Written By: Traci Pritchard, MD, ArMA President
In each issue of The Arizona Pulse, we plan to highlight a prominent member of the Arizona Medical Association (ArMA) to learn more about them on a personal and professional level. Read on to learn more about Dr. James Carland.
1. You practiced and took care of patients for many years prior to the formation of MICA and taking the reigns as CEO and President. Could you have been as impactful as the leader of MICA had you not had so much clinical practice experience?
The short answer is no. What I learned in clinical practice is/was foundational to what I have done for the last twenty-one years.
“Clinical practice experience” is broad and encompasses everything from taking care of patients (and their moms, dads, and others) to managing a practice and participating in the broader medical community. As a pediatrician, I tried to be comforting to my patients and credible to their parents. That meant honesty and frankness combined with compassion. It meant explaining why something needed to be done rather than telling them what was to be done. It meant knowing my patients, respecting them and earning their trust and respect in return. And it meant the same for the personnel with whom I worked.
Throughout my years in practice I was involved in the broader medical community: organized medicine through ArMA, MCMS, the Arizona Chapter of AAP, and the two hospitals where I had admitting privileges. Recognizing the need to prioritize my activities, I soon focused on hospital activities and, after serving for many years on multiple medical staff committees, I was elected Chief of Staff of what is now Banner Desert Medical Center.
The 1980s was a period of practice consolidation and the formation of IPA’s. I became involved and gained experience working with physicians, managed care organizations, hospitals and more than a few lawyers in my roles as Chair of Desert Physician Association, an IPA in the East Valley, and as founding Chair of the Samaritan Group, the parent of the Samaritan Health Plan HMO, and the Samaritan PPO.
And throughout, I was developing and managing a pediatric practice that had grown to six pediatricians and three pediatric nurse practitioners by the time I retired from practice.
2. Is it typical for a Medical Malpractice insurance company to have so many physician leaders as does MICA?
MICA was founded through the combined efforts of ArMA and a number of attorneys working under the leadership of Jack Brooks, MD, a Phoenix-based ENT physician. Virtually all the other physician directed carriers across the U.S. that formed in the late 1970s and early 1980s had the same generic parentage: physicians and insurance professionals working together. For many years, these companies were managed by physicians. In the late 1970s, many of these pejoratively named “bedpan mutuals” joined together to form Physician Insurers Association of America (recently renamed Medical Professional Liability Association). MPLA today has forty domestic member companies following mergers, acquisitions, and a few bankruptcies. Those insurers have Boards composed primarily of physicians but only six still have physician leaders in an active management role.
3. Reading blogs and conversations with colleagues, it seems many physicians are increasingly stating a desire to leave the practice of medicine or do something more administrative in nature. How did you prepare yourself for such a tremendous shift of responsibility?
Difficult to answer as I did not have a conscious desire to leave practice when the offer to become MICA’s President/CEO arose. I found my practice enjoyable. It was growing with new patients, new pediatricians, and new nurse practitioners. I was on the Board of the IPA I helped start and the Board of the Maricopa Medical Foundation. Perhaps the better question is why the MICA Board selected me for the role. I suspect it reflected the experience gained from my involvement in the broader activities of medicine. As importantly, I believe it was influenced by my ability to articulate an analysis of MICA’s mission and goals, challenges and weakness, and strengths . . . and my willingness to provide my candid perspective on what needed to be done. I was able to communicate my vision of what a physician-led organization should be and to whom it should be accountable.
4. Do medical malpractice companies view part of their identity as being a physician advocate? Are there Medical Malpractice companies that do not focus solely on physician and healthcare professional liability?
A few view physician advocacy as an integral part of their mission. MICA certainly does. But, unfortunately, not nearly as many as did a few years ago. For example, a large national carrier headquartered in the south began as two mutually owned companies that merged to form a large, multi-line stock insurance company. It is now listed on the New York Stock Exchange (NYSE) and sells lines of insurance other than medical professional liability. Another, the oldest medical professional liability insurer in the U.S., is a commercial carrier owned by Berkshire Hathaway company. It shares the goals of its parent company. Others were formed by attorneys and/or insurance professionals, a few simply to grow and be sold for a profit and others to provide a profit stream to shareholders. Virtually all support active risk management activities to some degree but only a few have, as an integral part of their mission, the support, and the interests of their physician policyholders.
