Is This Case Likely to Close with a Payment?

Commentators

Elizabeth Mort, MD, MPH
Senior Vice President for Quality and Patient Safety
Massachusetts General Hospital
Associate Professor of Health Care Policy
Harvard Medical School

Douglas Borg, MHA, ARM, CPHRM, DFASHRM
Vice President of Risk and Quality
Premiere Insurance Management Services

Michael Paskavitz
Vice President
CRICO Strategies

Transcript

A new analysis of medical malpractice claims nationwide identifies three key factors most likely to predict whether the defendant provider will have to pay in a lawsuit. The report shows that a case will be more likely to close with indemnity if it features any of the following: 1. problems with patient assessment, 2. a failure to have or follow protocols, or 3. absent or insufficient documentation. According to Michael Paskavitz, Vice President of Candello, a division of CRICO which sponsored the research, this approach to analyzing malpractice data is new and in demand:

“There has been a desire for quite a long time to have the relationship between clinical care and financial investment and outcomes better understood.”

The data come from CRICO’s Comparative Benchmarking System (Candello), which features 450,000 closed malpractice cases from 22 insurers across the United States. Researchers looked at 37,000 medical professional liability cases closed between 2014 and 2018. And they looked at the data in a different way, using more advanced analytical processes than in prior Candello Reports, with statistical models designed to predict, rather than recount the outcomes of these malpractice cases. Paskavitz says this may help change the game on the financial side of the medical liability field:

“Trying to provide a predictive lens on our data for the use in managing risk—and that’s both the risk to patients but also the risk of a malpractice outcome—can be done in a practical and reliable way. And so I think it’s important to know that predictive analytics do have business value. They will have clinical value when applied appropriately as well. If you address these three specific things, the likelihood that you will have an event in itself and/or bad outcome from a malpractice claim, there is some certainty that that will be reduced, and that certainty is what I think people are looking for, some reliability and some certainty.”

Dr. Elizabeth Mort is a primary care physician and Senior Vice President for Quality and Patient Safety for Massachusetts General Hospital. She was an advisor for the Candello report, which is titled “Power to Predict: Leveraging Malpractice Data to Reduce Patient Harm and Financial Loss.”

“Looking at the data through the lens of contributing factors and also associating the events with your financial liability is a different way of looking at things and very, very helpful.”

Dr. Mort says that the three predictive factors are not surprising to her. But identifying their connection to case outcomes give both quality officers and financial leaders at institutions some critical ammunition to make decisions about resources and priorities.

“Having the financial information there also makes it very, very real for those that are looking at the financial balances in the hospitals, and it gives us information to share with our financial colleagues as we explore opportunities for making care safer.”

During a recent webinar to review the report, Douglas Borg of Premiere Insurance Management Services saw the potential right away. Borg is Vice President of Risk and Quality at Premiere:

“Much of what we do in risk management tends toward the subjective; hard to measure a lot of what we do. So I leap at any chance that I have to analyze data that helps to either support or direct work that we’re doing. As data systems and analytic algorithms have become more sophisticated, I’ve really been fascinated with the idea of applying the principles of AI to our work. So your study was really one of the first that I’ve seen with solid statistically significant results.”

The Candello database uses more than 200 contributing factor codes. These denote breakdowns in such areas as technical skill, communication, clinical judgment, environment, equipment and teamwork. Cases have an average of about four contributing factors per case. For the “Power to Predict…” report, CRICO controlled to examine which of these breakdowns in health care processes showed the highest odds of a claim closing with a payment. Analysis revealed that the odds of a case closing with indemnity went up 145 percent if it featured a lack of a protocol or failure to follow a protocol. For cases with patient assessment problems, the odds of payment went up 85 percent, and if the case featured documentation failures, the increased odds were 76 percent higher. Douglas Borg:

“What was surprising and very exciting honestly is the fact that you were able to use your data to confirm and quantify that link in a predictive way. So in my opinion, that’s one of the most valuable aspects of this work, demonstrating the link between the mitigating and proactive work that we do on the front end and the financial consequences down the road. You know, we’ve not really been able to show that in a consistent way before. That’s why it’s so difficult for many risk management programs to get the attention of senior leaders or acquire the people and resources necessary to engage in effective interventions. Everyone wants to know up front what’s the ROI? It’s really hard to make a case for adding FTEs or investing in new systems or processes if all you can promise is that you might be able to avoid a claim or lawsuit or two down the road. That’s a really tough sell. So ultimately, this work will be a positive step towards being able to predict with much more certainty the positive financial impact of working to reduce the frequency of those contributing factors.”

Borg says the industry needs standards for these kind of event and case data, and the Candello database is an effective approach. He says the analysis in the new Candello Benchmarking Report helps both sides of the clinical/financial divide.

“Clinical outcomes correlate strongly with financial results. That’s just a fact of life, but what the work does provide is a different way to look at the data. Most risk managers, they’ve got access to real time or near real time clinical data on the one hand. On the other hand, the financial outcomes for the claim and the litigation data is much more retrospective. There tends to be a lag, a significant time lag in some cases between what’s happening right now in the clinical world and the data provided by claims. So the work that you guys are doing by creating that link is one we haven’t had before. It allows us to say with more certainty that the deficiencies that we’re observing today in the clinical space, that the failure to follow a policy or a poor assessment, for example, those things have a quantifiable financial impact down the road.

For Dr. Mort at Mass General, the statistical validity that comes from a large national database of coded malpractice claims is critical because no single institution has enough cases of its own.

“Those of us who work in the area of quality and safety and who see adverse advents in one facility or even in a system, thankfully we’re looking at relatively small numbers. And what’s so valuable about the benchmarking report is the aggregated claims and then the analysis of that large number of claims representing experience over many, many institutions. It allows you to see the forest through the trees and allows you to step back, reflect on what you’ve seen in your institution but then learn from these aggregate patterns, and it really allows you to be strategic in your thinking and advance your initiatives, I think, in a much more effective way than if you were left to your own devices and only had access to your individual cases.”

The CRICO 2020 Benchmarking Report also evaluates the most common responsible services and what proportion of these cases involved high-severity injuries or closed for more than $1 million. The statistical analyses of each high-risk area are accompanied by strategies for risk reduction and claim defense. These suggestions were culled from a list of interventions and best practices widely considered effective. For example, patient assessment improvement ideas include addressing environmental obstacles that lead to ineffective communication between providers. Suggestions for improving protocols include focusing on policies germane to high-risk consequences. And recommended defense strategies for inadequate documentation—certainly an evergreen risk management issue—include using third-party testimony, electronic health record audit trails, communication records, and other collateral evidence to support appropriate care.

For Michael Paskavitz of Candello, the new report offers objective assurance that those efforts are worth doing.

“It’s using a rich dataset to help understand and provide some evidence behind things that people may already have a hunch for, may already have experience with, but they may not have actually statistical evidence that if you fix these contributing factors, you would reduce the likelihood of a claim probably in the first place, but then also the outcome of that claim so it becomes a business support tool in that way. It enables you to have an evidence base behind taking action to reduce risk where you have some certainty of what the outcome might be in terms of the malpractice outcome. So it really is, the value of it is really as a business tool to provide evidence that action taken will have benefit.”

The 2020 CBS Benchmarking Report: “The Power to Predict: Leveraging Malpractice Data to Reduce Patient Harm and Financial Loss,” is available at no charge on the Candello web site, www.candello.com/Insights/Candello-Reports/Power-to-Predict. I’m Tom Augello.