Risk Management
Allocating Resources for Risk Management
An Analysis of Office-Based Medical Practices’ Claims Data
by: Tom Snyder
Vice President, Healthcare Risk Services
Printable Version of this Article
In our visits to policyholders’ practices, we see many efforts to reduce risk and enhance patient safety. And in our discussions with policyholders, it’s clear that many are implementing specific measures to enhance care and protect patients. Will Rogers said, “Good judgment comes from experience, and a whole lot of that comes from bad judgment.” It is for that reason we share with you the bad experiences of others in the hope that you can avoid similar issues. Unfortunately, system failures and individual mistakes are quite diverse, requiring substantial modification to ensure the best outcomes in the future. We are all aware of the broad issues that are commonly noted in litigation, such as documentation, communication, informed consent, tracking and follow-up, education, etc. While these are all areas that require attention, there can be an alternative to trying to do everything and in so doing spreading your resources too thin.
The alternative is to figure out which tasks will net the most benefit and then focus energies there. That is the purpose of this article: to identify, as specifically as possible, the risk areas about which we should be most concerned and why they have made the list of top concerns. By interceding more fully in these areas, we achieve the most benefit. And while this approach may not answer everything, it may help you do that which is most effective.
Princeton’s healthcare risk services department reviewed all office-based claims from 2002 through 2008 to assess the most frequent issues. Our findings, while similar to that of claims analyses done at national levels, are exclusive to New Jersey. We have identified two areas that, with focused attention, could lead to the most benefit, particularly, although not exclusively, for primary care and medicine-based specialties: 1) Diagnostic-related allegations specific to cancer (CA); and 2) Medication-related allegations specific to management and monitoring of several drugs.
As evidenced in the graph below, at the highest levels of analysis, diagnosis-related and medication-related claims combined account for 67% of all claims and 78% of incurred dollars. Another category, medical treatment, accounts for an additional 19% of claims, but only 12% of incurred dollars. Furthermore, the breakdown of this category demonstrates a wide variety of issues that make it impractical to attempt to focus in one or two particular areas, which is the purpose of this article.
Diagnostic Allegations
Diagnostic-related allegations, including failure and delay, represent more than half of the total claims for the measured period, and 60% of the incurred dollars (indemnity and expense payments and reserves).
Approximately 45% of the diagnostic allegations involve the failure or delay in diagnosing cancer (see below). The next highest ranked disease in this category, acute myocardial infarction, represents only 5% of the total. Additionally, cancers represent 35% of the total dollars for the diagnostic category of claims, or 20% of the dollars for all claims.
A further breakdown, defining the types of cancer, indicates that nearly half are lung, breast, or colo-rectal cancers, and these three account for nearly 60% of the cancer claim-related dollars.
Medication-related allegations account for 15% of the total claims, and 18% of the dollars, making it the second most expensive allegation category. Of the claims that make up this category, nearly 70% involve improper management of the medication regimen, which does not include prescription or drug ordering errors. Furthermore, improper management accounts for 84% of the dollars in the medication allegation.
The top six categories of drugs that are implicated in the improper medication management allegations account for over half of the total, with anticoagulants accounting for 12%.
Risk Issues - What Went Wrong
As alluded to above, there are generally several system failures, or risk issues, that occur with each and every claim. Here we focus on the failures within the diagnostic CA allegations and medication-related management allegations that occur with the most frequency.
Risk issues are broken into several large categories and are identified in the graph below. This graph shows the relationship of these two allegations to that of the average of all allegations. The individual categories are discussed below.
*Multiple risk issues may cause totals to exceed 100%
Clinical judgment is by far the most prevalent risk issue in all allegations. It is the rare allegation that does not have a component of medical decision-making. (Unfortunately this is also the area that tends to present the most difficulty in finding simple fixes). Both diagnostic cancer and medication allegations, however, exceed the average frequency of this risk category.
While communication is a frequent issue in many allegations, it is a very big issue in the medication allegations. Also standing out for this allegation are administrative issues.
For diagnostic CA allegations, patient behavior and clinical systems (follow-up) issues exceed the average frequency in these risk issue categories.
As we explore each category further, there are several specific issues within each of the two allegations that are noteworthy and serve to provide additional focus.