The real key to understanding the mission and goals of a medical professional liability insurer, and its advocacy on behalf of physicians, is not to rely on the tag line found on marketing materials but to carefully read the insuring policy to understand what it does and does not cover and the requirements and responsibilities of each party.
5. How has the electronic health record impacted the defense of a malpractice case?
In short, it has made the defense of a malpractice case more difficult and more expensive. Consider that because of frequent upgrades to the software and user interface, a screen viewed by a treating physician a few years in the past is not necessarily the updated user interface screen that will be shown in a courtroom. More likely, there will be no user interface to show at all. Instead, there will be reams of pages of print that must be sifted through to reconstruct what was on that screen and what was readily available to the physician at the time care was rendered. The time print will record to the nearest second when a note was entered, when it was read, and how long it took to read before it was closed. Metadata will tell what, when, where and by whom. The time and cost to ferret out the information from the computer printout is substantial. Moreover, and more importantly, the user’s misuse of the record may create issues with the copy/paste function, perhaps the greatest of those issues particularly when the contents of the pasted note are not read and updated before insertion.
But the medicine is the same. It is merely the volume of documentation, and of detailed independent data elements that may or may not have been known at the time care was provided, that has changed.
6. Has the medical malpractice environment changed significantly over the last 20 years? Before being president of MICA, you practiced many years as a Pediatrician in our community and developed relationships with your patients and their parents and maybe the issues have changed?
Twenty years ago the frequency of claims and suits against physicians was almost double the frequency today. It reached a peak in 2002 when 8.8 percent of physicians had a claim or suit asserted each year. It was a period of multiple carriers failing. St. Paul ceased writing malpractice insurance shortly thereafter and another commercial carrier increased rates in Arizona 94% in one year, effectively leaving the market. It was a period when the cost and availability of medical liability insurance was the number one topic, a time when MICA again worked with organized medicine to enact tort reform legislation including the requirements for an affidavit of merit from a qualified physician and the qualification requirements of expert witnesses. Because those reforms were enacted, and because physician practices initiated intensive efforts to better understand and reduce medical errors, physicians’ concerns with medical professional liability dropped substantially. They have been supplanted by the challenges created by the myriad changes occurring in healthcare ranging from consolidation of practices to Byzantine compensation methodologies. Today, medical professional liability doesn’t even make the top ten list of physician concerns.
Will claims again rise enough to cause concern? Very likely they will. The emphasis on productivity, limited time with patients to diagnose, treat and develop a strong physician-patient relationship, rising patient expectations for a “good experience”, the competing demands for physicians to focus on patient care while ensuring the “wise and cost-effective management of limited clinical resources” (Physician Charter), and the growing fragmentation of care coupled with more frequent “handoffs” and miscommunication risks raise the probability that the frequency and the value of both claims and suits will increase. Already, in the hospital area, jury verdicts are topping $10 million with growing frequency.
7. For a variety of reasons, the iconic physician sole practitioner is being replaced by large and extremely large corporate medical groups and hospital employment models. Does this impact the relationship a medical malpractice attorney and insurance company has with a physician defending a case?
The short answer is, possibly. The most accurate answer resides in the Policy language. An insurance policy designates a “Named Insured” and it is to that individual or entity that the insurer owes its responsibility. In MICA’s experience, most large groups, and virtually all small groups, purchase a policy wherein each physician is a Named Insured and has his or her own limit of liability and his or her right to consent or withhold consent to the settlement. The insurer’s obligation to them is the same as if they were solo practitioners, and the obligations of their defense counsel are identical as well.
Nevertheless, MICA offers, and a few groups purchase, a policy with the group as the Named Insured. Physicians under the policy may or may not have individual limits of liability and may or may not retain the right to withhold consent to the settlement. In short, the insurance policy is responsible to the individual (or position) chosen and designated by the individual or group who is purchasing the insurance policy.
