Episode 072: Data-Driven Decisions

Speaker 1: You're listening to Your Practice Made Perfect; support, protection, and advice for 

practicing medical professionals brought to you by SVMIC.

Brian: Hello, welcome to this week's episode of our podcast. My name is Brian Fortenberry. Thanks for taking the time to join us. Today we're going to be talking to a couple of people that are going to be able to help us with some really great information. We have here Kathy Cartwright and Divya Parikh. Welcome, ladies. How are you?

Divya: I'm great, thanks so much.

Kathy: Great. Thanks, Brian.

Brian: Well thank you both for taking the time to be here. Before we really get started talking about the information in the data project, I wanted to give you ladies the opportunity to tell our listeners a little bit more about yourself, your background and your experience. Kathy, let's start with you. Tell us a little bit about yourself.

Kathy: I'm the Assistant Vice President of Risk Analytics at SVMIC. Basically, my department is responsible for evaluating the claim's data that we receive, and then we use that data to submit to the Data Sharing Project that the Medical Practice Liability Association uses for reporting purposes that Divya will share with us.

Brian: Well fantastic. Thanks for being here. And, Divya, take a moment to tell us a little bit about yourself and about your work there at MPL.

Divya: I'm Divya. I've been with the MPL Association for about 11 years. I am Vice President of Research and Education here where I do oversee the Data Sharing Project, and a number of our educational programs as well.

Brian: Well fantastic. Before we get started what is MPL? What does stand for? And tell us a little bit about the organization and its purpose.

Divya: Sure. When it comes to the MPL Association itself that stands for the Medical Professional Liability Association, which is formally the Physician Insurance Association of America or PIAA. And the MPL Association membership, these enterprises that are part of it are owned and operated by physicians, dentists, chiropractors, advanced care professionals, hospitals, and health systems, all with a commitment to medical professional liability. The Association members insure about two-thirds of America's private practicing healthcare professionals. And they also provide indemnification and other services to healthcare professionals around the world. The Association members also insure about 2,000 hospitals.

Brian: I know from experience myself the Association is connected with insurance groups and hospitals from as they say sea to shining sea. You truly are all over the country with many different organizations helping to join together to give information. And that really leads me to the next part of what I want to discuss today, it's the Data Sharing Project that the MPL has. What is the Data Sharing Project because there is obviously a lot of organizations, companies, and the like that are able to funnel information. Tell us about how does it gather the data and what does the MPL do with that data once they have it?

Divya: So the Data Sharing Project, which we also call the DSP, is the largest ongoing, independent, collaborative database of medical professional liability claims and lawsuits. Today we have over 330,000 claims and lawsuits that have been submitted since 1985. You asked how is the data submitted to the MPL Association?

Brian: Yes.

Divya: It's voluntarily submitted, semiannually, from a subgroup of the member companies within the MPL Association.

Brian: Well, Divya, you know everything is so data-driven in this industry, as is the case in many industries, so having that wealth of information is an incredible tool for them to be able to use. Kathy, I know that SVMIC contributes in part to the Data Sharing Project. Tell us a little bit about that relationship and how you guys submit the data.

Kathy: Certainly. Well once we pull the data from our claims system, basically on a quarterly basis or semiannual basis as Divya said, we submit a file to MPL Association that they can then upload to a website.

Brian: Very good. Well, let's kind of deep dive a little bit into what we have learned from the data. What specialties have the greatest risk for a liability exposure based on the information that you've been able to compile? And is there a different answer nationally or regionally?

Divya: Well I can give you some of our observations nationally, which over time it's interesting. A lot of this information doesn't change year to year all that significantly. The highest specialties that we see with claims reported against them, I don't think are a surprise to anyone really. We see them in obstetrics. We see it in general surgery, orthopedic surgery. And overall we compare about 20 to 25 different medical specialties in the Data Sharing Project. But we were surprised in recent years, probably in the last five years or so, to see more claims reported against internal medicine physicians, radiologists, and family practice.

Brian: Okay.

Divya: The average indemnities aren't necessarily that much higher, but we are seeing more in primary care.

Brian: So you're seeing an increase in the number, but not necessarily the severity. Is that what I'm understanding?

Divya: That's precise. We're starting to focus a little bit more on diagnostic related issues, and so many of the claims that we see are reported for diagnostic errors. But that's correct. The severity, overall severity, has gone up for all specialties. But in these primary care specialties, they still remain much lower than the surgical specialties overall.

Brian: And that leads me to my next question. You said you have seen the severity go up. What kind of changes have you seen in the specialties, with these high risks over the years that you've been collecting the data?

