STATEMENT OF THE PROBLEM
Brain injury constitutes a major public health threat in California. The number of people who sustain brain injury each year in California is estimated to exceed 222,000 per year . These numbers do not include between 144,000 to 342,000 sports-related concussions estimated to occur in California each year . Approximately 52,250 children in California sustain a brain injury and/or are hospitalized with a brain injury each year. These estimates derive from data collected at a National level . Brain injuries arise from a large variety of causes such as falls, motor vehicle accidents, being struck by or against an object, gunshots, stroke, heart attack, viral or bacterial infections, neoplasms, anoxia, toxic exposure and metabolic causes2. The CDC estimates that between 396,000 and 740,000 Californians are living with long-term disability as the result of traumatic brain injury (TBI) .
The statistics of this population are staggering in two regards. The first is that the numbers appear to be so high. The second is that this "silent epidemic" as it has been called for many years remains poorly understood in its scope and size. Epidemiologic studies are complex and difficult and established medical surveillance processes were not designed in anticipation of the myriad of complex issues that brain injury presents.
The event of brain injury begins lifelong disease processes. Disease management for brain injury includes emergency care, intensive care, hospital-based rehabilitation, non-hospital based rehabilitation, and vocational rehabilitation . Recovery from brain injury arising from concussion can be expected for approximately 80 to 95% of all individuals. Of the remainder, 20% will have persistence of at least one symptom for at least one year, while 5% will have five or more symptoms for at least one year . Brain injury is cumulative and repeated injuries constitute a major concern in the form of repeated concussions or more severe injuries .
Access to disease management, medical rehabilitation and vocational rehabilitation has deteriorated drastically since 1990. Length of stay for hospital based treatment in 1990 averaged 77 days, progressed to 48 days in 1999 and stands now between 11 and 46 days according to differing data sets. Hospital-based medical rehabilitation charges changed from $1532 per day in 1990 to $1356 in 1999 and are reported now at as low as $1000. This is equivalent to $618 in 1990 dollars using a 3% annual CPI.
Coverage for disease management, medical rehabilitation and vocational rehabilitation is severely restricted and is being systematically lessened by public and private payers alike resulting in unnecessarily heightened levels of disability, long term cost, job loss, financial impoverishment, and medical indigence . "Subprime" health insurance currently privatizes profit and socialized financial risk by systematically restricting or denying access to medical treatment for the disease of brain injury on par with other diagnoses. The disease of brain injury can cause other disease progression or acceleration. Medical treatment, medical rehabilitation and vocational rehabilitation are known to mitigate disease progression and complication and reduce long term cost of care and societal economic burden9-15.
No Californian has adequate access to appropriate disease management, medical rehabilitation or vocational rehabilitation for brain injury due to payer restrictions and access is sharply and rapidly diminishing. The economic burden associated with non-treatment is systematically shifted to the public sector as insurers disallow access to continued treatment resulting in very high levels of medical acuity and disability. Individuals cannot return to work and they and their families lose their income and health insurance altogether.
The nationally annualized direct and indirect costs of TBI have been estimated to range between $51.2 and $60 billion in the United States while the annual costs for stroke are estimated at $68.9 billion. The true extent of the economic impact to the state cannot be realized because the State has no epidemiology and surveillance program that thoroughly tracks brain injury16. Consequently, the State cannot know the exact economic burden resulting from brain injury. The likely inflated cost of untreated or improperly treated brain injury is distributed at least among California's Departments of Education, Corrections, Health, Rehabilitation, Developmental Disabilities and Medi-Cal programs17,18.
Cost of care for a single disabled person with brain injury over a lifetime can range from $1 to $30 million. Disease management, medical rehabilitation and vocational rehabilitation can save millions of dollars per life when expertly and expediently applied10,12-14,19.
Ample evidence from the private sector points to the clinical and cost effectiveness of intensive, expert multidisciplinary medical rehabilitation and disease management for brain injury of appropriate duration along a continuum of treatment that has evolved over the last thirty years. Workers' compensation systems at the State and national levels have managed billions of dollars in claims through these systems. The most effective management has resulted in marked reduction in disability for individuals with brain injury and marshaled excellent cost-effectiveness for the responsible financial parties. The best practices of these approaches should inform a systematic approach to medical treatment and disease management for all people who suffer a brain injury and the disease processes that follow.
