INSURANCE: COVERING MEDICAL RISK

IS THE UNHEALTHY EMPHASIS ON TARGETING MEDICAL PROFESSIONALS WITH MALPRACTICE DIVERTING OUR ATTENTION AWAY FROM FIXING SERIOUS SYSTEMIC PROBLEMS IN HEALTHCARE, BUT PROVIDING NO FINANCIAL RECOURSE FOR THOSE WHO SUFFER A ‘BAD OUTCOME?”  

         In the area of  Medical,  beyond the basic  Insurance plans to cover  treatment and care,  I would like to see an additional completely different Insurance with a new emphasis based on Medical risk to compensate patients who suffer a “bad outcome.” Such Insurance would entail a major divergence away from the punitive concept of Malpractice and recent attempts to cap payouts for damages.  When a patient’s treatment does not go according to plan, or not as well as expected, what they really need is a swift payout to cover real necessities and the expense of ongoing Medical treatment or long term care.  Fault is immaterial to this immediate need; however, the protracted legal efforts to assess willful negligence often postpone any relief that might be offered by insurance.  These attempts to demonize well intentioned Medical professionals have radically changed attitudes towards practice as they encourage negative trends like “Defensive Medicine.”  Theft insurance does not demand that we prosecute the thief; why must an insurance payout be so dependant on blame when Medical treatment simply fails?

         I see no reason why Insurers are not focusing more heavily on providing coverage for a “bad outcome” with regard to Medical care.  Money is squandered on Lawyers fighting acrimonious battles over who was at fault when a Medical error occurred or a patient did not do well in response to even the most sophisticated treatment, during a critical period when readily available cash to cover urgent expenses is a far greater priority.  At such times there is a genuine need for the security of an insurance payment that is not reliant on anything more than the cost associated with a poor response to treatment or bad surgical outcome.  On some occasions the fault lies with a non-compliant patient, but far more often Medical errors and bad outcomes are the result of multiple factors including systemic problems that are never addressed by Medical facilities because the current Malpractice system provides little incentive for them to do so.  This system diverts attention away from the route cause of problems that could be fixed to instead target Medical staff with full accountability in situations where they are helpless to improve conditions.

         Medical staff are human too and errors will occur; in reality few other professionals are ever held to the same zero tolerance standard of accountability with regard to their work.  The Medical profession does have a well established system of self monitoring referred to as M&Ms, (Morbidity and Mortality).  This process is extremely rigorous in reviewing all bad outcomes regardless of liability.  Doctors participate regularly in M&Ms to target any mistakes made and draw positive conclusions about possible lessons to be learned for improving the standard of care. 

        However, the current emphasis on blame in Medical Malpractice is extremely detrimental to the process of genuine honest analysis of bad outcomes.  Malpractice seeks to target a specific individual or group of individuals who might or might not be at fault. This punitive approach often leads to extraordinary efforts to try and obscure mistakes by hiding important data and facts so that the reputations of the Medical professionals involved are not irrevocably destroyed.  Generally several of the staff involved with a case will share responsibility for a mistake, but the most heavily insured will always represent the best target for a considerable Malpractice settlement.  Taking into account the prohibitive cost and significant personal commitment involved in acquiring Medical qualifications it is understandable that Doctors are reluctant to allow an isolated incident, a bad judgment call or the mistake of a subordinate to sabotage their entire career.  Inevitably, Doctors will start to avoid high risk procedures where they are at serious risk of being sued if treatment does not go well; obstetrics is a prime example where patients will suffer. 

       There are some very clear cut cases of obvious negligence or inappropriate conduct that defiantly warrant punitive action, but this should be handled via dedicated Medical tribunals and medically trained professional investigators.  Frequently the cause of a bad outcome is not an incompetent Doctor of an uncaring Nurse it is far more complicated than that and often involves a multitude of minor oversights for which no one individual is responsible. For the most part Doctors and Nurses endeavor to provide the very best standard of care in a working environment that is becoming increasingly unforgiving.

           While Malpractice remains distracted by finding “the culprit” Medical facilities are not encouraged to eliminate any of those contributing factors that lead to Medical errors. Unnecessary fatigue, stress and exhaustion are exacerbated by the drive to force Medical professionals to deliver more complex care with fewer and fewer staff.  Not only are we trying to cope with a cohort of far sicker patients than ever before, we are attempting to manage in the face of what I call “Deliberate Negligent Understaffing” of all our US Medical facilities.  Overstretched, Medical staff working torturous continuous hours of duty without relief will make mistakes, but this toxic work environment is totally unnecessary and driven only by greed.  Sadly this factor is rarely identified as the principal component in a bad outcome.  

         While the “Agency Nurse” is targeted as incompetent for overlooking a vital detail, the real issue was the chronic lack of experienced Nurses on duty.  The vast majority of Agency Nurses are highly experienced, but they are at a disadvantage when dumped into an unfamiliar work setting to plug the gaps in coverage.  When things go wrong the Agency Nurse becomes a convenient scapegoat allowing Hospitals to distance themselves from responsibility.  In most US facilities the ratio of temporary staff to permanent employees has become ridiculously high, while the experience level of those regular staff is being kept at bare minimum to meet the demand for cheap labor.  While we know that Nurse to patient ratios have a direct affect on the prognosis of those receiving care, few states have set mandatory standards.  Studies have quantified the increased risk when Nurses are forced to monitor too many patients at once, but, when errors occur, the “uncaring Nurse,” often an Agency temp, is blamed or Malpractice climbs the feeding chain for a bigger payout at the top.  

