Perspective Chapter: Healthcare Economics in the Wake of Trauma – Navigating Costs and Care for the Injured

Abstract

“Healthcare Economics in the Wake of Trauma: Navigating Costs and Care for the Injured,” delves into the intricate relationship between healthcare economics and the management of traumatic injuries. It offers an insightful analysis of medical cost implications, highlighting the financial challenges faced by traumatically injured patients. The chapter examines the spectrum of post-injury care, from immediate medical interventions to long-term rehabilitation, emphasizing the economic aspects of each phase. It also explores the broader impact of traumatic injuries on healthcare financing and policy, providing a comprehensive understanding of the economic ramifications for both individuals and the healthcare system. The focus is on presenting a balanced view that integrates economic considerations with the critical need for effective and compassionate care for the injured.

1. Introduction

Traumatic injuries impact the economics of healthcare at a speed that consistently outpaces our ability to understand the true depth of this issue. As traumatic injuries continue to test the resilience and efficiency of well-resourced healthcare systems in developed nations, the challenge of navigating the costs and care for the injured is not due to an inability to appreciate this crisis or from a lack of structure within existing theoretical frameworks. Rather, the gaps in our ability to address these challenges arise from economic models and outcomes-based research that are unable to fully articulate the experience of the injured and capture the consequential nature of traumatic injuries.

The economic impact of traumatic injuries exceeds the structured provisions of Ogden tables¹ in tort systems² in the United Kingdom and extends beyond the rigorous debate that lead tort reform³ efforts in the United States. The complexity of economic and medical issues that coalesce around traumatic injuries overshadows our ability to calculate damages with uniformity and predictability and supports the notion of why as a society we collectively remain reluctant when it comes to adopting a “going monetary rate” for injuries.

In “Healthcare Economics in the Wake of Trauma: Navigating Costs and Care for the Injured,” we provide an overview of the economic underpinnings of trauma care and its broader implications. The backdrop of this discussion is the substantial economic burden that traumatic injuries impose and the factors that complicate the ability of economic models to find a balanced resolution. The objective of this chapter is not to depreciate the nuance and rigor of our current systems but to elevate acknowledgment of where and why gaps in knowledge may exist.

2. The economic burden of injury

Economic burden manifests through direct costs such as emergency care, surgical treatments, hospital stays, and rehabilitation, alongside indirect costs such as diminished productivity, enduring disability, and the emotional toll on patients and their relatives. The methodologies and models used to calculate economic damages in personal injury cases aim to consider both non-pecuniary damages and the labor effects of disability. To reach a fair and balanced resolution, a multidisciplinary approach is required, which involves contributions from medical physicians and subject matter experts.

The complexity of these economic implications is due to the varying capacities of healthcare institutions, payers, and providers to accommodate traumatically injured individuals. The funding mechanisms for trauma care can have a significant impact on the availability and quality of medical treatment provided. This discussion examines the stages of traumatic injury from both a medical and economic perspective and analyzes the benchmarks that contribute to and limit the current understanding of the financial impact of traumatic injury.

The calculation of economic damages in personal injury cases is a complex and multifaceted process that aims to account for the non-pecuniary damages and the labor effects of disability. A fair and balanced resolution can only be reached through a multidisciplinary approach that involves contributions from medical physicians and subject matter experts.

The economic implications of traumatic injury are significant and vary depending on the capacities of healthcare institutions, payers, and providers to accommodate traumatically injured individuals. The funding mechanisms for trauma care can profoundly influence both the availability and the quality of medical treatment provided.

To better understand the financial impact of traumatic injury, it is essential to examine the stages of traumatic injury from both a medical and economic perspective. By analyzing the benchmarks that contribute to and limit our current understanding of these impacts, we can gain a deeper insight into the true cost of traumatic injury and advocate for better funding and support for those affected by it.