Divya: There are a few different ways to look at this just overall again nationally. We know that we've experienced a period of time where frequency has stabilized a bit. And that's not something that we capture in the Data Sharing Project, we just know this from actuarial data from the last five years. But, we have noticed that severity paid on claims pretty much for all severities overall, except for maybe obstetrics when we looked at that - severity has gone up as has the defense costs for the national statistics that we see overall. But when it comes to some of the other changes that we see we also look at what we call loss causation. And these are areas where we try to pinpoint why the claim was filed in the first place. What was causal to the patient complaint? And oftentimes where we identify some changes is within what medical conditions were named or reported to the DSP in those claims, and overall we still see if you'd like me to go into some of the specifics ...

Brian: Yeah, that'd be fantastic.

Divya: ...In obstetrics, we see an average indemnity payout of about $475,000 for instance, that's what we see overall. I think the latest data count that we looked at was as of 2017. And we continue to see improperly performed procedures in hysterectomies, diagnostic errors in breast cancer and ectopic pregnancies. We also see a failure to recognize a complication of hysterectomies and C-sections, as well as errors in manual deliveries. And so these are among the top patient allegations that we see.

Brian: Okay. So those really get to the causation like you were saying. Are there other aspects of the closed claims that you've reviewed that have really changed over the years? Is there any surprising trends I guess you would diagnose from this?

Divya: Yeah, it's a little slower in terms of the surprise. What we see is what are we tracking for a few years? Maybe like a three-year span. And over the most recent five-year period that we studied, we saw that neurosurgery remains as having the highest average indemnity payment, which I mentioned what it was for obstetrics a moment ago. For neurosurgery, it's closer to $585,000. So it's a fairly high average indemnity payout that we see for neurosurgery compared to other specialties reported in the DSP. Some of the top medical outcomes that are named in claims really have to do with complications of procedures in the central nervous system, postoperative infections, paraplegia, mechanical complications of internal orthopedic implants or grafts. So, a variety of different procedures that we see within neurosurgery.

Brian: When we're talking about the average, obviously we're looking at loss payments over the nation. And obviously say in your Dade County, Florida or Cook County, Illinois those numbers potentially are going to be much higher than say somewhere in the middle of the Midwest or other places like that. Is that fair to say?

Divya: That is fair to say. We do sometimes break the information out a bit more regionally. And specifically the way we do that is we look at it by different cap limits. So we'll have maybe three for four categories, looking at the information by various cap limits in order to quiet some of that noise that you have with certain jurisdictions or certain states that don't have caps. But overall when we're reporting this information, we're looking at it with all of the jurisdictions incorporated together and it represents all of the states within the U.S.

Brian: Kathy, how does SVMIC's information really line up with the national average?

Kathy: It's very similar. We obviously have a much smaller denominator than what the Data Sharing Project has, and so sometimes you have to wonder if you're looking at data that's skewed, because of one or two outstanding claims that may not really be a true reflection of what's going on specifically in our data.

Brian: That is so true because once you start using those factors of you're looking at a pool of 500 versus 5000, that can certainly skew the numbers. On a national basis, Divya, do you guys take those types of things into account? I guess you can filter out certain ways even from numbers of participants in a certain specialty to regions. Do you do special looks at things like that?

Divya: Yeah, you know, it depends on what the question is that you're looking at. When we're looking nationally at something like diagnostic error, or if we're just listing some of the chief medical factors. And if we find that improperly performed procedures really comprise about 30% of all the closed claims that are reported to the DSP, and it's followed by diagnostic error which has about 20%, so 50% is just for diagnostic error and improperly performed procedures. Overall over time, those numbers don't change very much. You know, so that's where we've seen a number of issues. That's where our risk management departments have really been at the forefront of developing a number of their programs.

As we try to go into it a little bit deeper, let's say we're looking at the diagnostic error and we're starting to see a little bit impacting surgical specialties. Within the DSP we may see about 50 or 100 claims, but in an individual company, you may see just one or two. That's where there's a little bit more power in having a national database to see how much can we break that down to look more closely to see if there are other claims that see similar findings. And then that's when we probably look a little bit more closely to see are these all in one region, one area? Or is this spans across the nation? And generally, what you'll hear us report either in our publications or in our presentations is what we're seeing consistently around the country.

Brian: Got you. That makes complete sense. As you were saying and as Kathy has alluded to as well, a lot of the risk management departments within these companies are developing programs based on this information trying to project it to the future. With that in mind, what do you see as maybe an emerging trend in medical professional liability today, those issues? Let's start with like advanced practice providers.

Divya: Yeah.

Brian: What do you see emerging in that direction?