        Ruthless cost containment policies for increasing Corporate profits at the expense of safe care are responsible for the huge increase in Medical errors.  Malpractice targeting beleaguered Medical staff is not alleviating this dangerous situation it is making it far worse. If the focus of Medical insurance was on outcome and providing financial relief for those who suffered a bad outcome then all of the players would be invested in making sure that the statistics were excellent at their facility and Hospitals could not continue dodging accountability at the expense of either temporary Nurses or their own Medical staff.  These for profit facilities would be forced to correct systemic problems or face the consequences of increased insurance premiums where their performance track record was the single most important factor in assessing the cost of coverage.    

        Only strong financial incentives will persuade people to take realistic responsibility for their own care.  Patients must also bear a certain level of responsibility for their own standard of compliance with a drug regimen or a rehab program and this component of risk cannot be ignored within Medical risk insurance.  Patients will feel really invested in monitoring their own compliance with treatment if their record of past compliance becomes a factor in gaining affordable Medical risk coverage.  Often it is the habitually noncompliant patient who requires more frequent Medical attention due to a tendency to ignore well recognized lifestyle risk factors and minimal attention to their own physical wellbeing.  Medical risk insurance would stimulate a greater vigilance in the monitoring of patient compliance. This would lead to swifter, generally more reliable, assessments regarding the efficacy of new treatment strategies or newly introduced drug regimens by minimizing unmonitored variables.  

       There would also be far more emphasis on analyzing the risk/benefit of undergoing certain types of radical treatment, with a realistic assessment of the potential for bad outcome taken very seriously by the patient based on the cost of insurance.  The cursory attention paid before signing consent forms negates any real understanding of risk.  We need to move away from the premise that “if anything goes wrong we can find someone to blame.”  The patients who have the best prognosis for recovery are those who are proactively participating in every aspect of their own care and have realistic expectations based on a thorough assessment of genuine risk; we need to encourage this type of positive approach to treatment.

        I believe that a new type of Medical risk Insurance should involve joint payment assessed according to the track record of the Medical facility, the experience of the Medical team selected, the past compliance of the patient and a financial evaluation of the risk/benefit of the treatment based on the potential for an adverse outcome. Such insurance would be designed to cover the true expense of dealing with the realities that a bad outcome would entail. A comprehensive benefit package might cover more than just the basics of any ongoing expenses incurred, but the cost of such insurance would be higher.  The protracted court proceedings to seek massive damages for pain and suffering would be negated by the prior determination of a “bad outcome” payout based on the extent of coverage chosen.  This would stimulate a more transparent and thorough evaluation of poor results, leaving any genuine Malpractice charges to specialized Medically trained investigators and a dedicated Medical tribunal. 

        There would be powerful incentives for Hospitals to insure that there were safe levels of Nursing coverage to provide diligent bedside care and enough thoroughly trained cleaning staff to provide high standards of sanitation to achieve lower infection rates. It would make sure that all patients took their role in compliance with treatment very seriously and maintained a realistic approach towards achieving the best possible prognosis.  However, it would provide faster access to financial relief if an insurance payout was not delayed by the lengthy legal process of assessing blame. This is the missing link in current Medical Insurance strategies the complete lack of incentive for patients to remain diligent in their compliance, with Doctors resorting to defensive Medicine, while the total lack of accountability enjoyed by Medical facilities condones negligent cost containment strategies.  

        Only when the financial cost associated with errors penalizes institutions for the consequences of incompetence will they realize the importance of qualified staff, ongoing training and the value of many years of experience. The current trend towards minimally trained aids and new Nurse graduates replacing higher paid tenured staff has depleted a valuable training resource for short term gains.  Managers in clinical areas of our Hospitals need to focus on reducing the risk to patients instead of perpetuating a system of Deliberate Negligent Understaffing to cut costs.   Strict control of staffing levels needs to be imposed industry wide, with Nurses required to document every incident of unsafe coverage in an incident report.  This will finally hold Managers accountable by removing the incentive of a fatter bonus check for those who exploit their staff or try to cull the ranks of higher paid tenured Nurses.  This policy has already failed financially since so many Hospitals are now squandering their HR budget on paying huge Agency commissions to bring back highly experienced Nurses who were once part of their regular staff!

        A major change in direction on Medical Insurance policies might just shift the emphasis away from inept “Top Heavy” Management and towards the safe delivery of care with appropriate Nurse to patient ratios and a concerted effort to eliminate the unnecessary fatigue responsible for errors.   Reducing the glut of Managers would also liberate funds needed for properly trained ancillary staff with a rigid agenda for Hospital grade cleaning to lower infection rates.  Please review other sections of this T.E.A.M., TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE site to read more about the C.U.T! Campaign to CONTROL UNDERSTAFFING TODAY.