8. Do you agree that a Medical Malpractice claim or suit is really a claim against a physician personally? Possibly related to the landscape change noted in a previous question, I have seen that physicians are less the decision maker as to whom will be their Medical Malpractice carrier. Do you also see this on your side as a real trend? If so, should physicians be concerned about having choice given the very personal nature of a claim or are there enough aligned interests that stressing over choice, or lack thereof is not a great concern?
A claim or suit alleging malpractice against a physician is very personal. It is a blanket assertion that the physician was negligent, even cavalier and careless but at least incompetent, in the care they provided to their patient and it resulted in significant harm. It is difficult to get more personal than that. It is often perceived as threatening the physician’s ability to practice medicine and invariably leads to significant stress in their practice and their personal relationships. And, based on the severity of the injury and the monetary value a jury may award, it may threaten their family, home and personal assets as well.
Physicians looking for a medical professional liability carrier will, of course, assess the cost but most will also judge a carrier’s “record” in defending or settling a claim, the requirement for unrestricted consent to settle a claim, and the support of the physician throughout the process of responding to a claim. When the decision to select and purchase a policy is fully delegated to a non-physician, the criteria may be similar but the prioritization may differ. In a large group, the group’s reputation may be of greater concern than that of a single physician and the cost of the policy may have greater priority than the financial strength of the carrier or its knowledge of the community and the courts, or its history. Most group CEO’s and CFO’s are tasked with reducing overhead cost, increasing efficiency and maximizing profit. As such, medical professional liability coverage may get little more consideration than an automobile, unemployment, premises and general liability insurance policy.
9. You have had two very successful and demanding careers. How do you maintain your drive and passion for medicine whether it was during your clinical years or leading MICA?
I enjoy what I do and I believe I make a positive difference. Same holds true for my years in practice.
10. Being in the risk management business, it would be interesting to know if you ever do high-risk activities for entertainment, for example, skydiving, black diamond skiing or other extreme adventures?
I consider myself as a low-risk individual who wants to have a pretty clear understanding of possible outcomes and alternatives. That has not prevented me from activities others might consider at least moderate if not high-risk, including motorcycles and airplanes. Of the former, my interest was brief and the latter was mitigated by attaining a commercial license, twin-engine, instrument rating. Put another way, if I can convert a high-risk to a low-risk through preparation, I will happily pursue it. But I would never willingly jump out of a perfectly good airplane.
11. Will you tell us about one experience or individual in your life, professional or personal, that has helped you be so successful?
Difficult to pin down one experience or one individual, but I could start with my father who allowed a relatively risk-averse child to repeatedly fail followed by numerous teachers and professors who provided the same latitude. All provided support and taught me to get up and try again. It may not be apparent from the foregoing questions and answers and the implication of the question itself, but I have failed as many time as I have succeeded. Maybe more. It is merely that my successes have been more consequential than my failures. I believe it has been my preparation and effort to understand the risks, and ways to minimize those risks, that has lessened the consequences of my failures.
James F. Carland, M.D.
Dr. Carland graduated cum laude from the University of Colorado School of Medicine. His first and second year of pediatric residency training was divided between the University of Colorado Medical Center in Denver and the University of Washington/Children’s Orthopedic Hospital in Seattle. Subsequently, he returned to Colorado for a fellowship in pediatric pulmonary disease and to serve as Chief Resident in Pediatrics at Denver Children’s Hospital.
Dr. Carland practiced pediatrics for nearly three decades in the east valley of Maricopa where he served on multiple hospital committees and two terms as Chief of Staff at Desert Samaritan Medical Center, now Banner Desert. He was selected to be President and Chief Executive Officer of MICA in 1997. In 2003 he was elected MICA’s Board Chair. He was twice elected Chairman of the Board of the Physician Insurers Association of America (PIAA – renamed Medical Professional Liability Association in 2017), an international trade association of medical professional liability insurance companies.
He is the recipient of the Arizona Medical Association Distinguished Service Award and the Arizona Osteopathic Medical Association Distinguished Service Award. In 2013 he was awarded the PIAA’s Peter Sweetland Award of Excellence.