3. Current models and methodologies

Economic damages are calculated through a combination of actuarial, life care planning, econometric, and finance-based models designed to estimate the financial impact of an injury over a lifetime. These economic models consider a range of variables, including lost earnings, cost of care, and life expectancy. The Ogden tables, utilized primarily within the UK, offer a standardized means to calculate lump sum damages for personal injury and wrongful death claims based on actuarial assessments of life expectancy and discount rates applied to future losses.

The Ogden tables provide a structured framework for damage calculation in the United Kingdom. However, these frameworks are not free from limitations. Though structured frameworks aim to align with population changes and preserve equal representation, changing population dynamics and the equitability of healthcare accessibility impose limitations that alter the accuracy of conclusions drawn.

One drawback of generalized population-based data is the ability to accurately measure medical outcomes of the injured and estimate the economic impact of opportunity cost that is lost in traumatic injury. When pursuing legal remedies to pacify the multidimensional impact of traumatic injuries, the injured are often stigmatized which shifts attention away from the potentially compounding effects of their individual circumstance, and potential loss in career progression [1]. Second, the inability to access medical care, and barriers that arise from the lack of an adequate support system further clouds the perception of their commitment to receiving medical attention for injuries they are dealing with. The inability of the injured to access healthcare, and the place of the setting which the medical care is obtained leads to analytical gaps in outcomes-based research. These gaps in data challenge the sufficiency of population-based assumptions in adjudicating a resolution. Additionally, the arbitrary nature of end-points within the study design of outcomes based research bears significant weight on the effectiveness of the research in reflecting the reality of the injured.

In the United States, a diversified approach to this debate is utilized. Economists and life care planners use present value calculations that factor in projected earnings growth, inflation, and the probability of employment, but without a singular, universally applied set of tables akin to the Ogden tables. These methodologies are supplemented by expert opinion to explain the interconnectedness of the financial impacts to a jury.

The utility of rigorous debate is an essential component to establishing the economic value of the injury. The monetary value of an injury is as significant to the injured as it is to the vested stakeholders of liability insurers seeking mitigate the verdicts perceived as ruinous. Tort reform represents the deliberate modification of the legal system that governs civil wrongs and damages and rationalizes the process of litigation and compensation of those who suffer injuries as the result of civil wrongs.

Through Tort reform, various jurisdictions aim to limit damages through caps on compensation, arguing that this is necessary to prevent insurance premium inflation and ensure the sustainability of liability insurance. However, in some instances, such reforms may proceed without adequate assessment of the accounting principles and special risk considerations employed by companies that provide liability insurance. The procession and implementation of reforms in the US are heavily debated because of the reforms effect on limiting compensation in order strike a balance between civil wrongs and damages, the need to provide just remedies to those wronged, and the necessity to prevent the exploitation of the legal system.

4. The role of non-pecuniary damages, labor effects of disability, healthcare inflation and hospital based care

Non-pecuniary damages represent compensations for intangible losses such as pain and suffering and loss of enjoyment of life. They are crucial in economically valuing damages. A nuanced approach that goes beyond financial metrics is required to appreciate the pernicious nature in which these losses play out. Psychological and sociological assessments should be integrated to arrive at a compensation figure that reflects the full scope of an individual’s loss. When it comes to disabilities, the labor effects of lost futures are critical considerations. They include reduced earning capacity and the need for vocational rehabilitation. Economic models and expert opinions must account for how disabilities affect a person’s ability to work. This involves considering sector-specific employment probabilities, the potential for retraining, and trends in labor market dynamics over time.

Healthcare inflation is a significant factor that complicates the calculation of economic damages. Medical care costs rise faster than general inflation, which make acknowledgement of medical cost inflation critical to accurately forecast healthcare cost trends. Recognition of healthcare inflation helps ensure that awarded sums remain adequate over time and contribute to a forward-looking analysis that considers trends in healthcare technology, and trends that affect the provision of healthcare.

