Medical malpractice is an issue that affects healthcare establishments and insurance companies from both legal and ethical perspectives. The primary implication of the problem is its impact on the health of individuals and the reputation of the clinic as an accountable care organization (ACO) that provides high-quality services. It is crucial for Anthem to have proper assessment criteria and strategies to manage the financial risks connected to medical malpractice.
Issue Description
The organization in question is an insurer Anthem that has to provide reimbursements to medical establishments for their services. While Anthem does not have to deal with malpractice claims directly, the company suffers from unnecessary payout for visits to medical establishments and drug prescriptions. The insurer does not account for malpractice claims or adverse patient outcomes, for instance, death, but the issue remains to be a risk factor due to indirect reimbursement implications.
The specific malpractice issues that Anthem deals with are connected to the increase in spending per patient by 5% in 2019 despite them using the same number of services per year (“This week in healthcare reform,” 2019).
One aspect of this safety issue is the improper management of chronically ill individuals who often visit the emergency department (ER) despite a possibility of receiving care at home or during a regular visit to a hospital that can be reduced by 30%. Reports indicate that over $8.3 billion is wasted each year due to the improper management of patients (“This week in healthcare reform,” 2019). Anthem has to reimburse providers for services event in cases where the results of their interventions are adverse.
Legal and Ethical Implications
The Patient Protection and Affordable Care Act outline the problem and encourage organizations to develop solutions that would help mitigate the issue and ensure safety (Zigrang, 2017). From an ethical perspective, the personnel of medical centers has a responsibility to help individuals, without causing harm to their health state and by adhering to the choices that patients make. This issue is the basis of work for all medical establishments. The internal context of the problem involves the emotional and professional impact that lawsuits and adverse events can have on physicians, while the external effects include the perception of medical care.
Risk Indicators
Firstly, performance indicators and measurements of risk should be included in the balanced scorecard to ensure proper control of this issue. Black, Wagner, and Zabinski (2017) argue that patient safety indicators (PSI) have a connection to the malpractice claims. According to the study conducted by the authors, healthcare organizations that pay more attention to PSIs are less likely to receive payout requests or legal claims.
Additionally, Rahimi, Kavosi, Shojaei, and Kharazmi (2017) developed a model that consists of 22 indicators, which can help track adverse events and implement strategies that will reduce the number of adverse events claims. Among those, the following can be used to identify the quality of services – discharge with personal satisfaction, hospital infection rate, clinical errors, the rate of patient complaints, and patient satisfaction percentage.
Thus, the risk financing issue can be identified by monitoring the balanced scorecard. Goals regarding a number of errors and complaints can be set, with appropriate strategies for achieving them to manage this issue. The challenges with this approach include bias connected to patient satisfaction rate and self-reporting of errors. However, the former does not affect PSI measures directly, while the latter can be mitigated by explaining the importance of reacting to problems that arise with patients appropriately.
Thus, the personnel of the clinic should be aware of both legal and ethical implications of malpractice and should cooperate with the establishment to improve PSI. Based on the literature, it can be concluded that measures that this medical clinic should take include increased attention to the safety of patients within the establishment.
Recommendations
The primary aim of this memo is to ensure that Anthem and its personnel can adopt strategies for lowering the risk of malpractice cases and the provision of unnecessary services to patients. One option is ensuring that providers have professional liability insurance and work in accordance with the “no blame” policy as an approach to managing the financial risks associated with the problem in question (Zigrang, 2017; Cooper et al., 2017).
The next strategy is connected to staid reimbursement and transition towards value-based practices. This issue results in increased payouts because the insurer has to provide payments for each patient visit, while the new system will improve the management of chronically ill patients by reducing visits to the ER (Guy, Gunnarsson, Saynisch, Chawla, & Nigam, 2015). Finally, Anthem should focus on creating a culture where providers are encouraged to present services that are helpful in adequately managing health conditions.
The organization should emphasize its projects such as telemedicine, pharmacy site-of-care, IngenioRx that will allow lowering costs due to mitigation of unnecessary care services. Through these initiatives, the insurer will be able to save approximately $4 billion each year (“Anthem promises more 2018 growth,” 2018). Thus, the issues outlined above drive up the cost per patient without providing more high-quality care to individuals.
It is also necessary to monitor the process of diagnosing illnesses because according to Nordqvist (2017), this aspect is the most common claim among patients seeking compensation. Thus, by implementing the new balanced scorecard, this clinic will be able to minimize the number of errors. These strategies provide an incentive for investing in preventative measures that would decrease the number of adverse cases and provide additional support in case such events occur.
Conclusion
Overall, medical malpractice is a serious issue that causes financial losses for Anthem. Thus, it is necessary to improve the existing balanced scorecard indicators by adding measurements that will help determine the number of adverse events and unsatisfied patients. Professional liability insurance improved approach to diagnosing and enhanced patient safety measures can ensure that this issue is mitigated within the establishments.
References
Anthem promises more 2018 growth and long-term drug savings. (2018). Web.
Black, B. S., Wagner, A. R., & Zabinski, Z. (2017). The association between patient safety indicators and medical malpractice risk: Evidence from Florida and Texas. American Journal of Health Economics, 3(2), 109-139.
Cooper, J., Edwards, A., Williams, H., Sheikh, A., Parry, G., Hibbert, P., … Carson-Stevens, A. (2017). Nature of blame in patient safety incident reports: Mixed methods analysis of a national database. The Annals of Family Medicine, 15(5), 455-461. Web.
Guy, D., Gunnarsson, C., Saynisch, P., Chawla, R., & Nigam, S. (2015). Do patient-centered medical homes reduce emergency department visits? Health Services Research, 50(2), 418-439. Web.
Nordqvist, C. (2017). Medical malpractice: What does it involve? Web.
Rahimi, H., Kavosi, Z., Shojaei, P., & Kharazmi, E. (2017). Key performance indicators in hospital based on balanced scorecard model. Journal of Health Management & Informatics, 4(1), 17-24.
This week in healthcare reform, February 15th, 2019. (2019). Web.
Zigrang, T. A. (2017). Tort reform: The impact of the ACA on medical malpractice. Health Capital, 10(4). Web.