COPIC’s 3Rs Program Recognize, Respond to and Resolve Patient

							   COPIC’s 3Rs Program
Recognize, Respond to and
  Resolve Patient Injury
       Richert Quinn M.D.
      3Rs Medical Director
 Presentation Overview
• Introduction
  Program Background
• COPIC‘s 3Rs Program Specifics
  Statistical Information
• 3Rs Program Case Studies
• Advantages/Lessons
  Physician/Patient Testimonials
• Conclusion
 3Rs Program Background
COPIC’s Claim Philosophy
  Compensate negligently injured patients
  Minimize waste of resources in tort system
  Defend defensible medicine regardless of
   cost
 3Rs Program Background

Traditional Claim System Broken
• Ineffective and Inefficient
  Adversarial
  Patient/Physician relationship shattered
  Unfair compensation
  Expensive
  Drawn out
  Does not identify substandard care
       3Rs Program Background
Noted Pattern of Behavior
•   Unanticipated medical event
•   Patient surprise
•   Physician denial
•   Communication absent or ineffective
•   Physician/Patient relationship suffers
•   Patient anger
•   Lawyer/lawsuit
                  3Rs Program
• Recognize          Unanticipated event
• Respond            Soon after event
• Resolve            Related issues

Risk Management Early Intervention
Program
 3Rs is a non-fault based program designed to prevent
  medical injuries from entering the ineffective, inefficient
  and adversarial legal system
             3Rs Program
• Started in 2000
• Early Intervention
•    Incident reporting
•    Emphasizes communication and disclosure
•    $25,000 for out of pocket expenses
•    $5,000 for loss of time
• ―No Fault‖
       Colorado Landscape
• Tort Reform
• Market dominance
• Legislative history-Tort Reform re-passed
  and ―I‘m Sorry‖ statute
• Relationships with BME and Dept. of
  Insurance
• ―Reporting Form‖ claims-made insurance
• Trust
      3Rs Program Specifics
Program Consideration
• Obtain I Am Sorry Legislation
  Protects health care providers expressions of
   concern regarding an unanticipated medical
   outcome from being used ―against interest‖ in
   a lawsuit.
  Signed into law 5/03
             3Rs Processes
• Occurrence Report-flags doctor as 3Rs
  participant
• Physician and COPIC in accord as to
  intervention
• Doctor tells patient about program, engages in
  disclosure process, and puts them in touch with
  3Rs administrator
• Coaching often required
• 3Rs Administrator supports physician and
  patient/family and reimburses upon obtaining
  receipts for out of pocket expenses
                Exclusions
•   Death
•   Formal written demand for compensation
•   Summons and Complaint
•   Attorney Involvement
•   Physician has ‗right of refusal‖
        Other Issues/Incentives
•   No Subrogation of Claims
•   Incentives for Participation
•   No waiver or release required
•   No Reporting to NPDB or BME
       3Rs Program Specifics
Program Goals
• Maintain the physician/patient relationship
• Encourage open/honest communication
  including disclosure of unanticipated event
• Encourage expressions of concern including an
  apology when appropriate
• Meet patients’ needs at crucial time
• Reduce litigation expenses
            3Rs Program
• Importance of Communication
• Disclosure skills
• Institute for Health Care Communication
     3Rs Program Specifics

Available Patient Benefits
• Reimbursement of related out-of-
  pocket medical expenses up to
  $25,000
• $100 per day, up to 50 days, to
  recognize loss of time from
  normal activities
• Reimbursement received in a
  timely fashion
       3Rs Program Specifics
Physician Responsibilities
• RECOGNIZE & Report incidents per usual
  procedure
• RESPOND to patient/family questions
• Explain injury (not a fault/blame discussion)
• Express concern, regret, empathy, apology
• Project future needs-hospital, meds, surgery,
  disability, etc.
• Assist with further RX, rehab, etc.
       3Rs Program Specifics
Physician Responsibilities
• Investigate and implement practice alterations
  designed to avoid injury in the future
• Continue to provide and meet patients‘ physical
  and emotional needs
• Allow 3Rs Administrator to assist patient with
  financial needs
• Be willing to attend COPIC’s educational
  seminars addressing physician/patient
  communication
       3Rs Program Specifics
Additional Program Considerations
• No release or waiver requested from the patient
• Program costs shared amongst all insured's
• Loss of time payments are taxable
    3Rs Program Highlights – 50 Month Financial Results (10/1/00-12/31/05)

Participants                   2532        310 for all 50 months; 1713 for 38/50 months

Reported Incidents             4674        Cornerstone = Early Incident / Event Reporting