To understand how the trend of consolidation of the healthcare market into large hospital systems contributes to cost inflation, charge-to-cost ratio is a key metric. The charge-to-cost ratio (CCR) in hospitals is a financial metric used to compare the total charges billed to patients (or insurers) for services rendered against the actual cost of providing those services. Mathematically, the CCR is calculated as the total charges divided by the total costs for a given period or for specific services or departments within a hospital. What is unclear is how much administrative charges within hospitals factor into CCR. To shed light on this lack of clarity, price-transparency acts have been mandated in the US to encourage Hospitals to share cost-data. The CCR can significantly vary between hospitals, and even between hospitals within the same hospital system due to differences in pricing strategies, cost structures, and patient demographics [2]. Variability in fee structures and lack of transparency in how charges are determined can lead to confusion and inefficiencies in the healthcare market, potentially driving up overall healthcare costs as patients and insurers who may not have clear benchmarks for comparison. Hospitals may use CCR as a level to compensate for underpayments from certain payers (e.g., Medicaid, Medicare) by charging more to private insurers or self-paying patients. This cost-shifting dynamic can contribute to healthcare inflation, as it leads to higher insurance premiums and out-of-pocket expenses for a segment of the population, reflecting a redistribution of healthcare costs rather than a reduction.

For-profit and non-for-profit Hospital systems in the United States have grown into multi-billion dollar entities that span multiple states and extend outside the country with satellite campuses in some instances. The shift toward healthcare consumerism is a stark contrast from the faith-based charitable missions from which hospitals originated. As large-scale healthcare systems increasingly represent the setting in which healthcare is rendered, attention will focus on facility fees, site-neutrality payments and the tax-exempt status of hospitals in an attempt to stem the tide of financial costs shouldered by patients [3].

American taxpayers footed the bill for at least $1.8 trillion in federal and state health care expenditures in 2022 compared to $1.6 trillion in individual income taxes collected the same year by the government, as reported in the latest data released by the Internal Revenue Service (IRS) [4, 5]. Despite financial commitment to health, life expectancy has gone down and quality of care has declined and health-care related debt remains the leading cause of bankruptcy. It is not hyperbole to conclude that our health care system, has transformed from caring for the poor to creating the poor and is now on pace to threaten the primacy of American economy.

Our current understanding of economic damages following traumatic injuries is characterized by disparate approaches and a pressing demand for methodological consistency. The search for solutions is lost in broader systemic inequalities, and the decline of quality becomes entrenched. While existing models offer a basis for dialog, mere descriptive statistics fail to capture the full scope.

Decisions that account for non-pecuniary damages, the impact of disability on work, and the rising healthcare costs will prove to be a more balanced representation of current arguments as opposed to debates based solely on snapshots of population data where proper discussion of metrics that matter is not had. As the economic landscape evolves, socioeconomic lines deepen, reinforcing the need for multi-dimensional economic models to bridge the gaps within economic damage calculation. Lastly, the relational trends that develop between payer policies for trauma patients, risk pool considerations of liability insurance companies, and patient outcomes may foster an understanding where limitations are acknowledged, and insights are gained.

5. Medical care and the cost of help

The road that emerges after a traumatic injury is paved with uncertainty and irrevocably re-routes the injured’s life plans in seconds. Aspirations and the ability to prioritize physical and financial well-being are abruptly paused before reality becomes audible again. Emergency medical services then arrive, performing basic life support measures before an ambulance ushers the patient into a world that was utterly unfamiliar to them moments before they were injured. Hospital-level medical attention, diagnostic testing, and specialist consultation follow the patient’s arrival at the hospital and quickly become foundational elements of the care team. As the patient progresses toward recovery, each phase of post-injury care involves unique medical needs and potential barriers to rehabilitation goals. The economic impact of the care required shapes the path of recovery for the patient and affects their family’s long-term trajectory and ability to preserve financial well-being.

5.1 Acute phase

The period following a traumatic event is crucial and involves resource-intensive care, a wide range of diagnostic tests, and medical support designed to stabilize the patient, treat critical injuries, and triage the patient appropriately. To analyze the financial impact of care for traumatic injuries, health care claims are organized based on when they occur during the patient’s treatment. This often results in the evaluation of hospital-based claims, primarily because these claims are more readily available.

