Risk management in obstetric care for family physicians: results of a 10-year project

BACKGROUND: Malpractice issues within the United States remain a critical factor for family physicians providing obstetric care. Although tort reform is being widely discussed, little has been written regarding the malpractice crisis from a risk management perspective. METHODS: Between 1989 and 1998, a 10-year risk management study at the UC Davis Health System provided a unique collaboration between researchers, a mutual insurance carrier and family physicians practicing obstetrics. Physicians were asked to comply with standardized clinical guidelines, attend continuing medical education (CME) seminars, and submit obstetric medical records for review. Feedback analysis was provided to each physician on their records, and the insurance carrier tracked interim malpractice claims. RESULTS: One hundred and ninety-four physicians participated, attending to 32,831 births. Compliance with project guidelines was 91%. Five closed obstetric cases were reported with only one settlement reported to the National Provider Data Bank. Physicians believed the project was beneficial to their practices. CONCLUSIONS: Family physicians practicing obstetrics are willing to participate in a collaborative risk management program and are compliant with standardized clinical guidelines. The monetary award for successful malpractice claims was relatively low. This collaborative risk management model may offer a potential solution to the current malpractice crisis.     

The Impact of Malpractice Liability Claims on Obstetrical Practice Patterns

Objectives. This paper examines whether malpractice claims have any impact on obstetrical practice patterns (C-section rates) and physician delivery volume.
Data Sources. Secondary data from the 1992–2000 Florida Hospital Inpatient Discharge File, the Florida Medical Professional Liability Insurance Claims File, and the American Medical Association's Master File on physician characteristics.
Study Design. The effects of malpractice claims on C-section rates and physician delivery volume were estimated using panel data and a fixed-effects multivariate model.
Data Collection. Variables were constructed from each data source and merged into a single panel dataset using consistent physician identifiers.
Principal Findings. I did not find evidence that physicians changed their practice patterns by increasing C-section rates in response to malpractice claims. However, physicians performed six fewer inpatient deliveries 3 years after the closing of a malpractice claim, after controlling for individual- and market-level characteristics. Physicians with high malpractice awards of U.S.$250,000 or more performed 14 fewer deliveries on average.
Conclusions. Malpractice claims led to a small reduction in physician delivery volume, but they did not have a significant impact on C-section rates.     

Medical malpractice among physicians: Who will be sued and who will pay?

This paper examines whether a physician's future claims of medical malpractice are predictable from information on the physician's recent claims history, training credentials, practice characteristics, and demographics. Data on the medical malpractice experience of 8,733 Michigan physicians between 1980 and 1989 is analyzed. We find strong evidence of repetition over time regarding who was sued and who paid claims. The worse a physician's malpractice litigation record during 1980–1984, the worse was his record during 1985–1989. Training credentials were also highly predictive of future malpractice experience. Physicians trained at lower ranked medical schools or who went through lower-ranked residency programs faced higher odds of developing adverse malpractice records, even after controlling for their previous litigation record. Growing internet access to information on these characteristics will help inform prospective patients if they wish to avoid physicians likely to be sued and likely to make payments in the future for malpractice. This revised version was published online in July 2006 with corrections to the Cover Date.     

Integrating quality with risk financing through a risk retention group

In Philadelphia, one of the nation's judicial battlegrounds, a clinical practice group of 360 physicians responded to the medical malpractice insurance crisis by creating a reciprocal risk retention group that has supported the group's best practices while almost eliminating the number of claims going to trial. This article describes how the insurance crisis helped change the culture of its physician practice group, restore the close physician‐patient relationship that lies at the heart of medicine, and shows how elements of this revolutionary program can be adopted by all professional liability insurers.     

