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Bill Klaproth (host): Welcome to the ASHRM Podcast, made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ASHRM, that's ASHRM.org/membership, to learn more and to become an ASHRM member. I'm Bill Klaproth.

And this podcast is sponsored by Preverity and we thank them for their support of the ASHRM podcast. You can learn more about them at preverity.com. So, let's talk about current trends in medical provider activities driving increased malpractice risk with Larry Van Horn, certified professional in healthcare risk management. Larry, thank you so much for your time. It's great to talk with you.

Larry Van Horn: Great to be with you today. Coming to you from a rainy Nashville, Tennessee, the nation's healthcare capital.

Bill Klaproth (host): Right. Well, I'm interested to talk to you about this. So, I know that you have observed a lot of data. Before we get started, can you tell me what data you've used to develop your insights?

Larry Van Horn: Sure. So, I leverage the data assets of Preverity, a unique organization, in that it has two key data assets that I use to look at the clinical practice of medicine. One, they work with about 20% of the commercial malpractice insurers in the United States. And they have the largest database in the US, identified database of physician malpractice history. So, they're uniquely positioned to see what providers are getting sued for.

The second thing is that they receive about 50% of the United States' commercial medical billing data updated weekly and about 60%, 65% of all prescriptions that are written in the United States updated weekly. And they have about eight years of history. So, they have visibility into what are doctors doing every day in the United States. What is their treatment intensity, scope of practice? How are they prescribing? What procedures are they doing? And they're uniquely able to tie that to the observed malpractice event to identify how does this clinical activity of the provider either increase or decrease the likelihood of a malpractice claim. And as we know in facilities, vast majority of facility and hospital risk is related to clinical decisions and clinical care directed by a physician.

Bill Klaproth (host): So when you take these two key data assets, as you call them, and put them together and learn from both of them, what does that tell you? How does that inform you?

Larry Van Horn: It allows me to surveil all of the clinical activity of US healthcare providers and examine how is practice changing, how are the clinical decisions that are made by physicians relating to malpractice verdicts, settlements and incidents. And it's really an unparalleled information and data source. I mean, they've got over 80 billion claims here and identified malpractices in over a million physician years. So, the data assets give me unparalleled access to talk to you about some of the things that I'm seeing when I look at this data today.

Bill Klaproth (host): Okay. That's exactly what we want to learn from you, Larry. So, what are areas that are of concern to health systems and risk managers?

Larry Van Horn: Given where I sit here in Nashville, Tennessee, I have the luxury of getting to talk with a lot of health systems. And they're all facing very significant financial challenges. And they're also experiencing increases in their malpractice costs, either through their risk retention groups in their captives or through their excess layers. And so, they're looking for ways and novel solutions that help them manage that financial exposure. And the conversation that we're driving here and engaging in is one around how is the clinical activity taking place in the facilities? How can we change the risk profile associated with the clinical activity to mitigate risk? And so, that's the big area that I think holds promise for changing the game. It's different than trying to settle cases differently or try doing things in that space. This is getting into the clinical process of care and saying, "Where are providers doing risky things? Are there things that we should be thinking about differently in the process and delivery of care that can actually reduce our future risk and frequency and bring down the kind of reserving requirements and allow us to change our SIRs?" That's what organizations have a lot of interest in right now.

Bill Klaproth (host): So, I guess that is the big question. How can we change the risk profile associated with the clinical activity to mitigate risk? What is that then? What is the answer to that?

Larry Van Horn: Well, first, it's understanding what's risky. And that's where the value of this big data comes in. When I talked to risk managers, they'll frequently talk about surgical site infection rates or VBAC activity as being things that are problematic for them. And using the data, we can be very nuanced in doing deep dives into these areas. The industry as a whole is concerned about telehealth, the role of mid levels, opioid-prescribing. These are all things that we can kind of walk through and I can give you some high level pictures on. But at the end of the day, it really boils down to the individual decisions made by an individual physician.

