34 AAOSNow September2010 ManagingYourPractice ManagingYourPractice September2010 AAOSNow 35

OnApril15,2010,theNewEng-landJournalofMedicinepublished“MalpracticeReform:Opportuni-tiesforLeadershipbyHealthCareInstitutionsandLiabilityInsurers.”Thearticlereferenced“disclosureandreimbursementprograms”and“disclosureandearlyofferpro-grams.”COPICInsuranceCom-pany’s3RsProgramisperhapsthebestknownactivedisclosureandreimbursementprogram.

COPICwasfoundedbymem-bersoftheColoradoMedicalSocietyintheearly1980s,duringanescalatingmalpracticecrisis.Inthelate1990s,K. Mason Howard, MD,COPIC’sfirstchairman,pro-posedaprogramofsupplementalbenefitsforpatientswhohadanunanticipatedoutcome.Calledthe“3RsProgram”—forRecognize,Respond,andResolve—thepro-gramlaunchedinOctober2000.

Fortunately,groundworkthathadbeenlaidyearspreviouslyforotherpurposesfacilitatedthesuc-cessoftheprograminColorado.Criticaltoanyearlyinterventionisearlyreporting;physicianshadtoreportunanticipatedoutcomesinaverytimelyway.COPIChad,fromitsinception,stressedtheimpor-tanceofearlyincidentreportingasintegraltoits“reportingform”variantofclaims-madeinsurance.ReportingformcoveragemeansthatcoverageattachesonlywhenthateventisreportedtoCOPIC.

Also,physicianshadahighleveloftrustwiththecompany.Strongrelationshipsexistedwiththestate’slicensingboard,insur-ancedepartment,andlegislature.An“I’mSorryStatute”withbroaddefinitionsofprotectedconversa-tionspassedtheColoradolegisla-turewithanearunanimousvotein2003.

Program overview Severalassumptionsandcriteriadrivethe3Rsprogram,includingthefollowing:•Participationbyinsuredphysi-

ciansisentirelyvoluntary.•Patientsareneveraskedtosign

awrittenwaiveroftheirrightto

seekanattorney,makeaformaldemand,orinitiateformalliti-gation,butiftheychoosethatroute,3Rsbenefitscease.

•TheprogramisadministeredbyCOPIC’sriskmanagementdepartmentandisnottobecon-fusedwithinsuranceclaims;thepaymentsareconsidereda“first-partysupplementalbenefit”andnotathird-partyinsurancepayment.

•Theprogramisbasedonanad-verseoutcomearisingfromthecourseofmedicalcarewithoutadeterminationofnegligence.Thephysiciansinvolvedinthecaredetermineprimarilywhichcasestoreport.COPIC’sexperi-ence,coupledwiththephysi-cian’sfirsthandknowledgeoftheevent,determinewhetherthecaseisappropriatefortheprogram.

•Paymentsaremadefor“out-of-pocket”medicalexpensesnotcoveredbyinsurance(maximum$25,000)and“lossoftime”ataperdiemof$100(maximum$5,000),foratotalof$30,000availabletothepatient.

•Casesinvolvingthedeathofapatientarenoteligiblefortheprogram.

•PatientswhofilecomplaintswiththeColoradoBoardofMedicalExaminersareexcludedfromparticipation.Becausepaymentsarenotmade

inresponsetoformalwrittende-mandsandnopatientisaskedforawaiverorrelease,thepaymentsarenotreportabletotheNationalPractitionerDataBank.

The impact of communicationProgramexperienceandanalysisrevealthesignificanceofeffectivephysiciancommunicationandtherolethisplaysinthepatient’sperceptionofeventsandabilitytoacceptthecircumstancesoftheoutcome.AqualitativestudyfromtheUniversityofColoradoHealthSciencesCentervalidatedthisview.

