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Martin Bree Triton Group, LLC.

Federal Tort Claims Act and Health Center Medical Malpractice Liability Protection Southeast Atlantic Health Disparities Collaboratives 2008 Annual Transformation Teams summit/Reunion March 28, 2008 Nashville, TN. Martin Bree Triton Group, LLC. Triton Group.

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Martin Bree Triton Group, LLC.

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  1. Federal Tort Claims Act andHealth Center Medical Malpractice Liability ProtectionSoutheast Atlantic Health Disparities Collaboratives2008 Annual Transformation Teams summit/ReunionMarch 28, 2008Nashville, TN Martin Bree Triton Group, LLC.

  2. Triton Group First Source of FTCA Program Information • Triton Group • 227 Hamburg. • Pompton Lakes, NJ 07442 • HRSA Contract No. 232-00-0097 • Martin J. Bree Susan Lewis • 772-873-1865 727-822-4271 • 772-873-1695 (fax) susanlewis@tampabay.rr.com • 856-625-8638 (cell) • mjbtriton@mac.com • Roger Fuydal • 866-FTCA-HELP - Toll Free Marty Hiller (Free Clinics) • (866-382-2435) 216-382-4150 • 973-831-8395 (Fax) mhiller862@hotmail.com • tritongp@optonline.net Triton Group, LLC

  3. How the Program Works • A scheme that provides immunity from lawsuit. • Appears similar to an occurrence malpractice policy. • Program in existence for 13 years. • Very successful in terms of savings for health centers and coverage of health centers and staff. Triton Group, LLC

  4. How the Program Works (cont.) • Under FSHCAA Health Centers are eligible to be deemed “federal employees”. • Provides immunity from lawsuit alleging medical malpractice. • Plaintiff’s only remedy is claim under Federal Tort Claims Act (FTCA). Triton Group, LLC

  5. How the Program Works (cont.) • Who, what , when where? • Who is covered - Relationship to Health Center. • What is covered – medical malpractice. • Where is it covered – scope of project. • When is it covered – scope of employment. Triton Group, LLC

  6. How the Program Works (cont.) • Who is Eligible to be Deemed: • Community Health Centers [section 330 (e)]. • Migrant Health Centers [section 330 (g)]. • Health Care for the Homeless [section 330 (h)]. • Public Housing Primary Care [section 330 (i)]. Triton Group, LLC

  7. How the Program Works (cont.) • Who is covered - people • Employees. • Officers. • Directors. • Governing board members. • Contractors (some, not all). Triton Group, LLC

  8. How the Program Works (cont.) • Who is covered - Employees • All employees, full time or part time. • Volunteers are not employees. • Employees get a W-2 at end of year. Triton Group, LLC

  9. How the Program Works (cont.) • Who is covered - Contractors • Any full time contract provider(over 32 1/2 hours per week). • Part time contract provider of services in the fields of family practice, ob-gyn, general internal medicine, or general pediatrics. • Contract must be between the deemed health center and the individual provider. • Contracts between the deemed health center and a corporation (including Professional Corporations) are not covered. Triton Group, LLC

  10. How the Program Works (cont.) • Contractors • 42 U.S.C. §233(g)(1)(A) “…any contractor of such an entity who is a physician, or other licensed or certified health care practitioner”. • 42 U.S.C. §233 (g)(5) “an individual may be considered a contractor”. • El Rio Case Triton Group, LLC

  11. How the Program Works (cont.) • What is covered? • Medical malpractice. • More specifically, medical, surgical, dental and related activities (if within the scope of employment and scope of project). Triton Group, LLC

  12. How the Program Works (cont.) • Where is it covered – within the scope of project • Only incidents that occur within the scope of the project are covered. (See Policy Information Notice 2008-01). • Scope of Project are the activities described in the grant application that are approved by Public Health Service via Notice of Grant Award. • An existing Scope of Project cannot be changed in a grant application. There is a separate process. • A grant award for a new section 330 activity does change the Scope of Project. Triton Group, LLC

  13. How the Program Works (cont.) • When is it covered • Coverage is only for acts that are within the scope of employment of the covered individual. • No Moonlighting. • Must be acting on behalf of the deemed entity. Triton Group, LLC

  14. FTCA Procedures • Procedure • Plaintiff files administrative claim against the United States. • DHHS reviews claim and may deny it, pay it or offer a settlement. • If DHHS denies claim plaintiff may file suit. • If DHHS does not act on claim within six months plaintiff may file suit. • When suit is filed case transferred to DOJ. • DOJ may attempt to settle suit otherwise it goes into litigation. Triton Group, LLC

  15. FTCA Procedures • Procedure • Plaintiffs often file suit in state court. • What to do: • Immediately fax complaint and deeming letter to: Lisa Barsoomian Department of Health and Human Service Office of General Counsel (OGC) 202-619-2922 (Fax) 202-619-2155 (Voice) • Have health center attorney request extension of time to reply. Triton Group, LLC

  16. Potential Problems • Contracts. • Sub-Recipients. • Scope of Project - Sites and Services. • Billing Arrangements. • Americans with Disabilities Act, Rehabilitation Act, Civil Rights Act. • Nursing Homes • Contracts with Correctional Institutions • Non-Health Center Patients Triton Group, LLC

  17. Scope of Project New Policy - PIN 2008-01 Baseline Scope Verification Process - PAL 2008-01

  18. Important issues • Insurance requirements of hospitals and Health Maintenance Organizations. • National Practitioner Data Bank. • Other Insurance. • Deeming Applications . • Credentialing – a critical issue. • Emergency Response - PIN 2007-16 Triton Group, LLC

