Tuesday, June 21, 2005

Reducing Malpractice Premiums By Reducing Malpractice: Lessons For Workplace Safety?

The Wall St. Journal had a fascinating story today about how a high-risk group of physicians have beaten back skyrocketing malpractice premiums -- not by passing tort reform legislation, but -- get this -- by reducing malpractice. But almost as interesting as the accomplishment itself is how they went about it and the lessons it teaches for all of us safety types.

I have written about the malpractice insurance racket before and the attempt by physicians' associations to blame rising premiums on frivolous lawsuits, greedy patients and trial lawyers, rather than on greedy insurance companies and, of course, too much malpractice. In fact, the fight has gotten so bitter, that some physicians have actually refused to treat trial lawyers.

Once one of the highest risk medical professions, anesthesiologists have made amazing progress:
Over the past two decades, patient deaths due to anesthesia have declined to one death per 200,000 to 300,000 cases from one for every 5,000 cases, according to studies compiled by the Institute of Medicine, an arm of the National Academies, a leading scientific advisory body.

Malpractice payments involving the nation's 30,000 anesthesiologists are down, too, and anesthesiologists typically pay some of the smallest malpractice premiums around. That's a huge change from when they were considered among the riskiest doctors to insure. Nationwide, the average annual premium for anesthesiologists is less than $21,000, according to a survey by the American Society of Anesthesiologists. An obstetrician might pay 10 times that amount, Medical Liability Monitor, an industry newsletter, reports.
So, how did they do it? Punishing incompetent anesthesiologists perhaps?

No. First, they decided to gather data. What was causing accidental anesthesia-related deaths? After overcoming initial resistance from the insurance industry, the Anesthesia Patient Safety Foundation gathered information on thousands of malpractice cases.

What did they find? Many fatalities were caused by inserting the patient's breathing tube down the esophagus into the stomach instead of down the trachea into the lungs. It was difficult to detect the mistake until it was too late. Although devices were developed to detect the problem, they were expensive and hospitals were reluctant to buy them until the American Society of Anesthesiologists made the devices the basic standards for anesthesia care. After that, if hospitals didn't purchase them, they opened themselves up to malpractice liability.

Another problem dealt with alarms:
Anesthesiologists are now focused on alarm bells. Modern anesthesia machines come equipped with audible alarms that sound when certain thresholds, such as oxygen levels, are crossed. But the alarms irritate many surgeons, so some anesthesiologists have turned them off. The foundation has documented 26 alarm-related malpractice claims between 1970 and 2002, or a little more than one a year. Of those, more than 20 resulted in either death or brain damage.

The foundation is pushing to adopt a formal standard that prohibits anesthesiologists from disabling the alarms. "I would not fly on an airplane if the pilot announced all the alarms were being turned off," says Robert K. Stoelting, the foundation's current president. "Our patients deserve the same safety net."
The most important lesson from this experience is that the anesthesiologists focused on addressing systemic problems instead of human fallibility.

But according to Neil Kochenour, medical director at the University of Utah Hospitals and Clinics, physicians are resistant:
Dr. Kochenour says his institution has tried to emulate the anesthesiologists by concentrating more on identifying systemic errors and less on individual blame. But these efforts run headlong into thinking drummed into physicians since medical school, he says. "I don't think physicians are very good systems thinkers, by and large," he says. Many, especially surgeons, prize their independence, he says, and that makes it hard to achieve the kind of cooperation necessary to reduce errors.

What lessons can this teach us about making workplaces safer? First, addressing systemic problems -- removing the hazard or unsafe condition -- is a much more effective way of dealing with safety problems than blaming the worker -- a lesson that the steel industry, the construction industry, railroads and BP Amoco have not learned.

Second, what finally drove the anesthesiologists to address their problems? Huge malpractice awards and rising premiums. Unfortunately, workers and their families can't sue construction companies that kill employees, and the business community has been successful in "reforming" workers comp laws whenever the premiums start getting too high by putting more of the burden on injured workers.

And finally, what lessons can we learn from this story about rising workers compensation rates? If the best way to fight rising medical malpractice premiums is to reduce the amount of malpractice, maybe the best way to fight rising workers compensation insurance premiums is .... to reduce workplace injuries.

As my kids would say, "Duh!"

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