physician liability trends paul a. greve, jr. jd rplu vice president g ge medical protective
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g GE Medical Protective 2
Physician Liability Trends: Physician Liability Trends: OverviewOverview
The State of Medical Professional Liability in 2001
PIAA Claims Trends 1985 -1999
GE Medical Protective’s Experience 1991 1999
Future Trends
Risk Control Measures
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The State of Medical Professional The State of Medical Professional
Liability in 2001Liability in 2001
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The State of Medical Professional The State of Medical Professional
Liability (MPL)Liability (MPL)
Claim Severity Has Escalated Nationally
MPL Insurance Industry Results Have Deteriorated
Effect of September 11th on the Insurance Industry
Focus for 2001: The Malpractice Problem
Knowledge is Power
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Claim Severity: Social Claim Severity: Social Environmental FactorsEnvironmental Factors
Impact of Managed Care
Publicity of Medical Errors
BBA Cutbacks
“Social Inflation”: Lottery, Athletes, Media
Disgruntled Healthcare Staff
Environment Will Not Improve Soon
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Claim Severity: Legal Claim Severity: Legal Environmental Factors Environmental Factors
Frequency is Flat or Up Slightly
Skyrocketing Verdicts and Settlements
Failure of Tort Reform
Sophisticated Plaintiff’s Bar
Juror Views of the Legal Process
Frequency of Severity is the Problem
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MPL Insurance Results MPL Insurance Results Deterioration Deterioration
Nursing Homes: Skyrocketing Prices and Decreasing Capacity
Hospitals: “A Disproportionate Share of the Industry’s Worsening Results”*
Physicians: Escalating Severity Improper Performance of a Procedure Failure to Diagnose
All Market Segments Affected
*Source: Medical Malpractice Insurance, Conning & Co., 2000
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MPL Insurance Results MPL Insurance Results Deterioration Deterioration
Virtually All Major Carriers Affected
Failures/Downgrades: PIE, PHICO, Frontier, Reliance, PIC
Loss Ratios’ Deterioration Due To:
– Severity
– Defense Costs, Including Medical Inflation
Reserve Redundancies Reduced
Worsening of MPL Results is Multi-Factored
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MPL Market Impact on Insureds MPL Market Impact on Insureds Nursing Homes
– Double to Triple Digit Increases
– Few Carriers– Mandatory Deductibles
– Lower Limits Available Hospitals
– Double to Triple Digit Increases– Fewer Carriers– Higher Attachments for SIRs May be Required
Physicians– Double Digit Increases– Still a Competitive Market
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Top 10 Medical Malpractice Top 10 Medical Malpractice WritersWriters
Company/Group 2000 Direct Premiums
St. Paul Companies
MLMIC Group
GE Capital Ins Group
Health Care Indemnity
CNA Ins Companies
Zurich/Farmers Group
Norcal Group
MIIX Group
Doctors Co Ins Group
PHICO Group
TOTAL: All U.S. Companies
$575,184
$499,719
$320,977
$243,144
$232,050
$230,061
$212,374
$209,750
$204,966
$182,476
$6,304,315
Source: A.M. Best Company, July 1999
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PIAA Claims TrendsPIAA Claims Trends1985-19991985-1999
Physician Insurers Association of America (PIAA)
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PIAA Claims TrendsPIAA Claims Trends1985-19991985-1999
Data submitted by more than 20 member companies.
156,000 closed claims and suits.
