EP 23: Evaluating Long-Term Medical Costs After a Catastrophic Injury (Part 2)

Well, so I'm just thinking about like, for myself, like, I have an old sports injury in my knee, for example, and, and it bothers me, sometimes I'm working out or whatever, it'll bother me sometimes, and but I can get by and I mean, I can adjust or whatever. So it doesn't really affect my work, or it doesn't really affect my ability to do the things I need to do to take care of my kids or get around the house or take care of my household responsibilities. But I'm thinking, Well, you know, once I get to be 6070 7580, that that knee might play a, that aggravated knee might cause a bigger and bigger problem going forward, do you have ways of accounting for that or identifying those types of issues? Um,

that would be up to the orthopedic surgeon, maybe an MRI, and then they will determine whether the injury exasperated and old injury. As a nurse, we do not diagnose. With medical diagnosis, we only do nursing diagnosis.

So you mentioned earlier that you you might there's certain circumstances in which you might reach out to the treating physicians or the orthopedist for those kinds of things. So how often do you do that? And what does that typically look like?

So like during life care plans, I will do an assessment of the client after I've reviewed their records and summarize them. And then after the assessment, I'll put a questionnaire together, and I will send that out to their physician, then I will do follow ups, making sure they got the form, they filled out the form, after they've sent it back, I review it, I make sure that I've addressed everything, and then I will make sure I reach out to the client one more time make sure that what I have addressed is what they're saying is what they've addressed. And then I will collaborate, call that physician and go over their, the clients questionnaire with them based on what their recommendations are, make sure there are no changes, and I didn't misinterpret something.

Okay, so So then, let me ask you this, is does any part of your let's take somebody who's, you know, paralyzed or lost a limb, for example, in one of these catastrophic accidents? At you know, you read about medical technology, you read about the future of medicine, and all the different things they're doing, whether it's stem cells, or sort of, you know, prosthetic limbs or artificial intelligence or whatever. Does any of your work account for any of these sort of break? technologies that might really change and impact a person who's suffered a catastrophic injury? Or is it more sort of conventional type things?

No, absolutely. I just did a cost projection for a gentleman who had a crush injury, and he lost these two fingers, his pinky and his ring finger, and I reached out to two different prosthetic people, and one person does them to where they look almost natural. So it's like your real finger, and then one is more mechanical. So I got cost projections for those. And I put those in my cost projection, but I left both different ones in there and versus taking one over the other because I'm not that client. And he gets the option to decide, do I want more natural looking? Or do I want the, you know, the mechanical one. So that was sent back to the attorney for them to discuss with the client so that they could incorporate which one that he would prefer? Because he was, you know, very depressed from losing his fingers and not looking natural. And so we had to do some psychology, evaluations and therapy for him on that as well. So no, we definitely take into futures.

You find. Sorry. That's okay. Do you find a lot of people after a catastrophic injuries have psychological injuries that are diagnosed and that need to be treated? Yes,

absolutely.

What? What does that look like? What is the what does that what does that future care look like in the case of a diagnosed mental health injury that's subsequent to physical injury?

Huge is depression. Huge is very, very huge as depression and then social anxiety they'll get because of now they might look different, or they might act different, or they don't have the same personalities they used to have. So they definitely lead need long term psychotherapy someone to talk to someone to help address those situations, someone to give them guidance on how to look at those and try to change maybe some of their habits that they used to do, and then incorporate new things to help them get back out there and have a quality life.

So do you still run into some of those conditions? that are not diagnosed, do you ever see things, records and think, hey, this person really should should have a mental health assessment to see if they do have any of these depression or social anxiety or different personality sort of situations?

Yeah, because when I review the records, I'm reading almost everything and including everything that that client will state because, you know, they're stating, I'm like, so depressed, or I can't do this anymore. I can't do that anymore. I always incorporate at least an evaluation with a psychotherapist, and they're a psychologist. And evaluation is definitely you know, key. And then they can always add in more business. So be not a you know, be not a physician myself, I would always give them the opportunity to at least an evaluation.

