OrthoBuzz occasionally receives posts from guest bloggers. In response to a recent study in The New England Journal of Medicine, the following commentary comes from Matthew Deren, MD.
Malpractice. The word itself causes a visceral reaction for many of us in medicine. Although the vast majority of physicians will not pay a malpractice claim during their careers, there is still concern about the quality of care provided by doctors with multiple claims paid, either through out-of-court settlements or through court verdicts. The National Practitioner Data Bank (NPDB) was created, in part, to help prevent a doctor with a long list of malpractice claims paid from moving to a new geographic area for a “fresh start” without full disclosure of his or her claims history.
In the March 28, 2019 issue of The New England Journal of Medicine, Studdert et al. examined changes in practice characteristics among physicians who had paid malpractice claims from 2003 through 2015. By linking the NPDB to Medicare data, the authors identified a cohort of >480,000 physicians, 89.0% of whom had paid no malpractice claims. Nearly 9% of physicians had one paid claim, while the remaining 2.3% of physicians had two or more paid claims. That 2.3% accounted for 38.9% of all the claims paid during the study period.
A total of 19,098 (4%) of claims paid were in orthopaedic surgery, which made it the seventh most-sued specialty studied. When evaluating the subgroup of all physicians with ≥3 claims paid, the authors noted that they were more likely to be male, 50 years of age or older, and to practice in surgical specialties. In multivariate analysis, physicians with at least one paid claim were more likely to leave the practice of medicine than those with none. Finally, physicians with multiple paid claims were more likely to switch into small or solo practices, but the study found “no clear association between the number of claims and the propensity to relocate, within or between states.”
To be clear, the number of malpractice claims paid by a doctor is not necessarily a reliable indicator of quality of care, though many patients arrive at that conclusion. Just as important, this study doesn’t conclude that solo practitioners—in orthopaedics or any other specialty—are more likely to have paid a higher number of claims. There are many excellent physicians in solo practices across the United States.
Ultimately, this study shows that the majority of physicians have not paid a single malpractice claim and that physicians who have paid multiple claims are not more likely than other doctors to relocate their practice. These findings should help patients trust the various procedures that are in place to prevent the exceedingly small number of physicians with a long list of malpractice payouts from relocating in an attempt to leave their history behind them. From the physician viewpoint, the findings emphasize that the impact of malpractice claims goes beyond the emotional and personal into the realm of prompting changes in practice environment.
Matthew Deren, MD is an orthopaedic surgeon at UMass Memorial Medical Center, an assistant professor at University of Massachusetts Medical School, and a member of the JBJS Social Media Advisory Board.
According to Medscape (login required), a dozen changes coming in 2015 could affect physician income and practice workflows. Here’s the list:
- Rise of High-Deductible Health Plans – According to the Kaiser Family Foundation, 18% of insured patients have at least a $2,000 deductible. Higher deductibles often mean more paperwork for practices, the need to provide cost estimates in advance, and increasing involvement with collection agencies.
- Declining Malpractice Premiums– For three benchmark specialties, ob/gyns, internists, and general surgeons, malpractice insurance premiums decreased by 13% since 2008. Some experts attribute the declines to tort reforms that were enacted many years ago, but most expect that premiums, which have proven to be cyclical, will start rising again.
- ICD-10 Really Coming– Many experts are saying the Oct. 1, 2015 deadline for the new ICD-10 coding system is for real this time, after repeated implementation delays. Although ICD-10 is supposed to cut down on errors and speed reimbursement, many physicians are skeptical that the technology will work.
- ACOs Enter a Crucial Year – 2015 marks the end of the 3- year shared-savings Medicare ACO contract, which shielded ACOs from losing money. Those that stay in the program will face financial penalties if they don’t hit certain targets. The Centers for Medicare & Medicaid Services (CMS) said that only one quarter existing Medicare ACOs received a shared-savings bonus.
- Concerns about Telemedicine– More patients may start using web- and phone-based physician services in 2015. The three largest telemedicine companies more than doubled their volume from 2011 to 2013 and continue to grow. Telemedicine does seem to be siphoning some patients from traditional practices, but the main concern is the quality of telemedicine-based diagnoses and treatments.
- Competition from Retail Clinics– Visits to walk-in, retail clinics skyrocketed by 400% from 2007 to 2009. Consultant Thomas Charland advises doctors to forge reciprocal referral relationships with retail clinics, rather than fighting them.
- PCPs to Lose Enhanced Medicaid Payments – At the beginning of 2015, Medicaid reimbursements for PCPs will fall back to their pre-“enhanced” levels, which average 40% below Medicare. Unless Congress extends the funding, some PCPs may be forced to reconsider how many Medicaid patients their practices can afford to take.
- Meaningful Use: Carrot Becomes Stick – In 2015, penalties for not entering the Medicare Meaningful Use program begin, starting at 1% of Medicare payments and moving to 3% in 2017. A survey by Medscape shows that 3 out of 4 doctors who have an EHR are attesting to Meaningful Use.
- Penalties Start under PQRS– In 2015. The Physician Quality Reporting System turns from voluntary to penalty-eligible. The penalty for not reporting quality data is 1.5% in 2015 and rises to 2% in 2016.
- New Physician-Payment Websites– Open Payment and Medicare payment websites report payments made to doctors either from Medicare or from drug and device manufacturers. Both websites have had technical glitches and have posted inaccurate information.
- Medicare Will Pay for Chronic Care Outreach –Medicare will pay physicians in 2015 for managing patients with two or more chronic conditions by phone or email. Doctors will receive $40.39 per patient per month for providing a minimum of 20 minutes of care. To qualify, doctors need to have an EHR system and be able to exchange patient information with other caregivers.
- New CPT Modifiers for Greater Specificity – Starting in January, instead of the catch-all, amorphous modifier 59, CMS will implement four new subset modifiers – XE, XS, XP and XU. The intention is to increase efficiency of payments to doctors.