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Closed Paid Total Avg.Specialty Claims Claims IndemnityIndemnity
Source: PIAA
AnesthesiologyEmergency Medicine*General SurgeryGenera/Family Practice*Internal Medicine*Neurology*NeurosurgeryOB/GYN SurgeryOrthopedic SurgeryPathology*Pediatrics*Plastic SurgeryRadiology*
5,9652,196
17,14218,13420,5402,4303,715
21,94715,7861,0824,8146,2008,257
$384,862,210$88,038,987
$914,741,313$860,371,583$924,572,102$134,846,928$255,603,243
$1,831,398,902
$645,990,588$69,223,500
$321,923,922$155,310,625$342,077,242
2,124622
6,1296,6275,595
5231,0437,9764,731
3251,4091,7352,493
$181,197$141,542$149,248$129,828$165,250$257,834$245,065$229,614$136,544$212,995$228,477$89,516
$137,215
PIAA Comparative Payment PIAA Comparative Payment
Analysis by SpecialtyAnalysis by Specialty Claims Closed Claims Closed
1985-19991985-1999
*Non-surgical
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PIAA Top Five Medical PIAA Top Five Medical
ConditionsConditionsClaims Closed 1985-1999Claims Closed 1985-1999
Malignant neoplasms of the female breast 3,320 $210,512 $17,248
Brain damaged infant 3,190 $480,224 $33,643
Pregnancy 2,517 $150,412 $13,060
Myocardial infarction 2,229 $188,351 $17,086
Displacement of intervertebral disc 2,097 $195,713 $17,260
Total AverageAverageCondition Claims IndemnityExpense
Source: PIAA
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PIAA Top Five Medical PIAA Top Five Medical
MisadventuresMisadventuresClaims Closed 1985-1999Claims Closed 1985-1999
Improper performance 40,355 $142,811 $14,356
Errors in diagnosis 32,727 $178,445 $15,902
No medical misadventure 32,536 $146,264 $14,161
Failure to supervise 9,612 $200,082 $21,985or monitor case
Medication errors 5,878 $122,715 $15,147
Total AverageAverageCondition Claims IndemnityExpense
Source: PIAA
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Physician Liability Trends: Physician Liability Trends: The Medical Protective Company’s The Medical Protective Company’s Experience Experience 1991-19991991-1999
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Average Payment for Paid CasesAverage Payment for Paid CasesAll Medical Specialties All Medical Specialties 1991 - 19991991 - 1999
Average Highest # of TotalYear Paid Cases Payment Cases Loss
Source: GE Medical Protective ®
199
1
199
2
199
3
199
4
199
5
199
6
199
7
199
8
199
9
$98,682
$121,61
4
$123,39
4
$139,15
9
$129,81
2
$137,30
3
$140,98
8
$172,60
4
$175,28
5
$2,400,00
0
$1,850,00
0
$1,600,00
0
$2,240,00
0
$1,025,00
0
$1,980,00
0
$4,500,00
0
$3,500,00
0
$2,000,00
0
2,784
2,701
2,725
2,901
2,936
3,636
3,559
3,058
2,933
$171,096,495
$174,533,704
$172,447,749
$188,448,977
$168,879,951
$182,119,075
$190,117,810
$221,611,849
$222,726,514
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The Medical Protective The Medical Protective CompanyCompany
Unstable Angina in repeated episodes resulting in arrest and death.
Failure to diagnose breast cancer.
Misdiagnosis of meningitis.
Delayed Caesarean.
Physician Liability Trends: Problem Cases
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Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Failure to Diagnose ConditionFailure to Diagnose Condition
Source: GE Medical Protective ®
Cancer
Heart
Infection
Aneurys
m
Spine
Avg. PaidCases
$218,651
$231,670
$278,234
$239,803
$166,074
% of Allegation
26.13%
9.97%
4.30%
2.42%
1.78%
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Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Improper TreatmentImproper Treatment
Source: GE Medical Protective ®
Heart
Spine
Infectio
n
Delivery
Avg. Paid
Cases
$118,438
$132,637
$130,135
$153,097
% of Allegation
4.78%
3.45%
2.87%
2.38%
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Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Failure to Prevent ConditionFailure to Prevent Condition
Source: GE Medical Protective ®
Infection
Blood
Dyscrasia
Fall
Perforation
Heart
Avg. PaidCases
$86,091
$1,505
$38,612
$137,092
$170,263
% of Allegation
14.13%
10.28%
9.88%
8.15%
3.01%
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Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Improper SurgeryImproper Surgery
Source: Medical Protective ®
Nerve
Injury
Perforatio
n
Artery
Spine
Duct
Avg.
PaidCases
$114,216
$147,630
$129,753
$192,382
$152,573
% of Allegati
on
8.44%
3.31%
3.31%
3.18%
2.63%
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Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Failure to Diagnose CancerFailure to Diagnose Cancer
Source: GE Medical Protective ®
Breast
Lung
Colon
Cervix
Prostate
Avg.
PaidCases
$162,049
$181,490
$175,474
$194,580
$265,430
% of Allegatio
n
32.58%
15.04%
9.98%
5.22%
3.98%
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Claims PaidClaims PaidEmergency Room Emergency Room 1995 - 19991995 - 1999
1995 $179,917 $4,521,332
1996 $101,904 $3,288,051
1997 $141,098 $5,871,982
1998 $325,406 $11,856,683
1999 $216,145 $5,995,968
Avg. Paid Cases TotalYear Including ALE Payout
Source: GE Medical Protective ®
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Top Allegations Top Allegations Emergency Room Emergency Room 1991 - 19991991 - 1999
Heart 21.43% $180,674Appendicitis 6.43% $58,900Aneurysm 5.71% $175,907Meningitis 5.71% $210,250Infection 3.57% $157,500Others 57.14% $167,469
% of AverageFailure to Diagnose Allegation Payment
Source: GE Medical Protective ®
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Emergency RoomEmergency Room
Lawsuit nightmare:
– Unexpected death.