You mentioned something about someone, someone having a different personality after something like this. What do you mean, give me an example? And why would that be the case,

they might hit their head on the steering wheel, they might hit their head on the back of the hand, wrist or the side of the window, or when they fall, they hit their head on the ground, just depends on where they might hit their head, it could change who they are. But it could also just change, name hinder. And just because it's a new, like, let's say the gentleman who lost his fingers. Now he's got a whole different outlook on what he looks like. That's traumatic in, you know, their social aspects, or they're depressed now because they don't look like these two.

So so so for example, we see this sometimes when young people have a debilitating are moving into disfigurement, then there they have some social anxiety about, okay, what's it going to be? Now when I go? When I go on a date, when I go? To work, when I go in a social setting? Are people going to look at me differently? Are people going to treat me differently? Are people gonna feel sorry? For me? Are people going to be repulsed? These kinds of things, you know, are natural questions that people have in that? Are these the kind of things that you're talking about? Correct? Yes. And what was what would be the prescribed treatment for these kinds of things? What would you do to address the future medical need of something like this? Um,

psychotherapy, definitely someone that can communicate with a psychologist.

I'm sorry about that. Go ahead. I'm sorry. So So So what you're trying to focus on is what are the comprehensive medical needs of a person who has a traumatic injury, if there is a way to treat their medical condition, physically, then that's a part of it. If there's some future technology that might be available, that's a part of it. If there's a psychological component, that's a part of it, and you try it, you're trying to quantify all these things and put them together in a usable report, that the, that the lawyer for this truck in traumatically injured person should be able to use to get compensation to to fund the treatment that's needed in the future. Is that the idea? Correct. So let me ask you as far as the psychological injuries? Well, first, let me ask you, are you doing more? Have you How long have you done this this type of work? And are you seeing it used these type of future medical analysis? calculations and projections used more? Now? Are they are they used less now than they were, say? 510 20 years ago? Well,

I haven't been doing the class projections by five or 10 years ago. I've been doing it for three years now. But I see them quite frequently and all the reports that I do based on their records.

Okay, and you said, let me ask you this, the mental health component to it. Are you seeing? It seems like years ago, people didn't take those mental health injuries as seriously as they do. Now, they would sort of, you know, the first priority would be the physical health and these mental health treatment. Plans or injury and mental health injuries weren't taking this seriously. Is that is that your is that your observation as well? Or do you feel differently? No, I

feel the same way. I feel they always focus on the the mechanical injury portion versus our socket, psychosocial, and the psychotherapy part of it.

But do you feel like the psychosis, social psychotherapy part of it is important? Oh, absolutely. So So, are you seeing more of those types of analyses? And are you are you finding them to be? And what what's the reception of these kinds of this kind of analysis on your part?

I think it's a great reception because people are realizing that not everybody is the same and that not everybody thinks the same and that everybody's brain is different. Because like me get in a car accident. I might not think anything of it because I've been a nurse for so many years. Yeah, whatever. I'll just go on where you got somebody else who's never been in one, and now they're traumatized. They can't get in their car. They have nightmares. Have that seeing that traumatic injury or the the accident all over again, you know, so yeah, it's huge. How

do you know the difference? I mean, is are there objectives ways to, to, to see the difference between somebody? Who's Who's what are the objective ways of to identify a person who's struggling with these kinds of things versus not?

asking them questions, you know, getting them to talk about the accident. When you do a good life care plan, I ask all those questions. Are you sexually selective? And if they say, Well, I'm gonna say, Okay, I know it's a tough subject. But do you have complications with that? are you fearful of it? Do you feel like you can't perform as much, and then if you can get them talking, it helps, then you can figure out what you need to do to get them the how

are you? So are you seeing when when you're putting these putting this information together in a report and sending it to the people for whom you work? Do you get feedback on whether this was valuable information.

And I don't hear anything back from the attorneys on how the cases went?