  19. Non-Health Center Patients • Federal Register Notice September 25, 1995 (Volume 60 Number 185) page 49417 – 49418. • Hospital On-Call Requirements. • Cross Coverage Arrangements. • Community Activities. • Other situations require a “Particularized Determination” See 99-08. Triton Group, LLC

  20. National Practitioner Data Bank (NPDB) • HRSA Participates in the NPDB. • 42 U.S.C. §401 – 431. • Assistant Secretary of Health elects to require PHS agencies to report – October 1987. • http://www.npdb-hipdb.com. Triton Group, LLC

  21. Other Insurance Needs • Gap or Wrap-around: covers medical malpractice not covered by FTCA. • Volunteers • Outside Scope of project • Contracts with corporations • Contracts with part time specialists • Peer review (maybe) • Tail Insurance • General Liability Insurance • Directors and Officers Liability • Proof of malpractice coverage – Triton Group Triton Group, LLC

  22. Deeming Applications • 2007 Policy • New organizations (never deemed before): • Submit application found in PIN 99-08 to BPHC. • Previously deemed entities • Submit application found in PAL 2007-02 to BPHC. • Due July 1, 2007. • All participating health centers should have received 2008 deeming letters by now. • 2008 Policy • Tentative due date June 1, 2008. (Look for a Program Assistance Letter around Mid April.) Triton Group, LLC

  23. Program ValueMalpractice Premium Savings • Studies conducted for Triton Group by Princeton Insurance Company and Huggins Actuarial Services. • Premiums calculated for 2002, 2005, 2006 • Used Uniform Data System (UDS) data for deemed Health Centers Triton Group, LLC

  24. Program ValueMalpractice Premium Savings Study Methodology • Used Occurrence Premiums with $1m/3m limits. • Premiums include 25% for taxes, profits, commissions, etc. • Each deemed Health Center rated by its specific territory. • Rates based on Full Time Equivalents by specialty. • Premium increased by 10% to cover corporation and allied personnel. Triton Group, LLC

  25. Program ValueMalpractice Premium Savings Study Results • 2002 Savings for deemed centers - $164,000,000 • 2005 Savings for deemed centers - $180,000,000 • 2006 Savings for deemed centers - $184,000,000 • 2007 Savings for deemed centers - $192,000,000 • Extrapolating from the studies: total savings since 1993 $1.6 billion Triton Group, LLC

  26. HRSA FTCA CLAIMS PER FISCAL YEAR Triton Group, LLC

  27. Triton Group, LLC

  28. 1,456 Medical Incidents 412 Deemed Health Centers (DHCs) 51 States/Territories 60% w/ final disposition 283 Obstetrics Related Claims 151 DHCs 36 States/Territories Incident Status SummaryHealth Center FTCA Malpractice IncidentsOct 1994 – Jun 30, 2006 Triton Group, LLC

  29. Severity of Injuries Resulting from Malpractice Incidents % of total NATIONAL N=1,456 Triton Group, LLC

  30. Nature of Occurrence Triton Group, LLC

  31. Triton Group, LLC

  32. Risk Management • Health Centers are expected to use a portion of savings to provide risk management services. (PIN 99-08 Para. XVIII). • NACHC –risk management training for groups of health centers. • Inspector General report on risk management in health centers. • Triton Group can provide risk management services. Triton Group, LLC

  33. Credentialing and Privileging PIN 2002-22 Credentialing and privileging required of all licensed or certified health care practitioners. Process for Licensed Independent Practitioners (LIPs) generally mimics JCAHO. Non-LIPs requires primary source verification of only license or certification. Volunteers included. Triton Group, LLC

  34. Risk Management Findings from Health Center Claims • Credentialing and Privileging • Competence of providers • Medical Records • Legibility • Completeness • Signatures • Availability • Birth Injuries • Existence and Proper use of protocols • Informed Consent Triton Group, LLC

  35. Recent Risk Management Recommendations (from HRSA Contractor - Keystone Peer Review Organization) • Training/CME: • Monitoring Pitocin Administration • Cord prolapse • GBS testing • Preceptor needs in labor and delivery setting Triton Group, LLC

  36. Recent Risk Management Recommendations • Illegible and/or Inadequate Medical Record Documentation • Accurate, complete and legible • Documentation of scheduled exams • Training in proper documentation • Use problem list and flow sheets for lab and meds • Encourage use of EMR • Documentation of conversations with patients or specialists Triton Group, LLC

  37. Recent Risk Management Recommendations • Policies/Procedures/Protocols • Lack of policies/procedure/protocol in 32% of cases reviewed • Examples: chest pain, handling of abnormal test results, adherence to ACOG 30 Minute “Decision to Incision” guideline. • Every health center should have its own customized set of well defined policies and procedures • Lack of algorithm for DVT/Pulmonary embolism prophylaxis • Lack of vaccine schedule for high-risk patients Triton Group, LLC

  38. Recent Risk Management Recommendations Training: Shoulder Dystocia Drills Other Lack of effective communication in 29% of cases: Failure to communicate plan of care with patients Failure to inform ptients of lab results Triton Group, LLC

  39. Triton Group First Source of FTCA Program Information • Triton Group • 227 Hamburg. • Pompton Lakes, NJ 07442 • HRSA Contract No. 232-00-0097 • Martin J. Bree Susan Lewis • 772-873-1865 727-822-4271 • 772-873-1695 (fax) susanlewis@tampabay.rr.com • 856-625-8638 (cell) • mjbtriton@mac.com • Roger Fuydal • 866-FTCA-HELP - Toll Free Marty Hiller (Free Clinics) • (866-382-2435) 216-382-4150 • 973-831-8395 (Fax) mhiller862@hotmail.com • tritongp@optonline.net Triton Group, LLC

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