The Role of Obstetrical Claims in The Role of Obstetrical Claims in Medical liabilityMedical liability

Alethia (Lee) Morgan, M.D. FACOGPatient Safety and Risk

Management COPIC

Disclosure

I have no relevant financial relationships to disclose

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What is in it for you today

• Impact of OB/GYN claims on medical liability• Impact medical liability rates on access to OB care• COPIC experience• Patient safety in OB

What specialty spends the highest percentage of their annual net income

on PLI coverage?

• Pediatrics• Obstetrics/Gynecology• Orthopedic Surgery• Emergency Medicine• Neurosurgery

What specialty spends the highest percentage of their annual net income

on PLI coverage?

• Pediatrics• Obstetrics/Gynecology• Orthopedic Surgery• Emergency Medicine• Neurosurgery

At least 1 claim filed against 89.2% respondents during their career

Average number of claims filed 2.62% against all ’06 respondents

At least 1 claim filed against respondents during their residency 37.3%

1996 1999 2003 2006

At least 1 claim filed 73% 76.5% 76.3% 89.2% during their career

Average number of claims 2.31 2.53 2.64 2.62 filed

At least 1 claim filed during their residency 27% 28.6% 29.6% 37.3%

PIAA Data Sharing Project

• Who• 21 US PLI companies

• What• Collects data on closed claims-1985-2007

• When • Puts out semi annual reports

• Why• Provide statistical data re: PLI to members

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Indemnity payments by specialty

Ob/Gyn• #1 for total claims reported

• #1 for percentage of paid claims/total claims• 35.2%• 5.7% more than any other specialty

• #1 for total indemnity paid

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PIAA Data Sharing System Report 082

Four top conditions/procedures for number of paid claims

• Account for over $9 billion paid• Over 35% of dollars paid out of top 40

1. Brain damaged infant2. Breast cancer3. Pregnancy4. Acute myocardial infarction

PIAA Data Sharing System Report 082

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Four top conditions/procedures for total indemnity dollars paid

1. Brain damaged baby2. Breast cancer3. Pregnancy4. Symptoms of abdomen and pelvis

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PIAA Data Sharing System Report 082

COPIC data (15+YRS)

By Error/site type• 49% conduct in L&D setting• 26% conduct related to technical performance and complications of

GYN surgery• 21% conduct related to diagnosis and treatment of non-obstetrical

conditions, usually in the office setting• 5% conduct directly related to prenatal care

COPIC data (15+YRS)

49% conduct in L&D setting• Neurologically impaired infants• Improper interpretation of FHR tracing• Failure to respond to abnormal FHR tracing in a timely

manner• Complications of VBAC• Complications of operative vaginal delivery

COPIC data (15+YRS)

26% conduct related to technical performance andcomplications of GYN surgery• Bowel / bladder/ureteral injury• Sepsis/ post-op infection / abscess• Unexpected/poor outcome• Lack of adequate indication for elective surgery

COPIC data (15+YRS)

21% conduct related to diagnosis and treatment ofnon-obstetrical conditions, usually in the office setting• Delayed DX of cancer Breast, Cervix, Ovary, Germ cell, Colon, Lung• Delayed DX of MI, PE, Intracranial Tragedies• Delayed DX of Severe Infectious Diseases • Medication Errors

COPIC data (15+YRS)

5% conduct directly related to prenatal care• antenatal DX of fetal abnormalities• genetic screening• group B strep• prematurity managementThe defense of L&D adverse outcomes often points to the prenatal record

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OB-GYN risks summarized

Most claims involve elements of communication or information breakdown

Many claims could have a causation defense, but the necessary elements were missing or not documented

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Prevention

Standardized Communication

Online EFM Course

Team Training

Disaster Training/Drills

Simulation

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Defense

ACOG neonatal encephalopathy guidelines and suggestions for practice

Proper documentation

Gather clinical evidence for timing

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COPIC patient safety initiatives

• OB Patient safety/RM seminar• Team work• Common language• Disaster drills• Simulation• Checklists• Standard orders

Checklists • Monitoring

– oxytocin – magnesium sulfate – misoprostol – Other high risk medications

• Documentation – Shoulder dystocia – Operative vaginal delivery

These are available at www.callcopic.com

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What do the checklists do for us?