I'll talk generalities today about secular trends over time, over years or geographies. But there's tremendous variation in the practice of medicine. And it's worthwhile to get down to the physician level, in part because that's where the intervention needs to take place. And so, what this data affords is the ability for a CMO or risk management officer in partnership with a CMO to sit there and have a conversation with Dr. Smith and say, "Dr. Smith, I just want to make you aware that your VBAC rate is 10 times the nation's average. And VBAC rates we perceive as being risky to the health system. And we'd like to have conversation with you about that." That's a conversation that can translate into potentially a change in practice behavior, a change in clinical decision-making, which actually will reduce the facility's future exposure.

Bill Klaproth (host): So then, what are you seeing in terms of VBAC rates specifically by OB-GYN facilities?

Larry Van Horn: Yeah. It's an interesting one because it's something that people have asked me about a lot. If I look across the United States, on average, the C-section rate in the United States is around 40%. It's gone up a little bit over the last four years, but it's roughly around 40%. If you look at the VBAC rates, they average about 1%, 1.2% of all deliveries are VBACs, that's vaginal birth after C-section. But we actually can compute that on a weekly basis for all physicians in the United States. And we'll see physicians who have VBAC rates of 10% and 15%, which is 10 to 12 times the nation's average who are very anomalous in their proclivity to do VBACs. I'll say for the United States as a whole, the VBAC rate is trending down somewhat. But there is really significant variation in that. Washington, DC, Hawaii, Delaware have some of the highest VBAC rates in the United States and they've grown markedly over the last four years. Whereas if you take states Alaska, South Dakota and Wyoming, the VBAC rate has been dropping quite significantly in those states.

Now, I don't have a narrative to say what's special about Delaware, Hawaiian, Washington, DC, relative to Alaska, South Dakota and Wyoming. But, there is very marked changes in a rate at a state level that we observe in the data, again going back to my preceding point, that masks the very significant variation across OBs within a given state with their proclivity to do VBACs. It's an interesting thing. It's something Preverity monitors and reports to health systems and risk managers regularly to can allow them the visibility to engage in the conversation.

Bill Klaproth (host): Right, to understand better why that is.

Larry Van Horn: Right.

Bill Klaproth (host): So, let me ask you this. You also mentioned telehealth and mid-levels. Let's talk about telehealth. What are you seeing as far as rates in the US?

Larry Van Horn: Well, we all lived through the COVID pandemic shut down. And we moved from a world prior to March of 2020 where telehealth was really not used very much. I mean, you might think about, say, 1% to 2% of all visits were through a telehealth platform. And then, with the shutdown, that grew massively, you know, at a 20-fold increase at its peak in the use of telehealth. And then, you've seen it trend off as things have resumed normalcy.

But what's interesting here is that, when I talk to people, particularly malpractice carriers, you know, they're concerned about what does telehealth do to the risk profile of clinical care and is this going to result in increased malpractice claims? And it's worthwhile unpacking that a little bit into two components.

One is, is telehealth being used for new patient visits? That is the first time that a patient encounters the physician or the nurse practitioner. Or is this being used for care with an established patient relationship? That is I have a relationship with my doc, and I'm just moving to telehealth. I think thankfully, for the vast majority of telehealth in the United States, it is used as an extension of a prior relationship that a patient has with the provider. Very little of the telehealth is new patients. So, I think that really at some level blunts the narrative that incomplete diagnosis, incomplete knowledge of the patient can result in misdiagnosis or whatnot. I think you could actually even view it as enhancing the patient-physician relationship.

So, we'll see. But I'm not personally overly concerned about the use of telehealth as being a risk increaser in the healthcare delivery system. At the same time, however, if I'm looking currently, there's massive variation in the rates with which telehealth is used. Wyoming, South Dakota, Utah, very little telehealth is used there. You're thinking we've returned back to pretty close to pre-pandemic telehealth use levels. Whereas if you look at places like California, Massachusetts, even Washington, DC, telehealth utilization remains quite hot. Twelve to eighteen percent of E&M visits, evaluation and management, is being done on a telehealth platform, which is eight times what it was pre-pandemic. So, there's a lot of variation in the use of telehealth nationwide.

Bill Klaproth (host): So by region or state, that use varies. But so far, the data is encouraging, you say.

Larry Van Horn: Right.

Bill Klaproth (host): So Larry, you mentioned also mid-levels. What can you tell us about mid-level providers?

