Future Medical Costs: Life Care Planning & The Crystal Ball. By Michele Nielsen, RN, MA, CCM, CRC, COHN-S, CPDM, CLCP

Transcription

1 Future Medical Costs: Life Care Planning & The Crystal Ball By Michele Nielsen, RN, MA, CCM, CRC, COHN-S, CPDM, CLCP Corinne 1 was born prematurely and weighed 2½ pounds. At six days of age a hole in her heart was repaired and a few days later she needed a shunt inserted from her brain to her abdomen to relieve hydrocephalus. During this initial hospitalization Corinne developed a perforated bowel and consequently underwent abdominal surgery. As a result of these early days, she was diagnosed with cerebral palsy (CP) and retinopathy of prematurity. At five years Corinne was able to move her arms and legs purposefully, say Mama, Daddy, use a communication board, and play with toys. She was attending pre-school. Her parents watched her carefully and took her to the hospital whenever her behavior varied from normal because they quickly learned this was indicative of shunt malfunction. When Corinne was nearly six years old she developed some vomiting, was listless and her color was poor. Her parents called an ambulance. Corinne was transported to the local major trauma center. Corinne arrived at the emergency department at 12:39 p.m. but the ED did not call her regular pediatric surgeon for over two hours, even though the parents were insistent that something was terribly wrong. As soon as Dr. Jones arrived, she took Corinne to the operating room to revise the shunt. Over three hours elapsed from the time Corinne was admitted to the ED and emergency surgery. As a result of the delay, Corinne is now in a persistent vegetative state (PVS). 1 All names have been changed.

2 You are taking this case to trial. How do you separate the pre-existing conditions from those caused by the malpractice? How do you determine, and present to the jury, economic damages? What medical care will be needed in the future? What happens when Corinne s parents are too old to continue to care for her? A Certified Life Care Planner is uniquely qualified to answer these questions. The Life Care Planner becomes involved in the overall presentation of proof regarding the nature, extent, and consequences of the injury to a person and the impact on their life. i Life Care Planning Life Care Planning is a subspecialty within the practice of rehabilitation which provides a road map for guiding patients, providers, and payers toward an appropriate long-term plan of care. ii Vocational counselors, clinical social workers, physicians, nurses, and others seek national certification in this subspecialty. The Life Care Planner addresses medical, social, educational and vocational needs of the individual through discussions and meetings with the treating physician, physical and occupational therapists, teachers, and others. Regarding Corinne, a developmental pediatrician examined her and differentiated pre-existing conditions from current conditions. In order to determine Corinne s economic damages, a Life Care Plan was developed that included Projected Evaluations, Projected Therapeutic Modalities, Routine Medical Care, Diagnostic Testing, Assistive Technology, Community Living Supports, Home Care Services, Medications, Supplies, Equipment Needs, Anticipated Surgical Interventions, Anticipated Hospitalizations, and Architectural Renovations. Actual costs were obtained 2

3 by calling physicians, therapists, hospitals, and Internet research. A partial example is shown in Tables 1 and 2. Table 1 Projected Evaluations Neurologic Evaluation Orthopedic Evaluation Neurosurgery Evaluation Occupational Therapy Evaluation Age/Year Initiated Age/Year Stopped Per Year Treatment Base Cost/Yr 7/2005 Life 1x/yr $455 Expectancy (LE) 7/2005 LE 1x/yr $258 7/2005 LE 1x/yr $258 7/2005 LE 2x/yr $400 Table 2 Projected Therapeutic Modalities Occupational Therapy Physical Therapy Age/Year Initiated Age/Year Stopped Per Year Treatment 7/2005 LE 50 $200/session 7/2005 LE 100 $150/session Base Cost/Yr $10,000 $15,000 Using the Life Care Planner s research and narrative report outlining the history of the case and the impact on the individual s future, the attorney then employs an economist to provide a present net value (PNV). The economist and the Life Care Planner communicate if there are any questions. For example, for another child with cerebral palsy, costs for an Optometrist and the need for eyeglasses were listed in the Life Care Plan under Routine Medical Care. However, these services were only projected to the age of 40. The economist questioned this end-point to make sure the Life Care Planner did not intend for these costs to occur through this child s lifetime. The 3

