Dr Michael Coglin, Chief Medical Officer, Healthscope Ltd - From Pay-for-Reporting to Pay-for-Performance – The Healthscope Story

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Dr Michael Coglin delivered the presentation at the 2014 Medico Legal Congress.

The Medico Legal Congress this is the longest running and most successful Medico Legal Congress in Australia, bringing together medical practitioners, lawyers, medical indemnity organisations and government representatives for open discussion on recent medical negligence cases and to provide solutions to current medico legal issues.

For more information about the event, please visit: http://www.healthcareconferences.com.au/medicolegalcongress14

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Dr Michael Coglin, Chief Medical Officer, Healthscope Ltd - From Pay-for-Reporting to Pay-for-Performance – The Healthscope Story

  1. 1. 1. From pay for reporting to pay for performance 2. Malpractice Litigation – a defendant’s perspective 23rd Annual Medico Legal Congress Sydney 27th March 2014 Dr Michael Coglin – Chief Medical Officer, Healthscope Ltd
  2. 2. “Ring the bells that still can ring Forget your perfect offering There is a crack in everything That’s how the light gets in” (Leonard Cohen Anthem)
  3. 3. Hospital League Tables 1830 “Were such reports of the various hospitals throughout Great Britain annually published, and the amount of expenditure given, a comparison of them would produce economy in the several departments. It might induce the medical officers to be more anxious to dismiss their patients, as soon as compatible with the strength of the convalescents, and to be more scrupulous in admitting slighter cases of disease, while the comparison of the expenditure for each patient would produce enquiry into the causes of its being higher in one hospital than in another, and the administration of hospitals would thus be conducted on better defined principles than at present.” Thirty fifth annual report of the Glasgow Royal Infirmary for 1829. Glasgow Med J 1830;3:109-15
  4. 4. International Experience • US  New York State cardiac surgery reporting scheme (1989)  Thompson Reuters 100 top hospitals annual survey (c. 1993)  Joint Commission‟s annual report on quality and safety (2006)  Commercial websites • UK  NHS risk adjusted clinical performance indicators (July 1997)  Dr Foster (2001) • Australia  “The Commonwealth and the States should collaborate to develop, by 1st July 2000, a set of risk adjusted clinical performance indicators which are comprehensive, consumer focused, and current. From that date, the department should publish annually comparative performance information on the indicators for the public and private hospitals…” (Duckett, et al, Health Services Policy Review Discussion Paper, March 1999)
  5. 5. Australia Gets with the Programme • Labour (“Rudd”) Government elected (Nov 2007) • National Health and Hospital Reform Commission established (Feb 2008) and reports (June 2009) • Minister Roxon announces “MyHospitals” website for public hospital performance reporting (private hospitals voluntary) (July 2010) • MyHospitals goes live with administrative (not clinical) data (Dec 2010) • MyHospitals reports first clinical data (staph aureus bacteraemia rates) for public (and small number of private) hospitals (27 October 2011) • MyHealthscope goes live (7 November 2011) 5
  6. 6. MyHealthscope – What is it? • 21 key performance indicators (initially 15) • Healthscope aggregate plus individual hospital level reporting • Performance trend over time eg. 3 years • Performance reported against industry standard/benchmark • Currently 645 data points with 95% meeting/exceeding benchmark • Narrative including links to health information • www.myhealthscope.com.au
  7. 7. Indicator Suite 2013 7 Health improvement • FIM scores (rehab outcomes) • HONOS rates (mental health outcomes) • MHQ-14 rates (mental health patient self-ratings) Accreditation • % EA ratings (ACHS accreditation) • Other awards Events to Avoid • Falls (medical/surgical/rehab patients) • Patients developing pressure ulcers Emergency • Triage categories 1-5 seen in required time Infection Control • Staph Aureus Bacteremia • Clostridium Difficile infection • Hand Hygiene compliance for different staff groups Surgery • Unplanned return to theatre Unplanned readmissions • Medical/surgical patients • Mental Health patients Obstetrics • Babies with healthy APGAR scores at 5 minutes • Length of stay after delivery
  8. 8. MyHealthscope Objectives – Why did we do it? • Inevitability of hospital performance reporting • Brand enhancement:  Industry leadership  Brand „quality‟ connotations  Quality performance exceptional • Competitive advantage especially compared with public hospitals • Attracts doctors, nursing and other staff, patients • Drives quality improvements internally • Accountability to funders and others • Pay for reporting pay for performance
  9. 9. MyHealthscope – The Response • Overwhelmingly positive • “I was pleased to see the information that has been released by the Healthscope group this week. This is an important step as it clearly demonstrates that there is a desire of some in the private sector to also transparently report performance indicators. I strongly support the principle of Healthscope’s actions. I want to see this reporting become standard practice with the private sector”. Nicola Roxon (Minister for Health and Ageing) • “A terrific initiative… “I am very pleased that you are taking a leadership role in this area. Congratulations, I am hopeful that you will be showing the light for others to follow.” Richard Bowden, BUPA Australia