Well, so I can tell you from our experience, that, that we find these studies to be in these insights analysis to be very helpful for us in terms of, because a lot of times, the adjusters the lawyers that people represent the defense or the insurance company will discount any kind of reference to future medical care, the idea being, hey, if you needed to care, you would have already received it. And then sometimes, what we find is that this ongoing care, we can't just wait until the end of the care because a lot of people are just never going to finish treating after a catastrophic accident. So so for us to be able to build a forecast, reliable forecasts based on, you know, experienced people who are in this industry who use accepted models and accepted literature on how to construct these kinds of future analytical studies. It's really valuable. And it is compelling to first insurance adjusters and insurance, defense lawyers, but also to juries. And so we find it to be very, very helpful. What about you? Do you? Do you ever do you occasionally testify about these kinds of things?

I have testified and I have not I have only seen one? I've done one deposition, and then one actual drill jury trial.

And so so why do you think that is what why is it that you've only got you've been doing it for a long time? And you've done lots of these things? But why do you think that? Are? Do you have an opinion as to why it's it's it's you haven't had to do it pen pen to testify very often?

I think, because my reports are pretty conservative to the fact that I'm not over costing things. And these are things that look, you know, like, Yes, this is a possibility that could happen. And then the they will mediate it out, and they don't go to court.

So the idea, then, I guess is that because you could probably just as soon just as easily be an expert for the defense as for the plaintiffs, right, if you're given conservative opinions that are documented in, in the literature and in medical records, and in your interviews, is

that fair? And that's fair to say? Yes, both sides.

So you're not really trying to just advocate exclusive for the plaintiff in a way that is, you know, only on on the plaintiff side of things, and, and all that you're trying to give a objective findings about what you see, and what kind of future medical care will be required. Is that is that is that your How do you approach it?

That is correct. I've done a couple of cases for the defense already, where I look at the usual usual customary reasonable charges to see if they're being charged to the right, you know, the fair value.

Well, let me ask you about that. We hear a lot about this usual customary and, and and reasonable charges. And I always, I always have questions about that, because I understand the the insurance companies perspective, I understand the defense lawyers perspective when he or she asks about those kinds of things. In other words, we can't have just hospitals charging, you know, a million dollars to pay for a broken finger to reset a broken finger. But as a consumer as a plaintiff, I don't have any control about what that bill is. I don't have any I go to the doctor and or I go to the hospital or go to the ER, I have a broken bone or some kind of traumatic injury. I don't even ask for anything half the most. It's a lot of times that person may not be conscious that what's the response to the to the argument that hey, this is beyond what a is reasonable and customary in an In the industry.

So when I do the costings, I take three different databases. So I use those and I look at the 75th percentile. That's the mean between the 50th and the 90th. So it's the 75th. And then I'll have the three databases tell me what the meaning is. So that's on average, across the board. And it's all based on zip codes as well. So we look at the zip code of the person where they're living, and then the three databases and then I pull that knee now, and that's the cost that I project. So I'm at like, the 75th percentile, so I'm not way above them that way under I'm like in the middle ball range. So when my attorneys are going out there and mediate, they know, they're not saying, Oh, we're charging, and 150% of all what should be charged. So I'm given them, you know, the, the leeway on both sides.

What about Do you ever look backwards at medical bills that have already been incurred? Not future, but past medical bills, and assess whether those medical bills are reasonable and necessary, according to the industry standards that you've described?

Yes, I've done that. For the defense. I've gone all the way back to 2017.

You have to do that for plaintiffs lawyers. No one asked me to Yeah. Well, after our discussion today, we might we might talk to you about that. Because, you know, sometimes the insurance companies will look at our past medical expenses and sort of make those arguments. And, you know, my position, you know, is like, we didn't, that's the best, how much we owed, like we didn't make I didn't make the bill, you know. But anyway, okay, well, hey, listen, thank you so much for being here. I appreciate you talking to us. I appreciate you giving us all this information. It's been very helpful. So thank you.

Well, thanks for having me. I appreciate that.