Health service utilization categories in the immediate aftermath of a traumatic injury include: Trauma activation services associated with the designated Trauma center, Inpatient, outpatient, Emergency department, surgery, administered medications, radiology, durable medical equipment and supplies, prescriptions, diagnostic testing, and laboratory services. Patients with life-threatening injuries often require immediate surgical interventions to repair or stabilize vital organ functions. Acute injuries are allocated to different trauma centers based on the ability of the accepting hospital to accommodate the patient’s medical condition. If operative intervention is required, patient transportability, operating room usage, radiology technician, surgical team, and anesthesia team formation must be readily available. The mobilization of medical professionals that make up the trauma team represents a fee called the trauma activation fee.

The margin of error for trauma-based medical care in the acute phase of an injury is minimal; trauma activation fees ensure that the services required in the rapid response phase are readily available and that a low margin for error is preserved. Trauma activation fees remain a growing area of debate due to large costs and price variability between the not-for-profit and for-profit designation of the hospital employing the trauma activation team [6]. Fees associated with trauma activation have a trickle-down effect on the consumer in the form of surprise bills. In the United States, surprise bills refer to residual fees that patients are financially responsible for. Surprise bills occur as a result of healthcare provider participation with the network of the insurance plan held by the patient. The end result is an in-network versus out-of-network classification; care rendered by providers designated as out-of-network results in fees that lead to substantial patient liability.

The price of care varies with each medical service provided, the charges vary based on the financial liability of the patient, not the value of the care provided. Claims related to ground ambulance services show significant differences based on geographic location, the impact of taxpayer subsidies which affect localities unevenly, and the various ownership models of the ambulance services. These ownership structures range from public sector and private equity to publicly traded companies, independents, and nonprofit organizations. The process of deciding to transport a patient with traumatic injuries to a suitably equipped hospital triggers what is known as trauma activation. This activation adheres to guidelines set by the American College of Surgeons (ACS) and is widely practiced across the United States. Furthermore, trauma centers are classified according to the level of resources they offer, a designation determined by specific criteria laid out in state legislation or regulations, ensuring a standardized approach to trauma care on a state-by-state basis.

Emergency medical services (EMS) represent the first line of care in the field and are critical decision-making personnel who correspond with hospital personnel when it comes to identifying seriously injured patients for transport to major trauma centers. Adhering to field triage guidelines matches patient needs with hospital resources and minimizes over triage of patients with less severe injuries to major trauma centers. Care offered at non-trauma centers is cheaper than major trauma centers, therefore the initial decision of where the provision of care should occur comes with cost implications. However, despite downstream sequelae that universally affects all parties, data suggests more than one-third of patients brought to major trauma centers do not meet field triage guidelines for transport resulting in a cost of $136.7 million dollars annually [7].

When seriously injured patients are brought to trauma centers that meet their needs, they are still subject to disproportionately high trauma activation fees depending on the trauma center to which they are brought. Research has shown a price variation in activation fees of tier one trauma centers in the United States from $1000 to $61,734 with a median of $9,500.

Despite the significance of major trauma centers to the societies they provide care for, financial stability of these centers is an issue of focus. Approximately one-fourth of major trauma centers in the United States are at high risk for financial vulnerability. The financial vulnerability of trauma centers is largely attributed to uncompensated care and negative operating margins [8]. Why major trauma centers operate at negative margins, despite their ability to bolster the healthcare safety net of the public and their inclusion into the expanse of larger hospital systems, is outside the scope of this chapter. Standardization of traumatic activation fees is a reasonable solution however these fees are affected by numerous factors including cost of living within the geographic region, hospital characteristics and availability of chargemaster data of hospitals. Standardization of trauma activation fees would require overarching legislation that remains sensitive to the balance between the rising costs of providing medical care and ensuring the availability of resources required by trauma centers for the acuity of care they provide.