                                           No incident with 3R criteria met has proceeded to full
3Rs Criteria Met               2174        litigation
                                           1235 of 2174 closed and 387 about to close with no $ paid,
Closed with no $ Paid          1622        simply satisfactory communication

Closed with payment             500        259 closed and 241 about to be closed with payment

                                           4 of 52 settled w/o lawyers, indemnity paid, & docs
Sent to Claims                  52         reported;
                                           12 also with 3R payments (no offset, not reported)
                                           About 50/50 spent so far for reimbursable expenses and
Spent so far                $2,908,137     loss of time
                                           Compared to avg. severity in 2003 of $88,056, and in 2004
Average paid per incident     $5,680       of $74,643, and in 2005 of $77,936

Dollar range per incident   $95 -$30,000   $30,000 maximum allowed

                                           Two FTE administrators; 1 P/T physician, 1 secretary,
Operational Costs            $975,899      managerial consulting
                                           All costs (reimbursement $, time loss $, & Administrative
Total Program Cost          $3,884,036     $) over 63 months


                                                                                                        17
After An Incident Is Resolved
Feedback from Subjective Evaluations

   • Patient and physician complete
     questionnaire
     – Physician/Patient relationships
       almost always still in tact
     – Patient‘s evaluations all favorable
       except patient’s perception of
       most physician’s communication
       skills not favorable
     – Physician’s false perception of
       their own communication skills
            Traditional Claim
               Resolution
                                  2003           2005
•   Closed Claims/Suits            643            584
     – Suits only                  237            338
     – Average Severity           $88,056        $77,936
•   Cases closed with
    no indemnity                   505            485
     – Average amount paid        $29,097        $27,980
•   Cases closed with
    indemnity paid                 138             99
     – Average amount paid        $303,326       $258,799

