OPTIMIZATION OF ARRANGEMENT OF MEDICAL AID IN ROAD TRAFFIC ACCIDENTS WITH PARTICIPATION OF LEGAL SUPPORT FROM SERVICE OF AVERAGE COMMISSIONERS
Bashkir State Medical University,
Ufa, Bashkortostan
At the present time, arrangement of medical assistance for victims of road traffic accidents [1] has overgrown the limits of strictly departmental approach [2, 3]. Optimization of efficiency of such activity without legal backing from services of average commissioners is not possible now. Increasing severity of such injuries, increasing level of social claims from the side of consumers of such specific type of services, as well as delay of regulatory and legal framework and chronical discrepancy between the medico-economic standards and the level of social economic development of the society has shown the whole range of problems and mismatches in the field of medical services [4, 5]. Dynamic development of the society has stimulated the increase in the level of consumer wants and expectations in the field of traumatological and orthopedic services for associated injuries after road traffic accidents (RTA) [4, 6].
The federal law about Mandatory Third Party Liability (MTPL) [7] (40-FZ, April, 25, 2002, “About Mandatory Vehicle Insurance”) was accepted in 2002. According to the law, the owners of motor vehicles make obligatory motor vehicle insurance for the third parties in case of damages as result of road traffic accidents. As for the compensation for health damage, the insurance limit is 160,000 roubles for each victim. According to MTPL rules, this limit includes the compensation of personal costs for treatment of road traffic injuries. For enforcement of the rights for the compensation, a victim addresses to an insurance company and presents the required package of the documents. A victim may use the services of average commissioners during gathering the necessary documents about a road traffic accident.
An average commissioner is a universal specialist in the field of road traffic safety and basics of insurance business who administers support, consultations and preparation of necessary documents for insurance compensation.
The services of average commissioners appeared in 1990s in Moscow and Saint Petersburg and thereafter in other cities. The services were developed by the insurance companies for identification of causes, patterns and amount of damages in insurance event of road traffic, first of all, for benefit of insurance carriers. But over the course of time they found some disadvantages or even diseconomy of such departments in an individual insurance company. Gradually, the services of average commissioners became more purpose-designed and independent. As result, the priorities have altered. Currently, the services of average commissioners work for benefit of victims.
The service of average commissioners for road injuries consists of three departments (Fig. 1):
1. The operational department.
The staff includes average commissioners. They receive calls from victims and their relatives, bystanders of road traffic accidents, doctors. An average commissioner is presented by any individual person with powers from the patient with Russian passport. The patient powers of an average commissioner are formalized with the notarial assignment.
In a behalf of the patient, average commissioners communicate with police and get necessary documents. If necessary, they help to arrange forensic medical expertise.
In a behalf of the patient, average commissioners communicate with employees of medical facilities, record medical prescriptions and discharge reports, make assistance in provision logistics and execution of treatment, collect documents for an insurance company.
In a behalf of the patient, average commissioners deliver all documents to legal department.
2. The legal department.
The staff includes lawyers who make a specialty out of judicial cases relating to health damage after RTA.
In a behalf of the patient, layers pass documents to insurance companies, judiciary establishments, court enforcement officers, banks. Also they carry on insurance polemics with insurance companies.
3. Assets Logistics.
The staff may include both individual and juridic persons. The aim of the department is to realize medical prescriptions for treatment with use of modern technologies, metal constructs, measures of care, orthoses, ambulatory accompaniment, rehabilitation, health resort treatment.
Figure 1
The organizational structure of the service of average commissioners of road traffic injury
CLINICAL RESULTS
The study included clinical records, the outcomes of injuries and health information from the average commissioners in relation to 207 patients with associated injuries who were treated in the hospitals of Ufa and Bashkortostan republic. The main group included the medical documents of the victims of RTA who received support from the average commissioners (101 persons). The control group included 106 persons who received treatment without support from average commissioners. The highest proportion of the patients falls within the age of 40-50 (26 %). The proportion of pedestrians was 57 %, passengers – 30 %, drivers – 13 %, men – 44 %, women – 56 %.
The dominating injuries after RTA were injuries to girdle of the inferior extremity (the pelvis – 21 %, the hip and the leg – 73 %), soft tissues (wounds, traumatic detachment of soft tissues – 51 %), injuries to girdle of the superior extremity (the upper arm, the forearm – 35 %), TBI with damages of fascial skeleton and cranial vault (22 %), thoracic (25 %), abdominal (18 %) and spinal injuries (16 %) [9, 10].
The patient with associated injury requires significant material and financial costs, which significantly exceed the volume of compulsory medical insurance [2, 6, 8]. It results in appearance of the conditions for preferable use of cheaper constructs, materials and implants, and, therefore, worsening operational properties and necessary conservative treatment of some injured segments. Therefore, eclecticism of approaches appears because of discrepancies between medical doctrine and financial economic provision, and it results in worsening outcomes of treatment, impeding early medical rehabilitation, social and home reintegration.
All necessary range of metal constructs was timely provided for the patients under supervision of the service of average commissioners. It decreased the period of aftercare after hospital discharge, time of rehabilitation and future disability.
The comparative analysis included the surgical patients with legal backing from the service of average commissioners and the patients without additional financial and legal support. With the support of the service of average commissioners the high amount of surgical interventions was realized with use of modern technologies and expensive qualitative metal constructs (Fig. 2). Treatment was payed according to the federal law #40 “About Mandatory Insurance of Civil Liability for Owners of Motor Vehicles”.
