Objectives Objectives Understand types of malpractice insurance - PDF document

Richard O. Davis, MD 2/14/2017 Tips for Optimal Management of Tips for Optimal Management of Risk in Obstetrical Care Risk in Obstetrical Care Richard O. Davis, M.D. Richard O. Davis, M.D. Objectives Objectives  Understand types of malpractice insurance coverage  Discuss the importance of risk management in the p g hospital and office setting  Understand pitfalls in the Electronic Medical Record  Discuss recent trends in medical malpractice claims NO CONFLICTS ROD Progress Meeting 2017.ppt 1

Richard O. Davis, MD 2/14/2017 Risk Management Risk Management  Hospital Setting Hospital Setting  Health  Health Health Systemwide Health Systemwide Systemwide Systemwide  Office Setting Office Setting UAB Risk Management UAB Risk Management  Assessment: Understand the facts/investigation  Assess level of risk  Standard of care (internal and/or external review)  Individual practitioner(s) or system(s)  Focus on resolution and quality improvement Incident Reports are Privileged Incident Reports are Privileged and Confidential and Confidential  Incident Reports at UAB are Electronic. Incident Reports at UAB are Electronic.  Never refer to an Incident Report in the Never refer to an Incident Report in the Medical Record. Medical Record. Medical Record Medical Record  Never Place an Incident Report in the Never Place an Incident Report in the Medical Record. Medical Record.  Never Document your conversation with Never Document your conversation with Risk Management in the Medical Record. Risk Management in the Medical Record.  Never email or text following an adverse Never email or text following an adverse event. event. ROD Progress Meeting 2017.ppt 2

Richard O. Davis, MD 2/14/2017 Statute of Limitations Statute of Limitations - - Alabama Alabama  Injury Injury - - 2 years from date of injury 2 years from date of injury  – could be up to four years. could be up to four years.  Death  Death Death - 2 years from date of death Death - 2 years from date of death. 2 years from date of death 2 years from date of death.  Children Children – under 4 under 4 - - until his/her 8th birthday until his/her 8th birthday – over 8 over 8 - - 4 years. 4 years. 7 Type of Insurance Coverage Type of Insurance Coverage  Claims Made – Requires tail coverage  Occurrence  1 million/3 million Top Medical Specialties by Top Medical Specialties by Average Indemnity 2012 Average Indemnity 2012 1. OB/GYN $425,000 2. Neurosurgery $421,000 3 3. Pediatrics Pediatrics $398 000 $398,000 4. Neurology $395,000 5. Anesthesiology $378,000 All Specialties $329,000 PIAA ROD Progress Meeting 2017.ppt 3

Richard O. Davis, MD 2/14/2017 2014 Medical Malpractice Trend Review 2008 2014 Medical Malpractice Trend Review 2008- -2013 2013 Verdicts or settlements of $5 million or more Verdicts or settlements of $5 million or more Total cases 245 4,561,357,254 OB/GYN *64 1,465,752,756 Emergency Medicine E M di i 13 13 116,349,078 116 349 078 Anesthesiology 11 209,541,570 General Surgery 9 86,050,000 * 60 were birth injury cases (all exceeded $5 million) The Risk Authority Stanford University Medical Network Top Ten Medical Professional Top Ten Medical Professional Liability Insurers Liability Insurers 2013 Rank Company Not Previous Written 1 Berkshire Hathaway 825.5 M 2 Doctors Company 736.1 3 MLMIC (NY) 542 4 4 Pro Assurance Pro Assurance 494 9 494.9 5 CNA 477.2 6 PRI (NY) 373.2 7 AIG 351.5 8 Coverys 346.2 9 NORCAL 285.7 10 ISMIE Mutual (llinois) 243.2 Source: AM Best 2014 Obstetric Claims Obstetric Claims Metrics Hospitals Metrics Hospitals  About 1 in every 3,711 births results in About 1 in every 3,711 births results in claim with indemnity claim with indemnity  Average value of these cases including  Average value of these cases, including Average value of these cases including Average value of these cases, including defense, is 1.1 M defense, is 1.1 M  The cost per delivery to cover liability is, The cost per delivery to cover liability is, on average, $296 on average, $296 Source: Berkley Med 2015 Source: Berkley Med 2015 ROD Progress Meeting 2017.ppt 4

Richard O. Davis, MD 2/14/2017 Hospital Excess Claims Hospital Excess Claims  Failure to Diagnosis Fetal Distress Failure to Diagnosis Fetal Distress   Failure to Timely perform Cesarean Failure to Timely perform Cesarean  Surgical Care Surgical Care Surgical Care Surgical Care  Shoulder Dystocia Shoulder Dystocia Source: Berkley Med Source: Berkley Med Top Chief Medical Factors Top Chief Medical Factors  Improper Performance Improper Performance  Errors in Diagnosis Errors in Diagnosis  Failure to Supervise or Monitor Care Failure to Supervise or Monitor Care Failure to Supervise or Monitor Care Failure to Supervise or Monitor Care  Medication Errors Medication Errors Prevalence and Characteristics of Physicians Prone to Malpractice Claims Studdert DM, Birmark MM, Mello MM, et al. Stanford University School of Medicine and y Stanford University Law School, Melbourne School of Population and Global Health, Department of Health and Human Services New Engl J Med 2016;374:354-62. ROD Progress Meeting 2017.ppt 5