Divya: So we have a few different areas that we're looking at, and you just touched upon one of the areas that many of us are looking at more closely which are these advanced care professionals. And currently, in the Data Sharing Project, we define them as the CRNAs, the NPs, the surgical assistants, and the physician's assistants. We kind of keep it to that category even though we're also looking at a number of other advanced care professionals and nursing specialties. But we're starting to see in the last probably three years, more and more of the MPL Association insurance companies are starting to provide some independent coverage for these practitioners. Because before they used to really be part of the policy for the physicians-

Brian: Right.

Divya: ... and you couldn't identify a lot of claims trends that named them independently.

Brian: You know and I'm sitting here thinking as you're talking, it may take a few years before we have true information just because, like you say, for so long, and at SVMIC as well I believe, is they're all covered under the physician policy.

Divya: Right.

Brian: So parsing that out with that new information. I know another big trend that we're seeing in medicine today is telemedicine and telehealth. You're hearing more and more about that from even on a national level. What emerging trends are you seeing nationally? And then after that Kathy, anything that you might from a regional perspective in Tennessee. But, Divya, let's start with you. On a national perspective, what are you seeing with telemedicine?

Divya: Sure. Telemedicine has been interesting to study over the past decade because I think within the Data Sharing Project, we've actually been capturing it since the database began. And in the beginning, it was really to capture where the interaction between the physician and the patient occurred over the phone.

Brian: Yes.

Divya: And then over time you see how quickly the technology has advanced so that telehealth really encompasses so much more. I mean from smartphones to remote diagnostics, it spans all the different types of medical specialties. There's telepsychiatry. It's really exploded. And what I find really fascinating for telehealth is, we have not seen any major claim trends - in terms of the technology portion - being the main component of the claim, or the main reason for the claim. It's often been some sort of associated issue to the claim if it's been named, but not the primary cause. And just my own observation to this is, we've surveyed our members over the years a few times and with telemedicine practices often times it seems to be something where there's a lot of guidance in how to best do this or deliver this type of care. And really addressing the patient expectations of a tele-visit.

Brian: Sure.

Divya: Where is it that the patient should anticipate when they're not coming in for an in-person visit? It might be just follow up. It might be addressing a specific issue. A lot of that has really alleviated what we see in other types of medical encounters, and so I wonder if that's where our industry has been highly successful in just not having those tremendous trends of claims that we were anticipating initially.

Brian: That makes sense. Kathy, from a regional perspective of SVMIC, what trends have you been able to see?

Kathy: Well I think pretty much the same thing that Divya mentioned is, so far we have not seen claims where that was the cause of the problem, but we are trying to stay well ahead of it and it's definitely on our radar to keep a close eye on what's going on with telemedicine and telehealth.

Brian: Absolutely. So another area of concern for healthcare in general, really society if you open a newspaper, read any kind of magazine articles or listen to the TV or radio, is the opioid epidemic that our economy is facing, and certainly some areas of the country worse than others. What type of emerging trends, Divya, have you seen in that area according to not only what you have seen in the data that you've collected, but maybe some trends going forward?

Divya: Opioids are definitely on the minds of everyone in the realm of medical care delivery. And at the MPL Association, we have been discussing pretty robustly, mitigation risks and how to address the opioid crisis. When we looked at the opioid-related claims in recent past, we didn't find that many claims. At that time I think we found about 350 closed claims total and about $28 million in total indemnity that had been paid for opioid claims. 50% of those really were naming family practice medicine, internal medicine physicians predominantly. But I will say this, we're watching pain management much more closely. We're not just focusing on those prescribers in primary care, we're looking at orthopedic surgeons, anesthesiologists, acute surgeries, as well as chronic pain to really see if we going forward begin to identify opioid-related claims in our database in the next few years. But much like some of the other issues that have sometimes come up before we've seen the claims data, again the risk management departments, as well as the patient safety officers, have really been at the forefront of designing better ways to bring those numbers down for the death cases especially in opioid management.

Brian: Absolutely. Kathy, from your regional perspective, is this consistent with what you're seeing as well?

Kathy: Absolutely. There are a few claims out there that are related to controlled substance issues or opioids, but there's not a huge cohort of those yet. We will be keeping an eye on that and trying to see what are going to be the responses and how we're dealing with those when they start.

Brian: Well, we have only been able to really just tap into a small portion of what the Data Sharing Project along with the MPL Association is doing, and I just want to thank both you, Divya and Kathy, for your work in this area because this type of project and this information is really the backbone of what helps companies and healthcare make these types of decisions going forward. So, Divya Parikh, Kathy Cartwright, thank you so much for being here with us today.

Divya: My pleasure. Thanks.

Kathy: Thank you, Brian.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect, with your host Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast. 

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state and change over time.