Clinical Judgment
Patient monitoring and management of therapy issues, rather than selection of therapy or prescription issues, are very prevalent in medication-related allegations. It is the management of the anticoagulants, most notably Coumadin, antibiotics, and antidepressants, that account for over 30% of these allegations. The addition of antiLipemics, antiNeoplastics and steroids to that list covers over 50% of these allegations. In diagnostic CA allegations, inadequate patient assessment and failure to obtain referrals for consults exceed the averages of all allegations. Of note, poor documentation can lead to a belief that the assessment was inadequate, even when that may not have been the case.
Office Based Systems
Office based systems represent issues related to ensuring appropriate follow-up, follow through, and/or care continuation. Failures in reporting findings to the patient or ensuring that tests were completed are issues in diagnostic CA allegations, whereas issues in identifying the one provider who is to coordinate care standout in medication related allegations. Lack of a system to facilitate and track these functions is often noted.
Administrative Risk Issues
Administrative risk issues in medication-related allegations consist of policy and procedure (P&P) issues (such as not having a P&P or failure to adhere to a P&P) regarding how prescriptions get renewed, procedures for medication reconciliation and monitoring, and staff education regarding P&P. Diagnostic CA allegations, on the other hand, involve issues of missing documents such as the test result, and in some cases the entire record.
Documentation Risk Issues
In both allegations insufficient documentation, rather than mechanics (e.g., sloppy handwriting), is the dominant issue. In diagnostic CA allegations it is the documentation related to clinical findings, clinical thinking and/or follow-up that is most frequent. With medication allegations it is the documentation of the education efforts including instructions to patients that is most common.
Communication Risk Issues
Communication issues in medication allegations are more significantly patient related and involve education and understanding, whereas in diagnostic CA allegations they are disproportionately higher in provider-to-provider communication and generally involve follow-up of test results and coordination of care (specifically, determining who is “in charge”).
Behavior Related Risk Issues
Patient non-compliance with recommended testing or follow-up in diagnostic CA allegations and treatment/meds in medication allegations are the key behavioral risk issues. Both are related to the education of patients on the importance of recommended testing or follow up, and poor mechanisms, as indicated in office systems above, to ensure that follow-up care is completed or documented.
Summary
While there are many allegations and many more issues that contributed to them, there are ways to focus efforts to gain maximum benefit. And while no effort(s) can guarantee that future allegations of medical malpractice will be prevented, focused efforts can have a great impact on mitigating these risks. From this data analysis we conclude:
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Failure or delay in the diagnosis of cancers (lung, breast and colon in particular) are the most frequent claims allegation in the office setting. Furthermore, issues related to poor documentation of clinical findings and rationale, poor follow up to ensure that tests are completed and results have found their way into appropriate hands, lost or not filed test results and patient education are among the major issues to be improved upon. Patient non-adherence to recommended treatment can reflect poorly on the physician if instructions are not clear and thoroughly documented. When cancer is even remotely suspected in any patient, ensuring that these issues have been fully considered will go a long way to providing both the provider and the patient with the best outcomes. Tracking systems for test results, missed appointments, and consultation results are very important in these efforts. Additionally, ensure that patients fully understand the risks associated with this disease and the importance of testing and follow up.
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Mismanagement of medication regimens, particularly that of anticoagulants, antidepressants and antibiotics, are frequent and expensive allegations. Factors related to patient education, staff education regarding policies and procedures, documentation of education efforts and clinical rationale, and coordination of care among providers are among the major issues. When prescribing these medications, particularly for longer periods of time, fully informing and educating patients can go a long way to preventing issues.
Diagnostic-related allegations specific to cancer and medication-related allegations specific to the management and monitoring of several drugs are but two issues to focus upon, but they have the greatest potential to result in substantial benefit. If processes are implemented to address the issues found in these specific allegations, they can go a long way in assisting in the prevention of other allegations that share similar features.
As demonstrated by the previous graphics, there are allegations and risk issues other than those discussed above that lead to litigation. They can be influenced by your practice focus and/or specialty. These areas should not be overlooked. Build upon the efforts you make to address the above issues as you can. Princeton consultants can help you decide where to go next. Call our toll-free risk resource line, at 866-Rx4-Risk, if you have questions or to request an onsite visit by one of our risk consultants.
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