– Typically young victim.
– Dependent children.
Failure to Diagnose Acute Myocardial Infarctions:
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Emergency RoomEmergency Room
Six major factors precipitate suits*:
– Inadequate history.
– Misinterpreted EKG.
– Failure to recognize atypical presentation.
– Reluctance to admit patients with vague/ suspicious symptoms.
– Misguided use of lab results.
– Inadequate physician training.
Failure to Diagnose Acute Myocardial Infarctions:
*Source: Emergency Medicine Risk Management: A Comprehensive Review. ACEP 1991.
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Claims PaidClaims PaidGeneral Practice General Practice 1995 - 19991995 - 1999
1995 $145,778 $30,075,801
1996 $146,970 $28,309,185
1997 $155,054 $32,716,298
1998 $168,608 $34,948,069
1999 $165,583 $30,441,205
Avg. Paid Cases TotalYear Including ALE Payout
Source: GE Medical Protective ®
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Top AllegationsTop Allegations
General Practice General Practice 1991 - 19991991 - 1999
Heart 18.38% $182,811Cancer 6.28% $173,510Infection 4.82% $104,842Tumor 4.64% $135,610Appendicitis 3.28% $96,119Others 62.60% $144,657
% of AverageFailure to Diagnose Allegation Payment
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsGeneral Practice General Practice 1991 - 19991991 - 1999
Breast 29.66% $195,887Colon 15.86% $198,854Lung 15.52% $155,429Cervix 3.45% $55,601Larynx 2.76% $162,500Others 32.76% $209,765
% of AverageFailure to Diagnose Cancer Allegation Payment
Source: GE Medical Protective ®
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Claims PaidClaims PaidInternal Medicine Internal Medicine 1995 - 19991995 - 1999
1995 $163,528 $25,335,340
1996 $181,299 $36,611,055
1997 $183,986 $29,774,984
1998 $186,428 $29,811,680
1999 $213,473 $36,387,961
Avg. Paid Cases TotalYear Including ALE Payout
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsInternal Medicine Internal Medicine 1991 - 19991991 - 1999
Heart 19.17% $173,984Cancer 6.68% $181,338Infection 5.04% $164,375Aneurysm 4.49% $237,607Tumor 3.94% $141,136Others 60.68% $152,610
% of AverageFailure to Diagnose Allegation Payment
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsInternal Medicine Internal Medicine 1991 - 19991991 - 1999
Colon 22.04% $176,000Lung 17.76% $172,103Breast 16.12% $112,190Prostate 7.57% $172,500Stomach 5.26% $143,063Others 31.25% $111,531
% of AverageFailure to Diagnose Cancer Allegation Payment
Source: GE Medical Protective ®
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Claims PaidClaims PaidObstetrics/Gynecology Obstetrics/Gynecology 1995 - 19991995 - 1999
1995 $196,462 $11,955,992
1996 $154,137 $9,319,898
1997 $144,206 $8,000,475
1998 $101,616 $4,184,435
1999 $253,944 $10,932,418
Avg. Paid Cases TotalYear Including ALE Payout
Source: GE Medical Protective ®
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Top AllegationsTop Allegations Obstetrics/Gynecology Obstetrics/Gynecology 1991 - 19991991 - 1999
Fetal Distress 25.97% $277,539Ectopic Pregnancy 7.14% $32,500Uterine Pregnancy 5.84% $47,381Cancer 5.19% $85,544Infection 4.55% $120,209Others 51.30% $194,231
% of AverageFailure to Diagnose Allegation Payment
Source: GE Medical Protective ®
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Obstetrics/GynecologyObstetrics/Gynecology
Expense of long-term care.
Advice of a family member.
Perception of having been misled.
Desire for more information.
Desire for revenge.
Desire to protect others.