Thank you for joining us, and we'll see you next time.

Well, so I'm just thinking about like, for myself, like, I have an old sports injury in my knee, for example, and, and it bothers me, sometimes I'm working out or whatever, it'll bother me sometimes, and but I can get by and I mean, I can adjust or whatever. So it doesn't really affect my work, or it doesn't really affect my ability to do the things I need to do to take care of my kids or get around the house or take care of my household responsibilities. But I'm thinking, Well, you know, once I get to be 6070 7580, that that knee might play a, that aggravated knee might cause a bigger and bigger problem going forward, do you have ways of accounting for that or identifying those types of issues? Um,

that would be up to the orthopedic surgeon, maybe an MRI, and then they will determine whether the injury exasperated and old injury. As a nurse, we do not diagnose. With medical diagnosis, we only do nursing diagnosis.

So you mentioned earlier that you you might there's certain circumstances in which you might reach out to the treating physicians or the orthopedist for those kinds of things. So how often do you do that? And what does that typically look like?

So like during life care plans, I will do an assessment of the client after I've reviewed their records and summarize them. And then after the assessment, I'll put a questionnaire together, and I will send that out to their physician, then I will do follow ups, making sure they got the form, they filled out the form, after they've sent it back, I review it, I make sure that I've addressed everything, and then I will make sure I reach out to the client one more time make sure that what I have addressed is what they're saying is what they've addressed. And then I will collaborate, call that physician and go over their, the clients questionnaire with them based on what their recommendations are, make sure there are no changes, and I didn't misinterpret something.

Okay, so So then, let me ask you this, is does any part of your let's take somebody who's, you know, paralyzed or lost a limb, for example, in one of these catastrophic accidents? At you know, you read about medical technology, you read about the future of medicine, and all the different things they're doing, whether it's stem cells, or sort of, you know, prosthetic limbs or artificial intelligence or whatever. Does any of your work account for any of these sort of break? technologies that might really change and impact a person who's suffered a catastrophic injury? Or is it more sort of conventional type things?

No, absolutely. I just did a cost projection for a gentleman who had a crush injury, and he lost these two fingers, his pinky and his ring finger, and I reached out to two different prosthetic people, and one person does them to where they look almost natural. So it's like your real finger, and then one is more mechanical. So I got cost projections for those. And I put those in my cost projection, but I left both different ones in there and versus taking one over the other because I'm not that client. And he gets the option to decide, do I want more natural looking? Or do I want the, you know, the mechanical one. So that was sent back to the attorney for them to discuss with the client so that they could incorporate which one that he would prefer? Because he was, you know, very depressed from losing his fingers and not looking natural. And so we had to do some psychology, evaluations and therapy for him on that as well. So no, we definitely take into futures.

You find. Sorry. That's okay. Do you find a lot of people after a catastrophic injuries have psychological injuries that are diagnosed and that need to be treated? Yes,

absolutely.

What? What does that look like? What is the what does that what does that future care look like in the case of a diagnosed mental health injury that's subsequent to physical injury?

Huge is depression. Huge is very, very huge as depression and then social anxiety they'll get because of now they might look different, or they might act different, or they don't have the same personalities they used to have. So they definitely lead need long term psychotherapy someone to talk to someone to help address those situations, someone to give them guidance on how to look at those and try to change maybe some of their habits that they used to do, and then incorporate new things to help them get back out there and have a quality life.

So do you still run into some of those conditions? that are not diagnosed, do you ever see things, records and think, hey, this person really should should have a mental health assessment to see if they do have any of these depression or social anxiety or different personality sort of situations?

Yeah, because when I review the records, I'm reading almost everything and including everything that that client will state because, you know, they're stating, I'm like, so depressed, or I can't do this anymore. I can't do that anymore. I always incorporate at least an evaluation with a psychotherapist, and they're a psychologist. And evaluation is definitely you know, key. And then they can always add in more business. So be not a you know, be not a physician myself, I would always give them the opportunity to at least an evaluation.