•   Cases closed with indemnity
    and costs greater than $1M    $13,758,785    $14,761,538
                                     (7 cases)    (6 cases)
•   3Rs Average Paid Incident     $6,094         $5,224
3Rs Program Benefits
• Addresses the needs of this patient
  – Information
  – Emotional support
  – Financial assistance
  – Early return to function
  – Protecting and preserving the
    patient/physician relationship
  – This patient retains the right to pursue a
    claim—no signed release
  – This patient may pursue a complaint to the
    CBME
3Rs Program Additional Benefits
  • 3Rs Protecting the Public
    – Learn from this patient to protect
      the next patient
       • Risk Management takes the lessons to
         other physicians
          – Entire quality bar raised for all patients
       • Their doctor took lessons learned,
         improved the quality of their practice,
         and became a better physician
                              COPIC 3Rs Program
                            10/01/00 through 6/2005
                      Top Ten Specialties by $ Amount Paid
                All Incidents Meeting Criteria (Paid and Unpaid)
    SPECIALTY             #INCIDENTS       # INCIDENTS PAID    $ AMOUNT PAID
                          PAID/UNPAID
     OB/GYN                   243                 96               $485, 334
  GEN SURGERY                 215                 65               $468,368
    IM GASTRO                 127                 45               $235,546
 ORTHO SURGERY                135                 27               $199,298
GYN MAJOR SURGERY             46                  24               $166,410
 FP OFFICE AMBUL              76                  24               $153,017
 PLASTIC SURGERY              52                  24               $149,230
  OPTH SURGERY                19                  9                 $ 68,584
UROLOGY SURGERY               44                  10                $ 67,258
 EMERGENCY MED                188                 18                $ 67,057
   ALL OTHERS                 360                 69               $275,729
      TOTAL                  1505                411               $2,335,831
      Most Frequent 3Rs Cases
•   Hysterectomy-110
•   Colonoscopy-83
•   Laparoscopic Cholecystectomy-37
•   Total Joint Arthroplasty-31
•   Complication of General Anesthesia-25
•   Delayed Dx of Appendicitis-25
•   EGD-22
•   ERCP-18
•   Breast Augmentation-16
               Case Study
• 55 y/o judge undergoes takedown gastric
  bypass, ventral hernia repair, develops
  enterocutaneous fistula
• Missed 6 months work, underwent 8 procedures,
  extensive parenteral nutrition
• Reimbursed $26,000 for loss of time and unpaid
  medical
• Patient very grateful; offered to sign release
• Maintains relationship with physician
               Case Study
• 65 y/o female undergoes attempted lap assisted
  vaginal hysterectomy
• Path=minimally invasive Grade I endometrial
  cancer
• Path=segment Left ureter excised
• Options discussed, underwent Left Nephrectomy
• Reimbursed airfare from Massachusetts for son
  and $150 in gardening bills
• Physician/patient relationship preserved
     3Rs Program Case Study
• 40 y/o female undergoes lap assisted vaginal
  hysterectomy
• Suffers ureter injury requiring stent placement
• Pt also suffers injury to bridge during procedure
• Reimbursed $7,017 for unpaid medical
  expenses and loss of time
• Pt extremely grateful for assistance and
  maintains a relationship with physician
    3Rs Program Case Study
• 6y/o male present to ortho with femur fx
  and is placed in hip spica cast
• F/u x-ray shows angulation/shortening
• Parents seek second opinion, pt
  undergoes external fixation
• Parents are reimbursed $8,575 for unpaid
  medical and loss of time
• Very appreciative of assistance
           3Rs Program
        Advantages/Lessons
Reserve Estimates vs. Dollars Spent
• Independent claims adjuster‘s review of 225
  incidents that met criteria in 2003
• Total reserves set by independent adjuster =
  $1,499,450
• Total reimbursement in 3Rs = $609,808
• Potential indemnity savings = $889,642
• Plus legal cost of equal number of dollars
           3Rs Program
        Advantages/Lessons
Adverse Event From The Patient’s
Perspective
• Results of focus group interviews
  3Rs Program patients interviewed in collaboration
   with UCHSC researcher
• Identified patient experiences/needs
  Worries
  Traumas - physical, emotional, financial
  Frustrations
           3Rs Program
        Advantages/Lessons
Adverse Events From The Patient’s
Perspective
• Perceptions related to communication
   Good communication = honest mistake
   Poor communication = error/negligence
• Traumas
   Significance of financial trauma
        3Rs Program
     Advantages/Lessons
Adverse Events From The Patient’s Perspective
• Excerpts from patient comments on 3Rs Program
   ―COPIC was wonderful. It was wonderful to have
     this available.‖
   ―They were readily and available to give.‖
   ―Refreshing not to be battling.‖
   ―Extremely gentle…good listeners.‖
   ―Easy to talk to.‖
   ―Made me feel comfortable.‖
   ―Calmed down and reassured.‖
            3Rs Program
         Advantages/Lessons
Patient Testimonials
 ―We are simply overwhelmed at receiving such a positive and
  helpful response to our situation…with your and COPIC‘s help it
  was not nearly as traumatic as it may have been.‖
 ―Thank you - it is an excellent program.‖
 ―This is an excellent alternative for settling medical misfortunes.
  The positive nature of the program allowed all of us to heal rather
  than to grieve.‖
 ―This program really helped us financially when I couldn‘t work and
  needed it most.‖
 ―Your program, by paying all the bills promptly, eased my worry. I
  think it‘s a great program for doctors to appease patients from
  suing.‖
            3Rs Program
         Advantages/Lessons
Physician Testimonials
 “3Rs Program helps defuse unexpected outcomes at same time
  giving support and additional source of caring to patients; money
  well spent. I’m personally grateful for the 3Rs Program and feel it
  likely averted litigation.”
 “Thanks, this is a great idea. Communication and understanding
  are key. This patient is still my patient.”
 “Rapid attention to patient’s concerns defused the situation.”
 “Both the patient and her mother have elected to continue care
  with me and my office. I consider this to be the ultimate sign of a
  successful resolution.”
 “I feel this may be the most helpful program I’ve seen a
  malpractice carrier implement. Fantastic.”
Lessons Learned
  from Patients                                     Financial

         Poor              Confusion     No Information
      Communication                          or Help




             ANGER


                                Frustration
                                               Legal
                          Financial           Consult
    Break In Relationship Trauma
                          Build-up
                                        Social
 Physical                              Pressure    Emotional
 3Rs Program Conclusion

Average COPIC Costs - 2004

Closed Claims/Suits    =     $ 74,562

Claims/Suits with no
indemnity paid         =     $ 25,392

Claims/Suits with      =     $292,691
indemnity paid

3Rs Incidents          =     $ 5,733
(166/507@952K)
      3Rs Program Conclusion
           Comparison of Processes
• Traditional Claims
   Adversarial          • 3Rs Program
   Shattered               Supportive/Caring
     physician/patient      Preserved/enhanced
     relationship            physician/patient
   Ineffective              relationship
   Inefficient             Targeted/focused
   Lacks in learning       Timely/efficient
   No way to address       Overflowing in lessons
     substandard care       Risk Management
                             intervention
     3Rs Program Conclusion
       Assessment of Program Goals
• Program Goals
  Maintain relationship   • Goals Met
  Disclose/communicate      In many cases
  Express concern            Improved and understood
  Patient needs              Enhanced and appreciated

  Reduce LAE                Addressed
                             Preliminary analysis
                              encouraging