5.2 Post-acute phase

While immediate medical interventions are crucial for survival, long-term rehabilitation plays an equally vital role in maximizing functional recovery and helping trauma survivors regain independence. The phase of care in which rehabilitation occurs is regarded as the post-acute phase of care and is where the burden of injury and the extent of disability is understood. An aging population and advances in healthcare are likely to contribute to an increasing need for rehabilitation services.

The scope and duration of rehabilitation vary widely depending on the nature and severity of injuries. Key medical components of rehabilitation include but are not limited to Physical and Occupational therapy, Speech therapy, cognitive rehabilitation, psychological counseling, continued specialist consultation and care, durable medical equipment, and home modifications.

The economic implications of long-term rehabilitation are unique to the individual circumstances of each patient. Cost-influencing factors such as the care setting, the length of the rehabilitation period, and the presence of a supportive network play a critical role; in cases of traumatic injuries, these elements must be promptly and efficiently addressed.

Rehabilitation can occur in inpatient rehab facilities, outpatient clinics, skilled nursing homes, or in the patient’s home, each with varying cost structures. The length of rehabilitation can be extensive, particularly with severe injuries. Costs accumulate over time, leading to financial stress for patients and their families. Growing recognition-implications of Lost Income and Caregiver Burden often go underestimated due to poor follow-up with respect to research participation. Prolonged rehabilitation can further reduce income or require family members to act as caregivers, resulting in lost economic opportunities for both the patient and caregivers. The principle of rehabilitation is focused primarily on the restoration of functional mobility which provides the injured party with the potential to return to a pre-injury work status.

Evaluation of return to work/study in patients involved in major trauma involving pelvic fractures in Australia revealed 59% of the patients had reached the benchmark of returning to work 24 months after injury. Of those who had returned to work, the proportion returning to their pre-injury workplace declined 15% over the following 24 months [9]. In Canada, severe traumatic injury was associated with a return to work 79.3% 36 months after injury, with a resultant mean earnings loss of 19%. Additionally, Physical and mental challenges persisted at month 36 for these patients [10]. Research on return to work rates in the United States of America revealed that among 500 trauma patients at a level 1 trauma center between 2009 and 2011 followed prospectively for 12 months in the United States found that 64% reported a decrease in monthly income, 58% reported unemployment as a result of their injuries, 30% reported a job change related to their injury, and 85% reported financial problems as a direct result of their injury [10, 11].

6. Insured and in debt

Two terms embedded in the ethos of the injured and required for understanding the depth of what is endured by these patients are “financial toxicity” and “catastrophic health expenditures.” Financial toxicity is defined as the financial hardship the patient experiences as a side effect of his or her illness and medical treatment for that illness [12, 13].

Applying the concept of Financial Toxicity to patients who require medical care because of injury reveals the post-discharge burden of injury among working-age survivors in the United States extends beyond the capacity for work. Food insecurity, difficulty accessing and affording health care, forced unemployment and forgone medical care due to cost, were also associated with traumatic injury sequelae in the US [14]. After being discharged from the hospital, large medical bills result in out-of-pocket expenses. Expenses may stem from uncovered services, out-of-network providers, owed deductibles, and co-pays. Often, these costs are converted to medical debt, which is then sold to debt collection agencies, re-packaged and, saddled with additional interest rates of up to 27% that compound annually [15]. Debt may impact credit scores when they exceed $400, impact the patient’s ability to obtain future loans, and, in some instances, lead non-profit hospitals to displace the patients from their homes [16]. If the injured party returns to work, expectations of their pre-injury physical capacity are uncertain, and the potential loss of employer-sponsored benefits or segmentation into a level of coverage commensurate with their new healthcare risks is an expected outcome. Declines in physical health, and mental health may affect the ability to generate income. New medical debt compounded by the loss of work-related income can cause significant financial hardship that threatens subsistence spending on food, housing, and other health care needs [14]. Financial sequelae cascades until bankruptcy is filed. Financial and Physical well-being is consumed in this process; often, musculoskeletal pathology persists in the form of permanent injury, and psychological symptoms such as depression exist as an under diagnosed byproduct of the traumatic injury.