Aseriesofinterviewswerefa-cilitatedwiththesepatients,andinsomecasesfamilymembers,aimedatidentifyingpatientneedsandperceptionsfollowinganun-anticipatedmedicaloutcome.Par-ticipantssharedtheexperienceofphysical,emotional,andfinancialworries,trauma,andfrustrations

relatedtotheiroutcomes.Whenthecommunicationwith

thephysicianwasgood,open,andhonest,theoutcomewasviewedasanhonestmistake.Patientsreferredtotheiroutcomesunderthesecir-cumstancesasbothforgivableandunderstandable.Conversely,whenthecommunicationwasperceivedaspoorornonexistent,thesameoutcomewasviewedasanerrorornegligence.

Asaresult,trainingindisclosureisofsignificantimportancetotheprogram.

Easing financial and emotional burdensThesignificanceofpatients’finan-cialburdenfollowingunexpectedoutcomesalsobecameevidentdur-ingtheseinterviews.Overwhelm-ingly,patientscommentedonthedevastatingimpactofthefinancialburdenandhowthiscarriedoverintowhattheywereundergoingphysicallyandemotionally.

Addressingthefinancialaspectproactivelytominimizetheburdenassociatedwiththeunexpectedcostsrelatedtotheinjuryisanimportantpartoftheprogram.Successfulprogramadministrationfacilitatesthenecessarycommu-nicationandsupportstheinsuredphysicianandthepatientthrough-outthisprocess.

Followinganunexpectedout-come,patientsgothroughapro-cesssimilartothegrievingprocess:denial,anger,bargaining,depres-sion,andacceptance.Alltoooften,thesepatientsget“stuck”inanger;anentireindustryofpersonalinjurylawhasbeenspawnedinresponsetothatanger.Yet,evenwhenpatientsreceivemoniesfromthetortsystem,theangerpersistsandthearrestedgriefprocessleavesthepatientlessthanwhole.

Underthe3Rsprogram,thephysicianisencouragedtoremaininvolvedasthepatientprogressestocompleterecovery,evenifthedoctorisnolongerprovidingdirectcare.Thisongoinginvolvementisessentialinfacilitatingthepatientthroughthisprocessandcrucialtoeffectingapositiveresolution.

Outcomes dataStatisticalanalysisofthe3Rsprogramfrominception(October2000)throughDecember31,2009,revealsthefollowinginformation:•Overall,about60percentofthe

totalinsuredbaseparticipates.•About80percentofprocedural

specialistsparticipate,comparedto41percentofnonprocedural-ists,inpartbecauseproceduraladverseoutcomesaremoreame-nabletothe3Rsapproachthanarethedelayeddiagnosisorfail-uretodiagnoseclaimscommontoprimarycareandemergencymedicinespecialties.

•Atotalof1,829patientshavereceivedreimbursement,withanaveragepaymentof$4,977perpaidcase.

•Ofthesepatients,60(3.4per-cent)subsequentlyfiledaclaimorsuitwithCOPIC.

•Theseclaimsorsuitshavere-sultedinindemnitypaymentsviathetortsystemin11cases(0.6percent).Specifictoorthopaedicsurgery,

thefollowingarethefivemostcommoncomplicationsthathavebeenreportedandsuccessfullyworkedthroughthe3Rsprogram:1.Postproceduresurgical

infections2.Failedprocedurenecessitating

furtherintervention

Litigationalternative:COPIC’s3RsprogramByAlanLembitz,MD

Disclosureandearlyreimbursementcandetermedicalliabilitylawsuits

Table1:Differencesbetweentraditionalliabilitysystemand3Rsprogram

TraditionalSystem 3RsProgram

Adversarial Supportive/caring

Shatteredphysician/patientrelationship Preserved/enhancedphysician/patientrelationship

Ineffective Targeted/focused

Inefficient Timely/sensible

Lacksinlearning Overflowinginlessons

Nowaytoaddresssubstandardcare Riskmanagementintervention

OrthOpaedic risk Manager

See 3Rs, page 37

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