You mentioned something about someone, someone having a different personality after something like this. What do you mean, give me an example? And why would that be the case,

they might hit their head on the steering wheel, they might hit their head on the back of the hand, wrist or the side of the window, or when they fall, they hit their head on the ground, just depends on where they might hit their head, it could change who they are. But it could also just change, name hinder. And just because it's a new, like, let's say the gentleman who lost his fingers. Now he's got a whole different outlook on what he looks like. That's traumatic in, you know, their social aspects, or they're depressed now because they don't look like these two.

So so so for example, we see this sometimes when young people have a debilitating are moving into disfigurement, then there they have some social anxiety about, okay, what's it going to be? Now when I go? When I go on a date, when I go? To work, when I go in a social setting? Are people going to look at me differently? Are people going to treat me differently? Are people gonna feel sorry? For me? Are people going to be repulsed? These kinds of things, you know, are natural questions that people have in that? Are these the kind of things that you're talking about? Correct? Yes. And what was what would be the prescribed treatment for these kinds of things? What would you do to address the future medical need of something like this? Um,

psychotherapy, definitely someone that can communicate with a psychologist.

I'm sorry about that. Go ahead. I'm sorry. So So So what you're trying to focus on is what are the comprehensive medical needs of a person who has a traumatic injury, if there is a way to treat their medical condition, physically, then that's a part of it. If there's some future technology that might be available, that's a part of it. If there's a psychological component, that's a part of it, and you try it, you're trying to quantify all these things and put them together in a usable report, that the, that the lawyer for this truck in traumatically injured person should be able to use to get compensation to to fund the treatment that's needed in the future. Is that the idea? Correct. So let me ask you as far as the psychological injuries? Well, first, let me ask you, are you doing more? Have you How long have you done this this type of work? And are you seeing it used these type of future medical analysis? calculations and projections used more? Now? Are they are they used less now than they were, say? 510 20 years ago? Well,

I haven't been doing the class projections by five or 10 years ago. I've been doing it for three years now. But I see them quite frequently and all the reports that I do based on their records.

Okay, and you said, let me ask you this, the mental health component to it. Are you seeing? It seems like years ago, people didn't take those mental health injuries as seriously as they do. Now, they would sort of, you know, the first priority would be the physical health and these mental health treatment. Plans or injury and mental health injuries weren't taking this seriously. Is that is that your is that your observation as well? Or do you feel differently? No, I

feel the same way. I feel they always focus on the the mechanical injury portion versus our socket, psychosocial, and the psychotherapy part of it.

But do you feel like the psychosis, social psychotherapy part of it is important? Oh, absolutely. So So, are you seeing more of those types of analyses? And are you are you finding them to be? And what what's the reception of these kinds of this kind of analysis on your part?

I think it's a great reception because people are realizing that not everybody is the same and that not everybody thinks the same and that everybody's brain is different. Because like me get in a car accident. I might not think anything of it because I've been a nurse for so many years. Yeah, whatever. I'll just go on where you got somebody else who's never been in one, and now they're traumatized. They can't get in their car. They have nightmares. Have that seeing that traumatic injury or the the accident all over again, you know, so yeah, it's huge. How

do you know the difference? I mean, is are there objectives ways to, to, to see the difference between somebody? Who's Who's what are the objective ways of to identify a person who's struggling with these kinds of things versus not?

asking them questions, you know, getting them to talk about the accident. When you do a good life care plan, I ask all those questions. Are you sexually selective? And if they say, Well, I'm gonna say, Okay, I know it's a tough subject. But do you have complications with that? are you fearful of it? Do you feel like you can't perform as much, and then if you can get them talking, it helps, then you can figure out what you need to do to get them the how

are you? So are you seeing when when you're putting these putting this information together in a report and sending it to the people for whom you work? Do you get feedback on whether this was valuable information.

And I don't hear anything back from the attorneys on how the cases went?