As more attention is paid to the burden of this crisis, the magnitude of impact is better served by the metrics that fall under Catastrophic Health expenditures (CHE). Catastrophic Health expenditures are defined as any charges or out-of-pocket expenses greater than or equal to 40% of annual post-subsistence income (income after paying for food). When applying the metric of CHE to uninsured patients admitted for trauma, 70.8% were at risk [17].

When the criteria of CHE are extended beyond hospital visit-based claims to charges accrued in post-acute care, the extent of economic impact that occurs from traumatic injuries is viewed with higher resolution and indicates that 70–90% of all uninsured trauma patients are at risk of financial hardship as a result of their injuries. To stem the crisis that skyrocketed health care costs imposed on individuals and families, the Affordable Care Act (ACA) became law in January 2010, with the main provisions of the law enacted in January 2014. The ACA intended to expand healthcare access and mitigate the impact of injury and disease on the uninsured. In achieving this feat, the ACA created new opportunities for insurance companies by subsidizing the purchase of health insurance.

A decade later, trauma-related expenses have proven insurance expansion to be an insufficient safety net. In 2016, in the US, 53% of adults between the ages of 18 and 64 without insurance reported difficulties with paying medical bills, and 20% of patients within the same age cohort who possessed health insurance with insurance deductibles between $1,500 and $3,000 and above for a family reported difficulties paying medical bills. Of the medical bills studied, 66% were attributed to a short-term medical stay or one-time medical expense such as an injury [18]. Health insurance deductibles are the amount you pay for covered healthcare services before your insurance plan contributes payment to a portion of your bills. Out-of-pocket (OOP) maximums include deductible payments but do not include out-of-network charges accrued by providers with the insurance plan. Out-of-pocket maximum limits represent the maximum out-of-pocket costs before the insurance plan covers medical bills. In 2024, OOP Maximums for an individual were $9,450 and were $18,000 for a family. In 2030, the estimated OOP limit for single coverage is $14,100. Comparing trends between wage increases using projections provided by the Congressional Budget Office (CBO) and Centers for Medicare and Medicaid Services (CMS) National Health Expenditure Accounts and OOP limits through the Affordable Care Act, OOP limits are outpacing wage growth. Between 2014 and 2023, the ACA OOP limit increased by 43% compared to a 31% increase in wage and salary growth. Between 2014 and 2033, the CBO expects wages to grow by 83%, and the ACA’s maximum OOP limit is expected to grow by 122% over the same period. As the statistical disparities widen, the distortion of the market continues, less protection is offered to the insured, and higher premiums owed to Insurance companies will invariably be handled through federal premium subsidies [19]. Paradoxically, after specific provisions of the ACA came into effect, the net income of large health insurance companies increased by 8.7% between 2017 and 2018. The gain in net insurer profits was more than doubled by increases in Health Insurance stock prices in the S&P 500 since the law took effect in January 2014 [20].

The socioeconomic status of the traumatically injured compounds the financial burden, with patients of lower economic standing being disproportionally affected despite access to government-funded programs. A 2021 report published in the Journal of the American Medical Association found that people in states that did not expand Medicaid in 2014 were 34% more likely to incur medical debt and had more medical debt than Medicaid participants in states where Medicaid expanded [21].

Moving away from public sector funding mechanisms for traumatic injuries toward private health insurance in the United States has not proven to be a financial safeguard for the injured. In 2021, credit reports of patients who were admitted to the hospital between July 2020 and December 2020 for traumatic injuries and who held private insurance during their care were 70% more likely to incur medical debt. Additionally, insured patients who were traumatically injured had a 110% higher bankruptcy rate compared with patient cohorts admitted to the hospital for reasons unrelated to trauma [22, 23].

