litigation alternative: copic’s 3rs program new eng- … april 15, 2010, the new eng-land journal...
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34 AAOSNow September2010 ManagingYourPractice ManagingYourPractice September2010 AAOSNow 35
OnApril15,2010,theNewEng-landJournalofMedicinepublished“MalpracticeReform:Opportuni-tiesforLeadershipbyHealthCareInstitutionsandLiabilityInsurers.”Thearticlereferenced“disclosureandreimbursementprograms”and“disclosureandearlyofferpro-grams.”COPICInsuranceCom-pany’s3RsProgramisperhapsthebestknownactivedisclosureandreimbursementprogram.
COPICwasfoundedbymem-bersoftheColoradoMedicalSocietyintheearly1980s,duringanescalatingmalpracticecrisis.Inthelate1990s,K. Mason Howard, MD,COPIC’sfirstchairman,pro-posedaprogramofsupplementalbenefitsforpatientswhohadanunanticipatedoutcome.Calledthe“3RsProgram”—forRecognize,Respond,andResolve—thepro-gramlaunchedinOctober2000.
Fortunately,groundworkthathadbeenlaidyearspreviouslyforotherpurposesfacilitatedthesuc-cessoftheprograminColorado.Criticaltoanyearlyinterventionisearlyreporting;physicianshadtoreportunanticipatedoutcomesinaverytimelyway.COPIChad,fromitsinception,stressedtheimpor-tanceofearlyincidentreportingasintegraltoits“reportingform”variantofclaims-madeinsurance.ReportingformcoveragemeansthatcoverageattachesonlywhenthateventisreportedtoCOPIC.
Also,physicianshadahighleveloftrustwiththecompany.Strongrelationshipsexistedwiththestate’slicensingboard,insur-ancedepartment,andlegislature.An“I’mSorryStatute”withbroaddefinitionsofprotectedconversa-tionspassedtheColoradolegisla-turewithanearunanimousvotein2003.
Program overview Severalassumptionsandcriteriadrivethe3Rsprogram,includingthefollowing:•Participationbyinsuredphysi-
ciansisentirelyvoluntary.•Patientsareneveraskedtosign
awrittenwaiveroftheirrightto
seekanattorney,makeaformaldemand,orinitiateformalliti-gation,butiftheychoosethatroute,3Rsbenefitscease.
•TheprogramisadministeredbyCOPIC’sriskmanagementdepartmentandisnottobecon-fusedwithinsuranceclaims;thepaymentsareconsidereda“first-partysupplementalbenefit”andnotathird-partyinsurancepayment.
•Theprogramisbasedonanad-verseoutcomearisingfromthecourseofmedicalcarewithoutadeterminationofnegligence.Thephysiciansinvolvedinthecaredetermineprimarilywhichcasestoreport.COPIC’sexperi-ence,coupledwiththephysi-cian’sfirsthandknowledgeoftheevent,determinewhetherthecaseisappropriatefortheprogram.
•Paymentsaremadefor“out-of-pocket”medicalexpensesnotcoveredbyinsurance(maximum$25,000)and“lossoftime”ataperdiemof$100(maximum$5,000),foratotalof$30,000availabletothepatient.
•Casesinvolvingthedeathofapatientarenoteligiblefortheprogram.
•PatientswhofilecomplaintswiththeColoradoBoardofMedicalExaminersareexcludedfromparticipation.Becausepaymentsarenotmade
inresponsetoformalwrittende-mandsandnopatientisaskedforawaiverorrelease,thepaymentsarenotreportabletotheNationalPractitionerDataBank.
The impact of communicationProgramexperienceandanalysisrevealthesignificanceofeffectivephysiciancommunicationandtherolethisplaysinthepatient’sperceptionofeventsandabilitytoacceptthecircumstancesoftheoutcome.AqualitativestudyfromtheUniversityofColoradoHealthSciencesCentervalidatedthisview.