These approaches have definitively demonstrated that medical rehabilitation stands as the single most effective treatment for brain injury in achieving maximized reductions in disability, improvements in independence, improvements in net health outcomes and quality of life, and lifetime cost savings. We know how to better return people to productive lives of independence, work and school, yet we are systematically preventing the majority of individuals who experience brain injury from realizing their best outcomes.
Veterans returning to California after serving in Operation Iraqi Freedom or Operation Enduring Freedom who have suffered brain injury can be expected to be under-counted statistically for many reasons. Whatever the reasons, these individuals and their families will come to know the same difficulties in accessing proper diagnosis and treatment for their neurologic conditions and they will experience similar lifelong disease processes including epilepsy, accelerated onsets of Alzheimer's and other neurodegenerative diseases, neuroendocrine disease, depression, suicide, and an incredible collection of other disease entities. They will fail economically, socially, vocationally, educationally and within their families. They will join the homeless, the medically indigent, the jobless, the institutionalized, the incarcerated and the socially isolated civilians with brain injury who suffer the indignities of brain injury untreated and uncared for. None who understand what military service requires would accept that this is the finest that our country can offer to its finest. While the Veterans' Administration and the Department of Defense struggle valiantly to define and meet the needs of these returning military service men and women, it remains significantly challenged and over-burdened. Claims backlogs alone cause substantial delays in accessing treatment and can range between months and years. Delayed treatment is recovery denied, whether for veterans or civilians, and while the inhumanity and impropriety of such an approach is obvious, the financial ramifications are less so. Simply put, failure to expertly and promptly diagnose and treat costs the Californian taxpayer huge sums of money per patient that are unrivaled by nearly any other medical diagnosis.
The facts about brain injury are compelling. The solutions are elegantly simple and, properly crafted, can provide "win-win" scenarios for all parties. Listed below is a partial list of recommendations:
- Require public and private health plans to cover medically necessary medical rehabilitation for the treatment of brain injury consistent with Medical Treatment Guidelines for Traumatic Brain Injury of the Department of Labor, Division of Workers' Compensation of the State of Colorado across the entire established continuum of treatment. Disallow arbitrary timeframes that constrain treatment to periods of 30 to 100 days and are based rather on patient status and condition.
- Support the Department of Health in establishing a statewide traumatic brain injury registry system and to collect data relating to brain injuries.
- Support the Department of Health in establishing a process for identification of persons with brain injury currently being served by the Departments of Health, Education, Rehabilitation, Corrections, Developmental Disabilities and Medi-Cal programs.
- Increase DMV penalty fund fines commensurate with other States' penalty fund and allocations to provide at least $30 million in novel funding to be distributed between the University of California Brain Injury Research sites ($15 million), Department of Health ($10 million) and the Traumatic Brain Injury Services of California sites ($5 million).
- Require mandatory training of school athletic coaches, trainers, PE teachers, team physicians, and students in brain injury prevention. Require adoption of the CDC Guideline for Concussion by all organized athletic groups and activities. Require the purchase of catastrophic injury protections insurance for all student athletes that provides $5 million coverage for brain injury, spinal cord injury and/or catastrophic amputation and allow for equivalent recovery relief for school districts that purchase such coverage for students.
- Promote adherence to medical treatment standards via MediCal reimbursement policy that provides reimbursement at preferred rates for facilities that choose to adopt and comply with medical treatment standards for brain injury.
- Promote prompt and expert diagnosis and treatment of brain injury and related disease management for veterans and civilians. Establish a clearinghouse of State and Federal resource availability through a single source to enable all with brain injury and/or their families to gain rapid access to services such as housing, transportation, food assistance, return to work, return to school, respite care, and ongoing medical treatment and access.
- Promote injury prevention efforts to reduce the overall incidence of brain injury from falls, sports activities, motor vehicle and other cause.
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