Well, so I can tell you from our experience, that, that we find these studies to be in these insights analysis to be very helpful for us in terms of, because a lot of times, the adjusters the lawyers that people represent the defense or the insurance company will discount any kind of reference to future medical care, the idea being, hey, if you needed to care, you would have already received it. And then sometimes, what we find is that this ongoing care, we can't just wait until the end of the care because a lot of people are just never going to finish treating after a catastrophic accident. So so for us to be able to build a forecast, reliable forecasts based on, you know, experienced people who are in this industry who use accepted models and accepted literature on how to construct these kinds of future analytical studies. It's really valuable. And it is compelling to first insurance adjusters and insurance, defense lawyers, but also to juries. And so we find it to be very, very helpful. What about you? Do you? Do you ever do you occasionally testify about these kinds of things?

I have testified and I have not I have only seen one? I've done one deposition, and then one actual drill jury trial.

And so so why do you think that is what why is it that you've only got you've been doing it for a long time? And you've done lots of these things? But why do you think that? Are? Do you have an opinion as to why it's it's it's you haven't had to do it pen pen to testify very often?

I think, because my reports are pretty conservative to the fact that I'm not over costing things. And these are things that look, you know, like, Yes, this is a possibility that could happen. And then the they will mediate it out, and they don't go to court.

So the idea, then, I guess is that because you could probably just as soon just as easily be an expert for the defense as for the plaintiffs, right, if you're given conservative opinions that are documented in, in the literature and in medical records, and in your interviews, is

that fair? And that's fair to say? Yes, both sides.

So you're not really trying to just advocate exclusive for the plaintiff in a way that is, you know, only on on the plaintiff side of things, and, and all that you're trying to give a objective findings about what you see, and what kind of future medical care will be required. Is that is that is that your How do you approach it?

That is correct. I've done a couple of cases for the defense already, where I look at the usual usual customary reasonable charges to see if they're being charged to the right, you know, the fair value.

Well, let me ask you about that. We hear a lot about this usual customary and, and and reasonable charges. And I always, I always have questions about that, because I understand the the insurance companies perspective, I understand the defense lawyers perspective when he or she asks about those kinds of things. In other words, we can't have just hospitals charging, you know, a million dollars to pay for a broken finger to reset a broken finger. But as a consumer as a plaintiff, I don't have any control about what that bill is. I don't have any I go to the doctor and or I go to the hospital or go to the ER, I have a broken bone or some kind of traumatic injury. I don't even ask for anything half the most. It's a lot of times that person may not be conscious that what's the response to the to the argument that hey, this is beyond what a is reasonable and customary in an In the industry.

So when I do the costings, I take three different databases. So I use those and I look at the 75th percentile. That's the mean between the 50th and the 90th. So it's the 75th. And then I'll have the three databases tell me what the meaning is. So that's on average, across the board. And it's all based on zip codes as well. So we look at the zip code of the person where they're living, and then the three databases and then I pull that knee now, and that's the cost that I project. So I'm at like, the 75th percentile, so I'm not way above them that way under I'm like in the middle ball range. So when my attorneys are going out there and mediate, they know, they're not saying, Oh, we're charging, and 150% of all what should be charged. So I'm given them, you know, the, the leeway on both sides.

What about Do you ever look backwards at medical bills that have already been incurred? Not future, but past medical bills, and assess whether those medical bills are reasonable and necessary, according to the industry standards that you've described?

Yes, I've done that. For the defense. I've gone all the way back to 2017.

You have to do that for plaintiffs lawyers. No one asked me to Yeah. Well, after our discussion today, we might we might talk to you about that. Because, you know, sometimes the insurance companies will look at our past medical expenses and sort of make those arguments. And, you know, my position, you know, is like, we didn't, that's the best, how much we owed, like we didn't make I didn't make the bill, you know. But anyway, okay, well, hey, listen, thank you so much for being here. I appreciate you talking to us. I appreciate you giving us all this information. It's been very helpful. So thank you.

Well, thanks for having me. I appreciate that.

Thank you for joining us, and we'll see you next time.