Accuracy of physician billing claims for identifying acute respiratory infections in primary care

Objective. To assess the accuracy of physician billing claims for identifying acute respiratory infections in primary care. Study Setting. Nine primary care physician practices in Montreal, Canada (2002–2005). Study Design. A validation study was carried out to compare diagnoses in 3,526 physician billing claims with diagnoses documented in the corresponding patient medical records. Data Collection. In‐office medical record abstraction. Principal Findings. Claims had a high positive predictive value (PPV), negative predictive value, and specificity for identifying respiratory infections; however, their sensitivity was below 50 percent. Large variation in sensitivity and PPV was observed among physicians. Conclusions. Because claims data are now routinely used to monitor antibiotic prescribing in primary care, future research should determine if acute respiratory infection diagnoses are missing from claims at random, or if bias is present.     

Relation of patients' experiences with individual physicians to malpractice risk.

OBJECTIVE: Patient care experience survey data might be useful for managing individual physician malpractice risk, but available evidence is limited. This study assesses whether patients' experiences with individual physicians, as measured by a validated survey, are associated with patient complaints and malpractice lawsuits. DESIGN: Random samples of active patients in physicians' panels, with sample sizes adequate to provide highly reliable, stable information about patients' experiences with each physician (n = 19 202, average respondents per physician = 119) were used to assess the relation of patient survey measures to malpractice risk. SETTING: A large multi-specialty physician organization in eastern Massachusetts, USA. PARTICIPANTS: Physicians providing care for at least 5 years in adult primary care and select high-risk specialty departments between January 1996 and December 2005 (n = 161). MAIN OUTCOME MEASURES: Patient complaints (2001-05) and malpractice lawsuits (1996-2005). RESULTS: Compared to primary care physicians, high-risk specialists had a lower patient complaint rate (0.34 vs. 1.36 complaints per patient care full time equivalent; P < 0.001), but a higher lawsuit rate (0.09 vs. 0.05 lawsuits per patient care full time equivalent; P = 0.02). Irrespective of physician specialty, the quality of physician-patient interactions (IRR = 0.61; P < 0.001) and care coordination (IRR = 0.65; P < 0.001) were inversely associated with patient complaints. Patient survey measures were not associated with malpractice lawsuits. CONCLUSIONS: The results underscore the challenges organizations face when attempting to use patient survey data to manage individual physician medical malpractice risk. Because lawsuits are infrequent events, calibrating these validated patient survey measures to malpractice lawsuit risk will require large physician samples from diverse practices.     

Liability for managed care decisions: the Employee Retirement Income Security Act (ERISA) and the uneven playing field.

As managed care organizations expand their programs of quality assurance and physician evaluation, more medical malpractice lawsuits may be brought against managed care organizations on the ground that, like hospitals, they are legally responsible for negligent corporate acts that injure patients. However, the federal Employee Retirement Income Security Act (ERISA) shields managed care organizations from liability when they are part of an employee group health plan governed by ERISA. Unlike patients with other types of insurance, patients in ERISA health plans do not have a malpractice remedy for a managed care organization's negligence. A few federal appeals courts recently recognized that ERISA plans can be vicariously liable for their physicians' medical malpractice, but only if the physician is the plan's employee or agent. Yet ERISA still prohibits negligence claims against ERISA health plans for injuries resulting from denial of plan benefits, failure to use qualified physicians, utilization review, or improper plan administration. Current managed care operations do not neatly distinguish between administering benefits and controlling quality of care. Neither should the law. ERISA should be amended to provide employees with the same remedies that patients in non-ERISA plans enjoy.     

Canadian medical malpractice liability: an empirical analysis of recent trends

The determinants of the frequency of Canadian malpractice claims, the proportion of claims that result in payment, and the severity of these claims are examined. Inter-specialty variation in the frequency of malpractice claims is almost entirely related to the differential performance of major surgery. Various legal doctrines concerning both compensation and liability appear responsible for approximately half of the upward trend in the propensity to initiate malpractice litigation. We believe that the remaining explanations for growth in claims frequency are changes in social attitudes toward risk-bearing, increasing social distance between patients and physicians, and innovations in medical technology.     