Larry Van Horn: Yeah. Again, you know, coming out of COVID, people were very concerned that COVID resulted in a change in the practice of mid-levels, that they were increasing the scope of practice in part to secure access for the communities they serve and that, as a result, risk would be increasing in the mid-level population. What do we see? We see in general very little change in scope of practice for mid-levels nationwide. When we look at the prescriptions that they're writing, when we're looking at the diagnosis they are treating as well as the CPT codes of the procedures they're doing, there's been very little change pre, post-pandemic. Think of that as potentially being consoling to folks who are thinking about mid-levels being a source of risk. That said, there is really significant variation in the deployment of mid-levels in clinical care. There are states like Georgia, California, Pennsylvania that are notably very low in the use of mid-levels. Whereas the Northern plain states have a much higher use of mid-levels. So again, maybe there's a theme coming out of this. There's tremendous variation by venue, by locale in terms of practice patterns and the providers who are delivering care.

Bill Klaproth (host): Yeah. So, a lot of variables by state. That has to be challenging, isn't it?

Larry Van Horn: Part of the issue with mid-levels is that states have differing policies with regard to mid-level supervision and practice autonomy. So, there are regulatory issues at the state level that constrain the use of mid-levels. And those haven't changed markedly. Because of the public health emergency, a lot of the regulations were taken down and it almost begs to question, Bill, if you have to get rid of regulation or set it aside in a time of crisis, should you ever have the regulation to start with? It has secured greater access by relaxing some of the interstate licensure and scope of practice issues. And we'll have to see how this plays out.

Bill Klaproth (host): As with many things, that's for sure. So, we talked about VBAC, we talked about telehealth, we just talked about mid-level providers. Let's talk about opioid overprescription. That is always a hot news item. What insights can you share with us on that?

Larry Van Horn: Well, I think there's some really nice trends going on over time. I think we saw opioid-prescribing in the United States peak around 2014. And at a nationwide level, it's been declining pretty consistently over time. We do know, based on the analytics conducted by Preverity, that particularly for internal medicine, high opioid-prescribing providers have a statistically higher likelihood of being sued for malpractice. And so, there is a relationship between opioid-prescribing and malpractice events.

It's worthwhile noting that despite the seculars trend down in opioid-prescribing that, again, the devil's in the details, we see thousands of providers in the United States year over year who are increasing their opioid-prescribing. And Preverity monitors the opioid and benzodiazepine-prescribing of all US providers and benchmarks the opioid-prescribing rate of every physician relative to their specialty in the state. We think about that as being important to surface to health systems who want to engage in clinical risk management, because it affords a conversation with the physician. "Did you know, Dr. Jones, that you are in the tail of the distribution with respect to opioid-prescribing? And we know statistically that this actually increases risk." This isn't to say that all opioid-prescribing is inappropriate in any way, shape or form. I mean, if you have end-stage cancer and you're in hospice, opioid-prescribing is very clinically appropriate and we'd want to see that happen. So, thankfully, the data allows for a very nuanced characterization of that, but it's something that is on every risk manager's, I speak to, radar screen. And while the trend is dropping, there's certainly anomalous behavior in just about every state.

Bill Klaproth (host): Yeah. Well, it is good news that the trend is dropping. So, we are happy to hear that. And Larry, can you comment on providers practicing outside of their scope of responsibility? Are there any regional trends since we've been talking about regional and state trends that we should be aware of?

Larry Van Horn: Well, I think that the issue here is less a regional one, because what the folks at Preverity do is they'll take a family practice physician. And that's a really a coarse characterization of a specialty because you can have family practice docs who are primarily giving in-office primary care and you can have also family practice physicians who are doing appendectomies and doing surgery who are very different animals. And then, you can have family practice docs who are doing orthopedic procedures. And so, it's important from our perspective for a CMO and a health system to understand what are providers doing and is the organization comfortable with the scope of practice and whether providers are practicing consistent with the way they've been privileged in the organization. And Preverity allows an auditing capability to say, "You credentialed this family practice doc in your facility, but you didn't privilege him for doing any kind of surgery and he is. You might want to be aware of that, and that could be a problem."