Uncovering data that clarifies the financial impact of traumatic injuries remains challenging. The accuracy of our assessments are uniquely limited by the availability of data for a problem that is so pervasive for society. To obtain information on injuries, the focus has been primarily on out-of-pocket payments for inpatient admission and extracting information from credit reports. Longitudinal studies following patients post-discharge are consistently limited due to the varying factors that impede follow-up. Of the factors that impeded follow-up, cost and lack of provider-patient communication are paramount. As of 2022, data suggests 47% of Americans who have health insurance find the cost of health care difficult to afford, with 21% of insured patients delaying health care and 61% of uninsured delaying health care due to costs [18], leading one to conclude that the cost of care in the US continues to undermine the ability to use the healthcare-related services. In the United States, a unique aspect of the public health crisis is the increasing administrative costs in healthcare, which are bundled into the high cost of labor. To address the issue of rising market-based administrative service cost, it is essential to balance the savings generated by these services and their impact on benefit designs against the potential productivity losses of those who cannot afford but need care. Evaluating improvements to the market-based healthcare system must include recognizing the cost increases caused by the consolidation of hospitals and insurance companies. Although larger health systems and insurance providers may necessitate more administrative services, this expansion also risks leaving more people, especially those affected by trauma, without adequate care.

When traumatic injuries occur due to civil wrongs, ensuing litigation influences not only the accessibility of care but also the extent of economic impact the injured absorbs, which is quantifiable. As previously mentioned, the data analyzed to measure the depth of financial burden experienced by injured patients is fragmented by the availability of hospital-based claims and relies on patient-reported surveys and credit reports.

The majority of medical care received by traumatic injury survivors is performed in independently owned outpatient settings, often through the private practice sector. Health care provided through independent medical practices fragments data used in research due to the need for more standardization, limiting practical data availability. As the private practice sector of medicine atrophies due to the lack of inflation-adjusted payment and hospital acquisitions of medical practices expand, the path of medical care for the injured bifurcates. In the author’s experience, hospital-based care, in either inpatient or outpatient settings, an aversion exists to providing medical care for traumatically injured patients after the acute phase of care has ended. This aversion is mainly attributed to ongoing litigation. It occurs due to the unwillingness of hospital managers to allow their medical providers to be removed from work to participate in the process of litigation and the uncertainty over potential payment for the medical care rendered due to the ambiguous position of collateral source payer liability when an accident is on file for the insured.

A 2021 survey of forensic experts, their methods, estimates, and perspectives did not acknowledge the potential of how actuarial risk premiums impact the reliability of their predictions [24]. Actuarial risk is proportional to the reliability of assumptions implemented in pricing models used by insurance companies to set premiums and factors into risk segmentation. Risk segmentation reflects the redistribution of groups of insureds into risk tiers, ultimately affecting coverage and cost.

The reliance on Medicare rates as an acceptable unit of account for payment for establishing future payment is another deeply flawed approach that fails to acknowledge that Medicare rates do not accurately account for operational shifts in labor and cost. The replacement of payer networks with Medicare reference-based pricing improves provider access; however, this pricing model leaves patients vulnerable to costs due to a lack of facility fee coverage. Additionally, current Medicare rates to the private practice sector are 39% behind inflation [25].

7. Conclusion

In navigating the costs and care for the injured, the methodological quality of our approaches must move beyond the threshold of reproducibility if they are to adjudicate the future care of the injured to methods that acknowledge the complexity of the tasks at hand with unreserved confidence while incorporating practicality into the logic for determining future amounts. Utilizing a multidisciplinary approach that acknowledges limitations in the practicality of our knowledge rather than obscuring those limitations with population-based assumptions is essential. If not, those responsible for establishing the reasonable value of recovery for medical expenses of the traumatically injured will rely on methodologies unable to cope with the problem they are trying to confront.

Thanks

To my Mother, Riaan, Ahalya and Jedica. Every endeavor starts and ends with my love for you.