Factors impacting perceived threat of malpractice lawsuits by various medical specialists

A study was undertaken to examine perceived threat of malpractice lawsuits affecting different physician specialties and to examine factors that impact such perceptions of those specialties. The study used data collected by the Center for Studying Health System Change's 2008 Health Tracking Physician (HTP) Survey. The 2008 HTP data set consisted of 4720 physicians belonging to the American Medical Association. Primary care physicians, medical specialists, surgical specialists, psychiatrists, and obstetricians/gynecologists (ObGyns) physicians participated in the 2008 HTP Survey. The order (from high to low) of perceived threat of malpractice lawsuits for various specialists is surgical specialists (3.87), ObGyns (3.81), medical specialists (3.60), primary care physicians (3.55), and psychiatrists (3.12). Regression results indicate that patient interaction, insufficient care quality, competition, medical school, age, and career satisfaction impacted perceived threat of malpractice lawsuits for most of the specialties. For ObGyns, white non-Hispanic was the only factor that impacted perceived threat of malpractice lawsuits. The perceived threat of malpractice lawsuits varies by specialists. Patient interaction, insufficient care quality, competition, medical school, and career satisfaction are major predictors of such threats for most physician specialties.     

Medical school attended as a predictor of medical malpractice claims

Objectives: Following earlier research which showed that certain types of physicians are more likely to be sued for malpractice, this study explored (1) whether graduates of certain medical schools have consistently higher rates of lawsuits against them, (2) if the rates of lawsuits against physicians are associated with their school of graduation, and (3) whether the characteristics of the medical school explain any differences found.

Design: Retrospective analysis of malpractice claims data from three states merged with physician data from the AMA Masterfile (n=30 288).

Study subjects: All US medical schools with at least 5% of graduates practising in three study states (n=89).

Main outcome measures: Proportion of graduates from a medical school for a particular decade sued for medical malpractice between 1990 and 1997 and odds ratio for lawsuits against physicians from high and low outlier schools; correlations between the lawsuit rates of successive cohorts of graduates of specific medical schools.

Results: Medical schools that are outliers for malpractice lawsuits against their graduates in one decade are likely to retain their outlier status in the subsequent decade. In addition, outlier status of a physician's medical school in the decade before his or her graduation is predictive of that physician's malpractice claims experience (p<0.01). All correlations of cohorts were relatively high and all were statistically significant at p<0.001. Comparison of outlier and non-outlier schools showed that some differences exist in school ownership (p<0.05), years since established (p<0.05), and mean number of residents and fellows (p<0.01).

Conclusions: Consistent differences in malpractice experience exist among medical schools. Further research exploring alternative explanations for these differences needs to be conducted.

     

Torts to contract¿ moving from informed consent to shared decision‐making

Many claims of medical malpractice arise from a breakdown in communication between physician and patient. As a result, medical decision‐making may change from an informed consent model to a shared decision‐making strategy. Shared decision‐making, a contract derivative, will trigger contract obligations and change the face of medical malpractice from tort to contract.     

An alternative method of determining standard of care in alleged cases of malpractice

BACKGROUND: Physician experts hired and prepared by litigants provide most information on standard of care for medical malpractice cases. Because this information may not be objective or accurate, we examined the feasibility and potential value of surveying peer physicians to assess standard of care. METHODS: The survey method was evaluated for a medical malpractice case involving a patient hospitalized with abdominal pain. An abstract of the medical record was created that included the patient characteristics and physician decisions most likely to influence patient outcome. The abstract and questionnaire were sent to 16 academic family physicians and to 20 randomly chosen primary care physicians in Iowa who practiced in communities of similar size to the defendant's community. RESULTS: All 16 academic and 18 (90%) community physicians completed the survey. All respondents judged the patient as presenting with an acute abdomen, and 89% of the community physicians and 100% of the academic physicians judged the care as below standard. More than half the physicians surveyed listed the autopsy diagnosis (perforated ulcer) in their differential. CONCLUSION: Surveys of randomly selected physicians are feasible to perform for medical malpractice cases. A pro-physician bias has little if any influence on the results.     

