physician liability trends paul a. greve, jr. jd rplu vice president g ge medical protective

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


The State of Medical Professional The State of Medical Professional

Liability in 2001Liability in 2001


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


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


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


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


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


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


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


PIAA Claims TrendsPIAA Claims Trends1985-19991985-1999

Physician Insurers Association of America (PIAA)


PIAA Claims TrendsPIAA Claims Trends1985-19991985-1999

Data submitted by more than 20 member companies.

156,000 closed claims and suits.


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


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


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


Physician Liability Trends: Physician Liability Trends: The Medical Protective Company’s The Medical Protective Company’s Experience Experience 1991-19991991-1999


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


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


Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Failure to Diagnose ConditionFailure to Diagnose Condition


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%


Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Improper TreatmentImproper Treatment


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%


Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Failure to Prevent ConditionFailure to Prevent Condition


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%


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%


Top Allegations:Top Allegations:All Medical Specialties All Medical Specialties 1991 - 19991991 - 1999Failure to Diagnose CancerFailure to Diagnose Cancer


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%


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



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



Emergency RoomEmergency Room

Lawsuit nightmare:

– Unexpected death.

– Typically young victim.

– Dependent children.

Failure to Diagnose Acute Myocardial Infarctions:


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.


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




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




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



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




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




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




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




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




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


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




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




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



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


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




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




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



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




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



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*


Physician Liability: Future Physician Liability: Future TrendsTrends


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



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.



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.



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



Digitization/Automation

– Medical Records

– Medication Administration

– Medical Technology

Systems Analysis

– Medications

– Diagnoses

Evidence Based Patient Safety Practices

Risk Control Measures, cont.

physician liability trends paul a. greve, jr. jd rplu vice president g ge medical protective

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