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Significant Risk and Uncertainty in Medical Malpractice Loss Reserving. Bill Burns Vice President & Actuary CLRS September 12, 2006. General loss reserving guidance provided in several sources. ASOP 36 Statement of Principles (1988) COPLFR (P&C Practice Notes).

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significant risk and uncertainty in medical malpractice loss reserving

Significant Risk and Uncertaintyin Medical Malpractice Loss Reserving

Bill Burns

Vice President & Actuary

CLRS

September 12, 2006

general loss reserving guidance provided in several sources
General loss reserving guidance provided in several sources
  • ASOP 36
  • Statement of Principles (1988)
  • COPLFR (P&C Practice Notes)
asop 36 uses terms such as
ASOP 36 uses terms such as:
  • Material Adverse Deviation
  • Changing Conditions
  • External Conditions
  • Significant Risks and Uncertainty
section 3 3 3 of asop 36 addresses the issues of significant risks and uncertainty as follows
Section 3.3.3 of ASOP 36 addresses the issues of “Significant Risks and Uncertainty” as follows:

“When the actuary reasonably believes that there are significant risks and uncertainties that could result in material adverse deviation the actuary should include an explanatory paragraph in the SAO. The paragraph should contain…a description of the major factors or particular conditions underlying risks and uncertainties that the actuary believes could result in material adverse deviation.”

statement of principles says
Statement of Principles says:

Considerations — Understanding the trends and changes affecting the data base is a prerequisite to the application of actuarially sound reserving methods. A knowledge of changes…is essential to the accurate interpretation and evaluation of observed data…

coplfr practice note says
COPLFR Practice Note says:

“The opining actuary is expected to use his/her discretion as to which risk factors and issues merit discussion in the opinion.”

slide7
COPLFR provides a (partial) list of the types of risk factors (and underlying exposures) for which comments may be appropriate
  • Asbestos
  • Construction Defect
  • Recently Enacted Legislation
  • Tobacco
  • Med Mal Legislative Issues
  • Mold
question 1
Question 1

What significant risks and uncertainties – if any – exist in medical malpractice that actuaries mightconsider disclosing in their SAO’s?

med mal factors that have been considered
Med Mal factors that have been “considered”:
  • Tort Reforms
  • Nursing Homes
  • Breast Implants
  • Pedicle Screws
  • Others?
the field of medicine is changing more rapidly than almost any other
The field of medicine is changing more rapidly than almost any other:
  • Delivery
  • Drugs
  • Technology
  • Procedures
delivery of medicine then
Delivery of medicine — then…
  • Family Doctor
  • Specialists
  • Hospitals
and now
…and now
  • Primary Care Physicians
  • Specialists
  • Hospitals
  • Outpatient Surgery
    • Physicians’ Offices
    • Ambulatory Surgi-Centers (ASC)
facts about outpatient surgery
Facts about outpatient surgery
  • 70% of all surgery done in U.S.
  • 14 million done in 2005
    • 20% in doctors’ offices
    • 80% in ASC’s
  • Most ASC’s are accredited (JCAHO, AAAASF)
  • Most doctors’ offices are not regulated
  • Many doctors are not board certified in the procedures they perform
facts about outpatient surgery cont d
Facts about outpatient surgery (cont’d)
  • Doctors are paid more for office surgery
    • Medicare pays $600 more for a colonoscopy
  • Doctors’ offices are the most dangerous place to undergo anesthesia
    • Outdated/Malfunctioning equipment
    • Doctors administering anesthesia and operating
  • Patients are 12x more likely to die or get injured in offices than in hospitals (Archives of Surgery, 2003)
some facts about legal drugs
Some facts about (legal) drugs
  • Thousands of pharmaceutical companies worldwide
  • “Market” > 4,000 drugs (and rising)
  • ~800,000 doctors in U.S.
  • > 1.5Bn prescriptions written annually in U.S.
drugs cont d
Drugs (cont’d)
  • Come in all shapes, sizes, colors and dosages
  • Taken 1x, 2x, 6x daily
  • Taken in the morning, at night or as needed
  • Many have similar sounding names but have completely different purposes
  • Is it any wonder medication errors are one of the leading causes of med mal losses?
drugs cont d17
Drugs (cont’d)
  • Hospitals are using new technologies to reduce medication errors but what about those that happen outside the hospital setting?
  • “Medical Mixologist”
technologies and procedures
Technologies and Procedures
  • Two-edged sword
  • Extend and improve quality of life
  • Introduce new errors (learning curve)
  • Warning label: new medical technologies and procedures may be hazardous to your health!
examples
Examples

Laparoscopic Cholecystectomy (“Lap Choly”)

  • Minimally invasive
  • Decreased visibility
  • Unfamiliar with instruments
  • More claims, higher awards until doctors were over the learning curve (three years)
bariatric surgery
Bariatric Surgery
  • Rapid increase in number of procedures
  • Number of surgery related mortalities and complications
  • What is the mortality rate?
  • Where are doctors in the learning curve?
  • What would an obesity pandemic mean?
other factors to think about
Other factors to think about:
  • Patient safety
  • Electronic medical records
  • Tele-radiology
  • Use of robots
  • Evidenced based medicine
  • New specialties
question 2
Question 2

If we agree there are significant risks and uncertainties in medical malpractice should actuaries try to quantify their impact on loss reserves or is an explanatory paragraph sufficient?

consider
Consider…
  • Underwriters are expected to constantly use more efficient ways of evaluation and quantifying risk.
  • Should actuaries be content to say:

“My projections make no provision for the extraordinary future emergence of new classes of losses or types of losses not sufficiently represented in the Company’s historical database or which are not yet quantifiable.”

  • Or to issue a qualified opinion?
conclusion
Conclusion
  • The numbers do not reveal their secrets easily
  • “Actuaries need to be curious, sometimes even more than they need to be intelligent…What good is applying a tried-and-true theory if you don’t understand the problem or the underlying drivers involved, or if you’ve misidentified a key risk?” (Sam Gutterman, Contingencies, July/August 06)
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