Make explicit the minimum expected steps in a complex system

Help memory recall

Provide a conservative, “default” mode of management which will be carried out in the absence of our specific order to the contrary in a specific patient.

Used in this manner, it is much more difficult for a patient to be injured by these medications.

Patient safety toolkit

• Keep the patient and family informed• Workup an unhealthy baby early• Document, Document, Document• Honest disclosure to patient and

family when problems occur• Keep the lines of communication

open with patient and family before and after discharge

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The best way to prevent being sued

Prevention of the problem from occurring in the 1st place

Thus patient safety is the lynchpin of risk management

But sometimes adverse outcomes occur despite perfect care

The ScienceThe Science

Officially endorsed by: CDC Child Neurology Society March of Dimes NICHD Royal Australian and NZ College of Ob/Gyn SMFM Society of Ob/Gyn of Canada

January 2003

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69% Antepartum risks

25% Antepartum and intrapartum risks

4% Intrapartum hypoxia only

2% No identified risk factors

NNE

Are Obstetricians an Endangered Species?

•There is currently no proven way to reduce the incidence of cerebral palsy in most cases•Obstetricians can expect to be sued approximately once every 10 years•Reimbursement is relatively fixed•Practitioners are leaving early at one end of the pipeline, and fewer students are entering training at the other end

• Accepted fewer public aid patients: 182 (26%)• Accepted fewer high-risk patients: 153(22%) • Performed more ultrasounds: 236 (33%)• Performed more Cesarean sections: 203(29%)• Stopped performing VBACs: 187 (26%)• Reduced salaries (of physicians/staff): 217 (31%)• Delayed upgrading office equipment: 145(20%)• Stopped practicing obstetrics: 99 (14%)• Stopped practicing obstetrics or

retired from practice: 110 (15%)‡ Changes specifically due to liability insurance costs or liability pressure*N=711

Effects of Liability: Changes in Practice‡ Among Respondents Who Have Practiced Obstetrics Between

1995 and 2006*

CGOS 2006 survey data of OB providers in CO

Access to Obstetrical CareLiability insurance premium increase $0/yr $5,000/yr $10,000/yr $15,000/yr

Providers continuing current obstetrical practice, No. (%)

476 (100) 424 (89) 336 (71) 267 (56)

Number of counties without practicing obstetrical care providers, No. (%)

23 (36) 24 (38) 29 (45) 32 (50)

Number of births in counties without obstetrical care providers, No. (%) ‡

1,783 (2.5)

1,902 (2.7)

2,988 (4.2)

3,808 (5.4)

Number of births in counties with limited availability of obstetrical care providers, No. (%) §

32,185 (45)

33,969 (48)

48,179 (68)

49,348 (70)

‡ Numbers and percentages are based on birth data collected for the year 2006 by the Colorado Department of Public Health and Environment.

§ Counties with 16 or more births per month per obstetrical care provider.

CGOS 2006 survey data of OB providers in CO

40%

50%

60%

70%

80%

90%

100%

$0 $5,000 $10,000 $15,000

Attrition among current providers of OB care due to increasing liabililty insurance premiums (2006 data)

All Providers of OB Care (N=476) OB/GYNs Practicing OB (N=243) FP doing OB (N = 195)

CGOS 2006 survey data of OB providers in CO

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Thank you

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Alethia (Lee) Morgan, M.D.LMorgan@copic.comwww.callcopic.com

Questions? “It has never been safer to have a babyand never more dangerous to be anobstetrician.”

MacLennan et al: JAMA 2005;294:1688-1690

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FP $13,544OB/Gyn $54,545

FP $ 60,402OB/Gyn $275,466

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2007

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