Emergency Physician Practice Changes After Being Named in a Malpractice Claim.

STUDY OBJECTIVE: Malpractice fear is a commonly cited cause for defensive medicine, but it is unclear whether being named in a malpractice claim changes physician practice patterns. We study whether there are changes in commonly used measures of emergency physician practice after being named in a malpractice claim. METHODS: We performed a retrospective difference-in-differences study comparing practice patterns of emergency physicians named in a malpractice claim and unnamed matched controls working contemporaneously in the same emergency departments (EDs), using data from a national emergency medicine management group (59 EDs in 11 US states from 2010 to 2015). We studied aggregate measures of care intensity (hospital admission rate and relative value units/visit), studied care speed (relative value units/hour and discharged patients' length of stay), and assessed patient experience (monthly physician Press Ganey percentile rank). RESULTS: A total of 65 emergency physicians named in at least 1 malpractice claim and 140 matched controls met inclusion criteria. After the malpractice claim filing date, there were no significant changes in measures of care intensity or speed. However, named emergency physicians' patient experience scores improved immediately after the malpractice claim filing date and showed sustained improvements by 6.52 Press Ganey percentile ranks (95% confidence interval 0.67 to 12.38), with the increase most prominent among those involved in the 46 failure-to-diagnose claims (10.52; 95% confidence interval 3.72 to 17.32). CONCLUSION: We observed a temporal improvement in patient satisfaction scores for emergency physicians in this sample after their being named in a malpractice claim relative to matched controls. Measures of care intensity and speed did not significantly change.

Changes in Reimbursement to Emergency Physicians After Medicaid Expansion Under the Patient Protection and Affordable Care Act.

STUDY OBJECTIVE: We examine the effect of Medicaid expansion on reimbursement for emergency physicians' professional services. METHODS: We conducted a retrospective study using data from a national emergency medicine group in a sample of 50 emergency departments (EDs) from July 1, 2012, to June 30, 2015. We categorized facilities in 14 states into full-expansion (23), partial-expansion (17), and nonexpansion (10) categories based on pre-expansion Medicaid eligibility criteria for all adults. We used a difference-in-differences design to assess the effect of Medicaid expansion on provider reimbursement per visit. Secondary outcomes included reimbursement per relative value unit and relative value units per visit, both overall and by payer type, controlling for age, sex, billing codes, and health system relationship. RESULTS: We studied greater than 6.7 million ED visits during July 2012 to December 2015, 3.0 million pre-expansion and 3.7 million postexpansion. After adjusting for covariates, reimbursement per visit increased 6.3% (95% confidence interval 1.4% to 11.1%) in full-expansion relative to nonexpansion states and did not change significantly in partial-expansion versus nonexpansion states. Reimbursement per visit for commercial insurance increased 17.1% (95% confidence interval 9.9% to 24.2%) in full-expansion versus nonexpansion states. Reimbursement for self-pay visits increased 9.7% (95% confidence interval 3.7% to 15.7%) in full-expansion versus nonexpansion states. Changes in payments were driven by higher reimbursement per relative value unit; relative value units per visit declined slightly in full-expansion compared with nonexpansion states. CONCLUSION: In this sample, full Medicaid expansion increased payments for emergency physicians' professional services compared with reimbursement in nonexpansion states. Higher reimbursement was driven primarily by lower proportions of uninsured patients and increased reimbursement per visit for both commercially insured and self-pay patients in states with full Medicaid expansion.

Measurement Under the Microscope: High Variability and Limited Construct Validity in Emergency Department Patient-Experience Scores.

STUDY OBJECTIVE: We evaluate variability and construct validity in commercially generated patient-experience survey data in a large sample of US emergency departments (EDs). METHODS: We used Press Ganey patient-experience data from a national emergency medicine group from 2012 to 2015 across 42 facilities and 242 physicians. We estimated variability as month-to-month changes in percentile scores and through intraclass correlations. Construct validity was assessed with linear regression analysis for monthly facility- and physician-level percentile scores. RESULTS: A total of 1,758 facility-months and 10,328 physician-months of data were included. Across facility-months, 40.8% had greater than 10 points of percentile change, 14.7% changed greater than 20 points, and 4.4% changed greater than 30. Across physician-months, 31.9% changed greater than 20 points, 21.5% changed greater than 30, and 13.6% changed greater than 40. Intraclass correlation estimates demonstrated similar variability; however, this was reduced as data were aggregated over fixed time increments. For facility-level construct validity, several facility factors predicted higher scores: teaching status; more older, male, and discharged patients without Medicaid insurance; lower patient volume; less requirement for physician night coverage; and shorter lengths of stay for discharged patients. For physician-level construct validity, younger physician age, participating in satisfaction training, increasing relative value units per visit, more commercially insured patients, higher computed tomography or magnetic resonance imaging use, working during less crowded times, and fewer night shifts predicted higher scores. CONCLUSION: In this sample, both physician- and facility-level patient-experience data varied greatly month to month, with physician variability being considerably higher. Facility-level scores have greater construct validity than physician-level ones. Optimizing data gathering may reduce variability in ED patient-experience data and better inform decisionmaking, quality measurement, and pay for performance.

Provider and Practice Factors Associated With Emergency Physicians' Being Named in a Malpractice Claim.

STUDY OBJECTIVE: We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim. METHODS: We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency medicine group (87 emergency departments [EDs] in 15 states from January 1, 2010, to June 30, 2014) to assess the relationship between individual physician and practice variables and being named in a malpractice claim. Individual and practice factors included years in practice, emergency medicine board certification, visit admission rate, relative value units generated per hour, total patients treated as attending physician of record, working at multiple facilities, working primarily overnight shifts, patient experience data percentile, and state malpractice environment. We assessed the relationship between emergency physician and practice variables and malpractice claims, using logistic regression. RESULTS: Of 9,477,150 ED visits involving 1,029 emergency physicians, there were 98 malpractice claims against 90 physicians (9%). Increasing total number of years in practice (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06) and higher visit volume (adjusted odds ratio 1.09 per 1,000 visits; 95% confidence interval 1.05 to 1.12) were associated with being named in a malpractice claim. No other factors were associated with malpractice claims. CONCLUSION: In this sample of emergency physicians, 1 in 11 were named in a malpractice claim during 4.5 years. Total number of years in practice and visit volume were the only identified factors associated with being named, suggesting that exposure to higher patient volumes and longer practice experience are the primary contributors to malpractice risk.