Richard O. Davis, MD 2/14/2017 National Practitioner Data Bank National Practitioner Data Bank (NPDB) (NPDB)  Confidential data repository  Created by Congress in 1986  Improve healthcare quality  Analyzed 66,426 claims paid against 54,099 physicians  Jan 1, 2005 – Dec 31, 2014 Physician Specialty Physician Specialty (Top 5) (Top 5)  Internal Medicine 15%  Obstetrics and Gynecology 13%  General Surgery  General Surgery 12% 12%  General Practice/Family Medicine 11%  Orthopedics 7% Physician Characteristics Physician Characteristics  Male Physician 82%  M.D. 92%  D.O. 8%  Trained in U.S. 77%  Metropolitan Area 87% ROD Progress Meeting 2017.ppt 6

Richard O. Davis, MD 2/14/2017 Claims Analysis (66,426) Claims Analysis (66,426) Death 21,509 (32%) Major physical injury 10,130 (15%) Significant physical injury 25,447 (38%) Minor physical injury 7,798 (12%) Emotional injury only 999 ( 2%) Injury Scale from National Association Injury Scale from National Association of Insurance Commissioners of Insurance Commissioners Disposition of Claims (66,426) Disposition of Claims (66,426) Settlement: 97% Verdict: 3% Total payment (2014 dollars) Mean 371,054 Median 204,750 Distribution of Claims Distribution of Claims  16% of physicians had at least 2 paid claims and accounted for 32% of all claims  4% of physicians had at least 3 paid  4% of physicians had at least 3 paid claims and accounted for 12% of all claims  1% of physicians had at least 4 paid claims and accounted for 5% of all claims ROD Progress Meeting 2017.ppt 7

Richard O. Davis, MD 2/14/2017 Factors Associated with Recurrent Factors Associated with Recurrent Claims Compared to Physicians with Claims Compared to Physicians with Only One Claim Only One Claim  2 paid claims = 1.97 hazard ratio  3 paid claims – 3.11 hazard ratio 3 id l i 3 11 h d ti  6 or more paid claims = 12.39 hazard ratio Recurrence Paid Claims by Specialty Recurrence Paid Claims by Specialty Compared to Internal Medicine Compared to Internal Medicine  Neurosurgeons = 2.32 hazard ratio  Orthopedic surgeons = 2.02 hazard O t oped c su geo s 0 a a d ratio  Obstetrician-Gynecologist – 1.89 hazard ratio  Psychiatrists and Pediatricians - <1 hazard ratio Distribution of Claims Distribution of Claims Analysis Performed with All 915,564 Analysis Performed with All 915,564 Active Physicians as Denominator Active Physicians as Denominator  Only 6% of physicians had a paid claim  1% of physicians with ≥ 2 paid claims accounted for 32% of all paid claims  0.2% of physicians with ≥ 3 paid claims accounted for 12% of all paid claims ROD Progress Meeting 2017.ppt 8

Richard O. Davis, MD 2/14/2017 “Shielding” “Shielding”  Some malpractice payments do not reach the NPDB  Settlements made in name of an institutional co- defendant  Shielding is most likely: • Physicians and hospitals covered by same insurer • Delivery system is tightly integrated • Physicians exert substantial control EHR Issues EHR Issues  Retrospective, cohort study of claims Retrospective, cohort study of claims Jan 1, 2012 Jan 1, 2012 – – Dec 31, 2014 Dec 31, 2014  CBS: National Malpractice Claims Database  CBS: National Malpractice Claims Database CBS: National Malpractice Claims Database CBS: National Malpractice Claims Database More than 500 hospitals and 165,000 More than 500 hospitals and 165,000 physicians physicians  147 (<1%) had 1 or more HER errors as 147 (<1%) had 1 or more HER errors as contributing factor contributing factor Graber, et al. J Patient Safety, 2015 Graber, et al. J Patient Safety, 2015 EHR Issues EHR Issues  Medication errors Medication errors 31% 31%  Diagnosis errors Diagnosis errors 28% 28%  Treatment complications  Treatment complications Treatment complications Treatment complications 31% 31% 31% 31%  Issues Identified Issues Identified - User related issues User related issues 63% 63% - Technology related issues Technology related issues 58% 58% Graber, et al. J Patient Safety, 2015 Graber, et al. J Patient Safety, 2015 ROD Progress Meeting 2017.ppt 9