Figure 2
Activity of surgical treatment with support from the service of average commissioners
The method of two-way analysis of variance was used for examination of influence of the service of average commissioners on time intervals of hospital treatment and time of posthospital recovery and rehabilitation. The time intervals of hospital treatment were almost identical in both groups (it is explained by the requirements of the medical and economic standards about adherence to time schedule of hospital stay), but the presurgical period was significantly shorter in the group with support from the service of average commissioners. The patients with mild health damage did not show any specific changes in time intervals of treatment. The significant decrease in time intervals of treatment and rehabilitation was noted in the injuries of middle and severe health damage. Also we noted the decreasing number of disability cases and lethal outcomes as result of injuries after RTA.
Use of legal support from the service of average commissioners provided the possibility for guiding the patient both in the period of hospital treatment and the whole duration of treatment and rehabilitation (from the moment of hospital admission from the accident site to full recovery including outpatient aftercare and health resort treatment) (Fig. 3).
Figure 3
Possibilities for follow-up of the patient according to the number of days. The stages of arrangement of medical assistance
The decreasing amount of days of outpatient treatment for the victims of RTA who received support from the service of average commissioners was associated with more qualitative hospital treatment. Longer rehabilitation period gives the possibilities for recovery, social and home reintegration of patients with severe concomitant injuries after RTA, and it is realized with full volume with engagement of additional sources of income for payment of health resort treatment and lost income.
After attraction of the service of average commissioners in health issues the new possibilities for treatment of patients after RTA appeared:
1) the extensive standards of realization of assistance (posthospital period of rehabilitation);
2) the evident decrease in the amount of complications (early professional rehabilitation, social reintegration, satisfaction of life quality);
3) representation of patient’s interests by lawyers (it is essential for patients with severe injuries who cannot represent own interests in an insurance company or the court);
4) enhancement of remedial factors (availability of expensive and qualitative drug therapy);
5) the model of optimal treatment:
a) minimization of iatrogenic events;
b) increasing quality of surgical treatment;
c) choice and adaptation of individual orthoses;
d) treatment in posthospital period (availability of home follow-up by specialized doctors, continuous orthopedic and traumatologic follow-up, dynamicity of observation, a recreation therapist);
e) rehabilitation in recovery period.
The analysis included treatment and the outcomes of associated multiple skeletal injuries after RTA in Bashkortostan in 2007-2015. The analysis has identified some perspective possibilities for improving quality of specialized medical aid for RTA victims. Such possibilities are based on higher quality of diagnostics, early effective treatment of skeletal injuries in shockogenic regions as a part of stable functional osteosynthesis and early functional rehabilitation that resulted in significant decrease in errors and complications and returning the patients to the basic microsocium.
The complex approach to arrangement of orthopedic and traumatologic assistance for multiple associated skeletal injuries after RTA with participation of the service of average commissioners significantly simplified the activity of the traumatologist-orthopedist and excluded accomplishment of inappropriate functions (such as material provision, execution of legal acts, accompanying the patient at all stages of treatment, return to the basic microsocium). Legal support excluded any claims and complaints of customers of medical services because of adequate and substantiated enforcement actions and objective understanding of rehabilitation expectations. Use of legal support excluded any uncertainty in prejudgement of a medical doctrine. Such law enforcement practice has allowed realization of the rational scheme for medical, legal and social doctrine of rehabilitation for RTA victims.
The modern level of development of the socioeconomic system (6th technological mode according to Schumpeter) has escalated the problem of estimation of outcomes of medical aid in socially significant traumatic injuries. Currently, one of the most acute problems is associated injury after RTA [1, 4, 5, 8]. Unfavorable outcomes are already beyond the bounds of life threatening or fatal injuries. The essential question is improvement of results of arrangement of specialized assistance.
At the modern level of social development, one of the efficient tools of the complex approach to medical aid for victims of RTA is use of legal support from the service of average commissioners. Legal support gives significant improvement of outcomes, expertise and monitoring of such social phenomenon and may be efficiently used both in daily practice and making administrative decisions.
CONCLUSION
1. Medical activity has the legal support from obligatory and voluntary medical insurance. However there are some limitations in regional budgets of hospitals, absence of motivation and succession. Medical, social and legal techniques of arrangement of aid for victims of RTA should involve early social and professional reintegration of patients with associated skeletal injuries, with main emphasis on legal support from the service of average commissioners.
2. Mistakes and complications during surgical treatment of skeletal injuries in RTA victims are conditioned by limited financial provision of the medical and economic standard at regional, municipal and intrahospital levels, delay in time of accomplishment of surgery, absence of succession between hospital, outpatient and rehabilitation treatment, absence of vigilance in development of early and long term complications (pulmonary embolism, phlebothrombosis and others).
3. The doctrine of treatment should include succession, subsequence and completeness of each clinical case, average commissioner’s estimation of health in social and home integration of victims of RTA.
4. Participation of average commissioners in health issues allows early medical and psychologic rehabilitation, as well as social and home reintegration for RTA victims.
The amendments for the federal law about Mandatory Third Party Liability are valid from April, 1, 2015. The insurance limit for health damage has increased from 160 to 500 thousand roubles. As result, the patient, the doctor and the average commissioner will have some additional possibilities for improvement of quality of treatment of road traffic injuries.