  10. 10. Media Outcomes • MyHospitals – one positive newspaper story; approximately 60 negative • MyHealthscope – 2 main stories syndicated and several local stories - 150 newspaper articles – nil negative media 10
  11. 11. Media Strategy 12
  12. 12. MyHealthscope – Regional and National Recognition • Presentations at national and international industry conferences and forums • Case study – Master of Health Administration (MHA) programme taught in Beijing, Nanjing, Shanghai, Hangzhou and Kunming • Australian Business Awards x 2 (2012) – Innovation and Community Contribution • Australian Council on Healthcare Standards (ACHS) “Outstanding Achievement Award” • Ongoing positive media coverage • All recent contracts with health insurers now contain quality “price signal” 13
  13. 13. Evaluation • Each of the original 15 indicator areas have improved from Year 1 to Year 2 • Individual hospital outliers improved • Effective in changing hospital/staff behaviour 14
  14. 14. Transparency and Accountability – Never Events • Healthscope/Bupa initiative launched October 2013 • No precedent in Australian health care • “Never Events” - “errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients” • 14 agreed clinical scenarios • Healthscope agrees to forgo payment 15
  15. 15. The „Gold Standard‟ Conversation • All healthcare interventions have attendant risks • Providers mitigate/minimise risks • In the best of hands „intrinsic‟ or „residual‟ risk remains • Providers must warn of material risks • In the absence of warnings the expectation is a perfect outcome 100% of the time • When the outcome is less than perfect, the patient says “How could this happen? Someone is to blame. Someone has been negligent. I am entitled to compensation. Who was that on the ad saying “we fight for fair…”? • MyHealthscope contributes to the conversation about realistic expectations 16
  16. 16. And now for something completely different…
  17. 17. 8 Paid Settlements 23 New Claims 301 Sentinel Events 27,108 Patient Incidents 617,008 Hospital Admissions 2,104,099 Medical Centre Attendances Delivering Excellent Risk Outcomes Activity v Adverse Events (12 months to 31.12.2013) (Includes ACHA) ** Including ACHA  Incident - Event/circumstance which could have/did lead to unintended and/or unnecessary harm to a person and/or complaint, loss or damage  Sentinel Event - Event in which death or serious harm to a patient has occurred or may occur  Claim - Formal demand for compensation for harm or other loss that allegedly resulted from healthcare has been received, or where management forms the reasonable belief that a claim may arise and reports the claim to the insurer  Settlement - Claim where compensation is paid pursuant to settlement or judgement with or without admission of liability 5,031,397 Australian Pathology Episodes
  18. 18. 2013 Claims and Litigation • 23 new claims opened (18 litigated, 5 precautionary notifications) • 71 claims closed • 8 closed with payment to plaintiff • Median payment to plaintiff AU$15k
  19. 19. The Standard Scenario • Multiple providers eg. private doctor(s), private hospital • Private hospital not liable for negligence of private treating doctor (Ellis v Wallsend District Hospital (1989) 17 NSWLR 553) • Private hospital has non-delegable duty limited to those services it provides. Private hospital does not provide medical services ie. the services of private treating doctors • Sue all possible defendants and investigate/estimate liability later • Some defendants will offer money to secure release (“risk”, “pragmatic”, “commercial” offers) with scant regard for liability • If offer not forthcoming then offer discontinuance on “bear own cost” basis • Defendant gratefully accepts and „wears‟ $10-50k defence costs • Even if unsuccessful at trial, plaintiffs will not be pursued for costs by successful defendants 20
  20. 20. Cost Consequences to Plaintiff of Discontinued or Unsuccessful Litigation • Failure to warn? • Review 7 plaintiff firm websites  1 silent on fees/costs  4 explain firm‟s own costs: “Q: So I won’t have to pay any fees unless I receive compensation? A: That’s right – so if you’re worried about whether you can afford a lawyer, you don’t have to” “If you don’t’ win your case there is no fee to pay” “We work on a no win no fee basis so you’ll only pay a fee if you win your case at the end of the claim”  2 make explicit reference to risk of paying the defendant‟s costs if the claim is unsuccessful (congratulations S&G!!!) 21
  21. 21. 22
  22. 22. An Alternative View • A $ in the plaintiff‟s hands has the same economic and moral weight as a $ of the defendant eg. entitlement costs • The responsibility of litigants and their lawyers is to ensure that the parties receive their just entitlements under the law, not to dispense Christian charity (“Darl, we‟ve got to get something for this poor woman - $25k will do it”) • An entitlement to compensation arises from negligence and liability, not from poor clinical outcomes or hardship • The threat of adverse publicity if a successful defendant pursues a plaintiff for costs • “Settle meritorious claims fairly and expeditiously – contest unmeritorious claims. It is better to spend $50,000 (net of cost recoveries) to successfully defend an unmeritorious claim than to spend $50,000 to make that claim go away” 23
  23. 23. When Things Go Badly Wrong • The Woy Woy pensioner • Dwyer v Bailey & Healthscope [2005] VCC 5 24
  24. 24. 25

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