patient Assessment
                                      Transport
                              Ambulance Medic Helicopter


      Hospital Emergency Department or Specialty Center

         Rehabilitation                      Return to Society
            Maryland EMS System
3           32                     2                                     159
H                    A             H       A


                                               51                   23
                 Baltimore City                                     H          7
                 A                                  A
                                 H                                             H
                 H
                             H
                         H     A
                 H
                          H    H       A
                         A H H
                 H                     H                        A
                         H     H                        H H
                     H                                    H
                 H
                         H                                160            13
                                                                                   116
                                                                         H


                                                                                   A
    A
        Areawide Trauma Centers
    H   Specialty Referral Centers
    H   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
              H            Pediatric
               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

                                                            Coordinator
                                                        4   Gathers Data



                                             EMRC
                                                            2
                            Randomization                       Data
                               Request                       Coordinator
                        1    and Protocol                       Paged
                                                                                              MIEMSS
                              Assignment


                                             Hospital
                                                                                         5
                                                                                   Data Submitted
                                                                                    to MIEMSS


                               3
                                                                            4
                       Patient Transported
                                                                    Coordinator
                                                                    Gathers Data



                        MAIS Runsheet
                   5
  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 (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

				
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