4 optometrist s office had told the Life Care Planner that people generally need glasses around the age of 40 because of presbyopia. Consequently, these costs were predicted only until age 40, as it would be anticipated to be a normal cost after that age. When a Life Care Planner is being cross-examined during trial, it is best to foresee the question, Ms. Nielsen, why are you costing out eye care throughout Jane s life when almost all people have to have eyeglasses around the age of 40? Of course, certain conditions warrant this cost beyond what a healthy individual would require, but this was not the case for this child. Loss of Earning Capacity If the Life Care Planner is credentialed in vocational rehabilitation, (s)he is qualified to include Loss of Earning Capacity. As Roger Weed has published, we should not confuse lost earnings with the capacity to earn. iii Dr. Weed has devised the mnemonic RAPEL method for determining earnings capacity. R stands for the Rehabilitation Plan, which may include vocational assistance, tuition, rehabilitation technology equipment and supplies. A ccess to the labor market, based on the SSDI concept of employability, determines worker traits, cognitive capabilities, and identification of jobs. The P in RAPEL refers to placeability, the real-world test of determining if the client can be successfully placed in a job. E refers to earnings capacity, based on the ability to earn an income, that earning capacity which the individual can reasonably attain and hold. The L refers to the labor force participation, or worklife expectancy, rate. It may take longer to find a job or to enter the labor market 4

5 than if the disability had not occurred. Time off work may be necessary for medical treatment, for example to treat pressure sores with a quadriplegic, paraplegic, or amputee. Less Catastrophic Cases Though you do not have all past medical expense bills in hand, it is possible to determine future costs on the basis of similar research as that done for a Life Care Plan in cases that are less catastrophic than that requiring a full Life Care Plan. Mr. Crawford was referred by the workers compensation insurance carrier in November He was a 44-year-old man who had sustained a left hand injury in 2001 and underwent three surgical procedures. His claim was closed in In mid-2004 Mr. Crawford began treating again in the same orthopedic clinic and his physician recommended surgery to remove hardware, a repeat tenolysis, and a PIP joint replacement. A second (staged) procedure was recommended to fuse the DIP joint. The following research was conducted: Table 3 CPT codes 26536, 20680, Source Cost MD & Assistant MD $5,373 Anesthesia Oregon Anesthesiology Approx. $1,050 Hospital Hospital Approx. $3,200 Hand Therapy Therapy Firm Approx. $2,750 Total: Approx. $12,373 Life Expectancy Life expectancy is the average of the survival times for the population, representing the expected number of years remaining for a typical member of the population. For a healthy population, life tables are used. It is impossible to predict an 5

6 individual s actual survival time accurately, except perhaps for persons scheduled for execution. iv Main factors in determining life expectancy are mobility, feeding and other basic functional skills. For most Life Care Plans, the Life Care Planner uses statistics for the general healthy population. Recent literature indicates sufficient studies exist to allow for some reduction in life expectancy for certain types of injuries. For example, a three-year-old male with cerebral palsy has different life expectancies as follows: Table 4 Group Life Expectancy (years) Unable to lift head, fed by gastrostomy 13 Able to lift head, fed by gastrostomy 20 Able to lift head, can feed self 46 Able to roll over, can feed self 56 General population 71 v Studies of large populations of spinal cord injured people have also provided enough statistics to allow determination of life expectancy: Table 5 v Group Life Expectancy (years), males, aged 25 Ventilator dependent 20 High quadriplegia (C1-C4) 32 Low quadriplegia (C5-C8) 38 Paraplegia (T1-S5) 42 General population 50 Not enough data is available to determine reduction of life expectancy for clients with acquired brain injury. If such a client is reasonably mobile, there may be little impact on life expectancy, and if (s)he is completely immobilized, then the life 6

7 expectancy may be decreased at most 15 years. As with those with cerebral palsy, clients who can walk well without support tend to have near-normal life expectancies. Corinne s Outcome With the plaintiff attorney s skill in trial preparation and mediation, and with information provided by the Life Care Plan, economist s report, and physicians input, Corinne s case was settled twelve days before trial. Conclusion It is possible to determine damages even if you have limited information. Your expert is able to help with case and trial preparation and with expert testimony (which is essentially simply educating the jury). To locate certified Life Care Planners in every state, please consult The American Association of Nurse Life Care Planners web site is i Fick, Nathaniel. Journal of Life Care Planning. Strategies For Selecting or Being Selected as the Life Care Planner Expert. (163-9) 2:3. ii Roughan, Jan. Inside Case Management. Life Care Planning: A Case Management Approach. 5:10 (9-12) 1/99. iii Weed, Roger. The Rehabilitation Professional. Assessing the Worth of a Child in Personal Injury Litigation Cases. (29-43) Jan/Feb iv Strauss, David. Shavelle, Robert. AVMA Medical & Legal Journal. Life expectancy: what lawyers need to know. v Pacuido, David. Strauss, David. Stavrie, Robert. LNC Resource. Life Expectancy: What Does It Really Mean? (18-19) Jan

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