Why Do OB Patients Sue?*
*Source: JAMA, March 11, 1992, Vol. 267, 1359-63
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Claims PaidClaims PaidPathology Pathology 1995 - 19991995 - 1999
1995 $198,110 $3,226,536
1996 $220,338 $4,001,088
1997 $208,245 $1,818,149
1998 $332,039 $4,297,244
1999 $270,666 $2,681,150
Avg. Paid Cases TotalYear Including ALE Payout
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsPathology Pathology 1991 - 19991991 - 1999
Cervix 39.77% $134,833Skin 13.64% $233,333Breast 5.68% $500,000Lung 5.68% $25,000Uterus 4.55% $125,000Others 30.68% $269,231
% of AverageFailure to Diagnose Cancer Allegation Payment
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsPathology Pathology 1991 - 19991991 - 1999
Cancer 66.67% $205,802Tumor 12.00% $268,631Hodgkin’s Disease 5.33% $115,000Lesion 2.67% $0Nevus 2.67% $57,500Others 10.67% $45,000
% of AverageMisdiagnosis Allegation Payment
Source: GE Medical Protective ®
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PathologyPathology
Johns Hopkins study: Of 6,171 cancer patients referred, 86 had diagnoses that were significantly wrong*.
Some cancers are more difficult to diagnose and more prone to errors:
– Cervical – Skin – Leukemia
– Liver – Ovarian – Lymphatic
– Prostate – Kidney
With less invasive surgery, pathologists have much less tissue to examine.
*Source: The Toronto Star, April 6, 2000
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Claims PaidClaims PaidPediatrics Pediatrics 1995 - 19991995 - 1999
1995 $173,351 $6,886,874
1996 $271,852 $10,468,257
1997 $208,854 $8,037,099
1998 $286,053 $13,015,421
1999 $210,814 $5,075,333
Avg. Paid Cases TotalYear Including ALE Payout
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsPediatrics Pediatrics 1991 - 19991991 - 1999
Meningitis 10.38% $220,004Heart 7.23% $192,250Infection 5.35% $212,486Tumor 4.40% $77,051Hip Dysplasia 3.46% $70,625Others 69.18% $181,580
% of AverageFailure to Diagnose Allegation Payment
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsPediatrics Pediatrics 1991 - 19991991 - 1999
Meningitis 13.04% $350,000Cesarean 10.14% $500,000Fetal Distress 5.80% $0Hydrocephalus 4.35% $512,500RDS 4.35% $326,667Others 62.32% $272,660
% of AverageDelay in Diagnosis Allegation Payment
Source: GE Medical Protective ®
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Claims PaidClaims PaidRadiology Radiology 1995 - 19991995 - 1999
1995 $132,382 $11,263,211
1996 $161,550 $11,992,032
1997 $127,674 $9,797,296
1998 $250,719 $19,211,478
1999 $222,811 $18,182,758
Avg. Paid Cases TotalYear Including ALE Payout
Source: GE Medical Protective ®
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Top AllegationsTop AllegationsRadiology Radiology 1991 - 19991991 - 1999
Cancer 10.68% $151,622Tumor 7.69% $223,867Aneurysm 5.34% $118,267Spine 5.34% $135,000Not Codeable 4.06% $146,250Others 66.88% $172,432
% of AverageDelay in Diagnosis Allegation Payment
Source: GE Medical Protective ®
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RadiologyRadiology
*Source: Overview of Diagnostic Radiology. ECRI, January 1996
Image quality.
Detection of malignancy.
Recognition of malignancy.
Communicating with the referring physician:
– Timeliness.
– Indications for therapy.
Factors Precipitating Lawsuits*
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Physician Liability: Future Physician Liability: Future TrendsTrends
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Physician LiabilityPhysician Liability
Effect of the Internet:
– Knowledge source for physician and patient.
– More informed patients.
– Privacy issues with medical records.
– Telemedicine issues.
Future Trends
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Physician LiabilityPhysician Liability
Effect of the Institute of Medicine report:
– Computerized prescription ordering/delivery systems to reduce medication errors.
– Computerization/systems approach applied more broadly to medical practice:
• Process redesign
• Systems redesign
– Greater use of practice guidelines.
Future Trends, con’t.
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Physician LiabilityPhysician Liability
Elimination of the ERISA Preemption:
– More suits against HMOs means increased cost for physician claims.
– More claims against physicians.
– Finger pointing.
– Pegram v. Herdrich, U.S. Supreme Court case in deliberation: physician financial incentives.
Future Trends, con’t.
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Physician LiabilityPhysician Liability
Better use of clinical information to reduce patient injuries.
– Benchmarking to eliminate substandard care.
– Disease management and practice protocols to reduce substandard care:
• Breast cancer
• Myocardial infarction
• Meningitis
Risk Control Measures
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Physician LiabilityPhysician Liability
Digitization/Automation
– Medical Records
– Medication Administration
– Medical Technology
Systems Analysis
– Medications
– Diagnoses
Evidence Based Patient Safety Practices
Risk Control Measures, cont.
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