The other thing, I was just talking to a health system the other day who called us up and said, "Hey, the thing we were talking about the other day, we had a $3-million malpractice verdict against us. And it would have been $250,000, but the provider credentialing slipped through the cracks. We thought he was credentialed, but the credentialing has lapsed. And one of the things that Preverity does with all the health systems is we audit the credential file monthly. And we're constantly evaluating is the care we see being delivered by credentialed providers? Are there providers outside of that, that we see associated with the organization and allow us to close that compliance audit loop? It's not clinical intervention. It's kind of a credentialing intervention to ensure that we don't have that kind of activity going on as well.

On a nationwide basis, when you're looking at a million physicians, you end up seeing physicians all the time who don't have board certification or fellowship training in various areas who are engaging in clinical practice that may or may not be considered risky by the organization. Preverity's perspective is you should be aware and you should make a conscious decision to say, "This is acceptable."

Bill Klaproth (host): Right. So, you said it's really important understanding of what doctors are doing, right? And understanding the risk associated with them potentially practicing outside of their scope of responsibility. It's incumbent on the organization to understand that. That's kind of first and foremost.

Larry Van Horn: Correct. I would say another interesting trend. One of the most risky specialties that we track and pay attention to is bariatric surgery. So, Roux-en-Y, lap bands, anything associated with bariatrics, that specialty has the highest malpractice frequency of that rate that we see in the data nationwide. And when we're dealing with our malpractice carriers, they definitely want to know that to price it.

But when we talk about health systems, the question is most bariatric surgeons are listed as general surgeons, are you aware that your surgeons are doing bariatrics? And if I look over the last five years, I've seen in 2017 there were about 3,400 physicians doing bariatrics. Today, we sit around 4,100 physicians doing bariatrics. So, there's been a market increase in the percentage of physicians who are engaging in bariatric surgery. Again, this isn't a statement about whether this is clinically appropriate or not, I'm assuming it is. But we need to be cognizant of the fact that it's an inherently high-risk surgical space and organizations need to be aware of that clinical activity going on in their facilities.

Bill Klaproth (host): That is a great example, Larry. Thank you for sharing that. And that really helps illustrate the issue perfectly. Well, this has been fascinating. I love talking about all these trends that you're discovering with the data, Larry. So, any final thoughts and conclusions that you can share with us?

Larry Van Horn: Yeah. I mean, I think the first thing that health systems and risk managers need to understand and know is where does the clinical risk sit in their organizations? What specialties, what procedures, what providers are generating that risk, and to start with that. And then, the next step is either clinical intervention around how do we mitigate that risk through practice modification or not. And following on to that, when something bad happens, what is the behavioral response of the provider and the organization to an event? And those two things together, we think, are central to health system risk mitigation.

Bill Klaproth (host): So number one, where does the risk sit in an organization, as you said. And then number two and 2A, if you will, understand the clinical intervention to mitigate risk and what is the behavioral response to an event after it. Those are the things we need to pay attention to.

Larry Van Horn: That's the way we see it. Yeah. And that's how we approach it. And we really are focused on number one and 2A and we partner with great individuals who work on the behavioral response intervention.

Bill Klaproth (host): So if the behavioral response is not up to par or not good, what is the outcome? What are the ramifications of that?

Larry Van Horn: The way in which a provider and the nursing staff interacts with the patient, what they acknowledge, how they communicate, ends up being very important in terms of mitigating the likelihood that can translate into a malpractice case. So, we need to have the clinical context to give rise to it, but then follow on is how the organization responds to that is important in terms of mitigating the extent to which that translates into a malpractice event.

Bill Klaproth (host): Yeah. That's a very important component of it. Well, Larry, thank you so much for your time today. This has really been interesting and informative. Thank you for your time again.

Larry Van Horn: Bill, thanks for having me on. It's been a pleasure.

Bill Klaproth (host): And once again, that's Larry Van Horn. And we'd like to thank Preverity for sponsoring this podcast and for their support of the ASHRM podcast. You can learn more about them at preverity.com. And the ASHRM podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management. You can visit ashrm.org/membership to learn more and to become an ASHRM member. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth. Thanks for listening.