"Health courts" and accountability for patient safety

Proposals that medical malpractice claims be removed from the tort system and processed in an alternative system, known as administrative compensation or "health courts," attract considerable policy interest during malpractice "crises," including the current one. This article describes current proposals for the design of a health court system and the system's advantages for improving patient safety. Among these advantages are the cultivation of a culture of transparency regarding medical errors and the creation of mechanisms to gather and analyze data on medical injuries. The article discusses the experiences of foreign countries with administrative compensation systems for medical injury, including their use of claims data for research on patient safety; choices regarding the compensation system's relationship to physician disciplinary processes; and the proposed system's possible limitations.     

Measuring efficiency of physician practices using data envelopment analysis

PURPOSE: Medical-group practices are becoming increasingly common-place, with more than a third of licensed physicians in the United States currently working in this mode. While previous studies have focused on physician practices, little attention has been focused specifically on the contribution of internal organizational factors to overall physician practice efficiency. This paper develops a model to help determine best practices of efficient physician offices while allowing for choices between inputs. Measuring how efficient practices provide services yields useful information to help improve performance of less efficient practices. DESIGN: Data for this study were obtained from the 1999 Medical Group Management Association (MGMA) Cost Report. In this study, 115 primary care physician practices are analyzed. Outputs are defined as gross charges; inputs include square footage and medical, technical, and administrative support personnel. METHODOLOGY: Data envelopment analysis (DEA) is used in this study to develop a model of practice outputs and inputs to help identify the most efficient medical groups. DEA is a linear programming technique that converts multiple input and output measures to a single comprehensive measure of efficiency. These practices are used as a reference set for comparisons with less efficient ones. CONCLUSION: The overall results indicate that size of physician practice does not increase efficiency. There does not appear to be extensive substitution among inputs. Compared to other practices, efficient practices seem to manage each input well.     

Medical malpractice litigation raises health-care cost, reduces access, and lowers quality of care

This article examines the impact of medical malpractice litigation on health-care cost, the availability of employer-sponsored health insurance, and the quality of health-care services. Among the findings are that unlimited, uncapped medical malpractice litigation added as much as 97.5 billion dollars annually to the cost of hospital and physician services; increased the annual cost of employer-provided health insurance by as much as 12.7 percent; decreased by 2.7 million the number of workers and their families covered by employer-provided health insurance; caused a 6 percent decline in physicians in the U.S., many of whom work in critical specialty areas; lost access to critical medical services for up to 14.4 million people; resulted in malpractice underwriting losses of 8.6 billion dollars in 2001, double that of 10 years earlier; and had a low predictive value in identifying whether medical malpractice had occurred.     

A patient, an internet article, and thou: challenges of the Internet in clinical practice

This article addresses issues a physician should consider when responding to medical research gathered by a patient from the Internet, discussing both potential medical malpractice liability and offering specific, recommended responses for physicians whose patients conduct online medical research.     

The National Practitioner Data Bank: the first 4 years.

The National Practitioner Data Bank became operational September 1, 1990, as a flagging system to identify health care practitioners who may have been involved in incidents of medical incompetence. Query volumes have grown substantially over the Data Bank''s first 4 years of operation. The greatest increase has come in the number of voluntary queries. By the end of 1994, the Data Bank had processed more than 4.5 million requests for information on practitioners, more than 1.5 million of which were received in 1994 alone. The proportion of queries for which the Data Bank contains information on the practitioner in question has grown as the Data Bank has come to contain more reports. During 1994, 7.9 percent of queries were matched. The Data Bank contained more than 97,500 reports at the end of 1994. More than 82 percent of the reports concerned malpractice payments. Licensure reports made up the bulk of the rest. Physicians predominate in reports, accounting for slightly more than 76 percent of the total. The remainder are related to dentists (16 percent) and all other types of practitioners (8 percent). Since reporting of adverse actions is mandatory only for physicians and dentists, the proportion of reports attributable to these types of practitioners is higher than it would be if adverse action reporting requirements were uniform for all practitioners. State malpractice payment rates and adverse action rates vary widely, but a State''s rate in any given year is highly correlated with its rate in any other year. State malpractice rates are not strongly correlated with adverse action rates, neither are the rates for physicians strongly correlated with those for dentists. There is a weak tendency for States with smaller physician populations to have higher levels of licensure and privileging actions.