Aseriesofinterviewswerefa-cilitatedwiththesepatients,andinsomecasesfamilymembers,aimedatidentifyingpatientneedsandperceptionsfollowinganun-anticipatedmedicaloutcome.Par-ticipantssharedtheexperienceofphysical,emotional,andfinancialworries,trauma,andfrustrations
relatedtotheiroutcomes.Whenthecommunicationwith
thephysicianwasgood,open,andhonest,theoutcomewasviewedasanhonestmistake.Patientsreferredtotheiroutcomesunderthesecir-cumstancesasbothforgivableandunderstandable.Conversely,whenthecommunicationwasperceivedaspoorornonexistent,thesameoutcomewasviewedasanerrorornegligence.
Asaresult,trainingindisclosureisofsignificantimportancetotheprogram.
Easing financial and emotional burdensThesignificanceofpatients’finan-cialburdenfollowingunexpectedoutcomesalsobecameevidentdur-ingtheseinterviews.Overwhelm-ingly,patientscommentedonthedevastatingimpactofthefinancialburdenandhowthiscarriedoverintowhattheywereundergoingphysicallyandemotionally.
Addressingthefinancialaspectproactivelytominimizetheburdenassociatedwiththeunexpectedcostsrelatedtotheinjuryisanimportantpartoftheprogram.Successfulprogramadministrationfacilitatesthenecessarycommu-nicationandsupportstheinsuredphysicianandthepatientthrough-outthisprocess.
Followinganunexpectedout-come,patientsgothroughapro-cesssimilartothegrievingprocess:denial,anger,bargaining,depres-sion,andacceptance.Alltoooften,thesepatientsget“stuck”inanger;anentireindustryofpersonalinjurylawhasbeenspawnedinresponsetothatanger.Yet,evenwhenpatientsreceivemoniesfromthetortsystem,theangerpersistsandthearrestedgriefprocessleavesthepatientlessthanwhole.
Underthe3Rsprogram,thephysicianisencouragedtoremaininvolvedasthepatientprogressestocompleterecovery,evenifthedoctorisnolongerprovidingdirectcare.Thisongoinginvolvementisessentialinfacilitatingthepatientthroughthisprocessandcrucialtoeffectingapositiveresolution.
Outcomes dataStatisticalanalysisofthe3Rsprogramfrominception(October2000)throughDecember31,2009,revealsthefollowinginformation:•Overall,about60percentofthe
totalinsuredbaseparticipates.•About80percentofprocedural
specialistsparticipate,comparedto41percentofnonprocedural-ists,inpartbecauseproceduraladverseoutcomesaremoreame-nabletothe3Rsapproachthanarethedelayeddiagnosisorfail-uretodiagnoseclaimscommontoprimarycareandemergencymedicinespecialties.
•Atotalof1,829patientshavereceivedreimbursement,withanaveragepaymentof$4,977perpaidcase.
•Ofthesepatients,60(3.4per-cent)subsequentlyfiledaclaimorsuitwithCOPIC.
•Theseclaimsorsuitshavere-sultedinindemnitypaymentsviathetortsystemin11cases(0.6percent).Specifictoorthopaedicsurgery,
thefollowingarethefivemostcommoncomplicationsthathavebeenreportedandsuccessfullyworkedthroughthe3Rsprogram:1.Postproceduresurgical
infections2.Failedprocedurenecessitating
furtherintervention
Litigationalternative:COPIC’s3RsprogramByAlanLembitz,MD
Disclosureandearlyreimbursementcandetermedicalliabilitylawsuits
Table1:Differencesbetweentraditionalliabilitysystemand3Rsprogram
TraditionalSystem 3RsProgram
Adversarial Supportive/caring
Shatteredphysician/patientrelationship Preserved/enhancedphysician/patientrelationship
Ineffective Targeted/focused
Inefficient Timely/sensible
Lacksinlearning Overflowinginlessons
Nowaytoaddresssubstandardcare Riskmanagementintervention
OrthOpaedic risk Manager
See 3Rs, page 37
AAOSNow_September2010.indd35 8/26/20101:43:16PM