June 24, 2013 by matray

editor's note: A version of this interview -- edited for length -- appears in the July 2013 edition of the Medical Liability Monitor. When Brian Atchinson assumed the chief executive position at PIAA, the trade association representing domestic and international medical professional liability insurance companies, risk retention groups, captives, trusts and other entities, the American healthcare delivery system was headlong into a period of unprecedented change. The Patient Protection & Affordable Care Act had been signed into law less than 18 months earlier, and its systemic reforms were compelling PIAA members to reevaluate their role in the healthcare market of tomorrow. At the conclusion of the first day of the 2013 PIAA Medical Liability Conference, which was hosted in Palm Desert, Calif., May 15-17, Atchinson sat down with Medical Liability Monitor to discuss the state of the medical professional liability industry and what challenges lay ahead as well as PIAA’s just announced rebranding effort and how its services will help shepherd member companies through this period of change. Following is a transcript of that conversation. Medical Liability Monitor: This is your second Medical Liability Conference as PIAA president. How has your understanding of the medical professional liability industry and the challenges it faces evolved? Brian Atchinson: There is a lot of change going on within the medical professional liability industry and marketplace, just as there is throughout the entire healthcare delivery system. I was fortunate to have a fairly good grounding in what used to be referred to as medical malpractice and is now more appropriately called medical professional liability. Early in my career, I worked for a hospital system company that ultimately became Tenet Healthcare. When I moved to Maine in 1988, I started working as an attorney representing hospitals and physician practices, mostly on business and practice issues. Soon after that I went to work for the state, for Commissioner Susan Collins, who oversaw the department of professional financial regulation and also chaired the governor’s health policy council. I was her legal counsel and functionally served as her deputy. Early on, I was assigned to tort reform and medical liability issues in the Maine state legislature and public policy domain. In 1992, when I became the insurance superintendent for the state of Maine, my very first week on the job, I had to preside over rate hearings for medical professional liability insurance. So, my familiarity with MPL issues comes from a few different perspectives. It provided me with a good foundation. Working in the Maine state government, I had the opportunity to learn from Medical Mutual Insurance Company of Maine, one of the mutuals set up many years ago. The essence of the PIAA companies is well represented by the Medical Mutual Insurance Company of Maine, and I learned a great deal from them. When there was a workers compensation crisis in Maine, and there were no companies willing to write workers compensation insurance, I took a page out of the medical liability industry playbook. We created an employer’s mutual, which was a great solution that still serves as the primary writer of workers compensation insurance in the state to this day. So, when I came back into the medical professional liability line of business, it felt very comfortable. I had to get up to speed on some of the current players and how the market has evolved, but it was interesting. In my prior work, when I was working with the Geneva Association, which is a think tank, and I was participating in meetings with the International Association of Insurance Supervisors debating with the global insurance regulators about systemic risk and whether or not there are elements of the insurance industry that could constitute systemic risk, there was a discussion about market disruption and what would happen if a dominant carrier left at a critical point. The example given by then NAIC president Dr. Terese Vaughan was the medical liability insurance marketplace and the successful response when the St. Paul companies exited the line suddenly, creating what was initially thought to be a tremendous, potentially disruptive void in the marketplace that could have had significant ramifications for the U.S. healthcare system. PIAA member companies met that challenge. There were a few other players in the market, but that is a great example of how PIAA member companies and the medical professional liability industry have a great sense of market needs. Returning to this industry after being away from it for a while has been very gratifying. This industry is so unique and so special. It really understands the role it serves for its insureds and others. I love the expression that someone said distinguishes PIAA member companies from most other lines of insurance – whether its health insurance or others – and it’s what my government relations team uses when they try to help people on capitol hill understand our industry – “our insureds actually like us”, which is not the case with some other lines of insurance. MLM: In your remarks opening the Medical Liability Conference this morning, you said that there is no greater place to address the current challenges facing the medical professional liability industry than here. What do you feel are the greatest challenges facing the industry today? BA: As a number of our speakers noted, there’s significant change going on, and we see many companies in the medical professional liability line of business adjusting to the change. They are expanding the scope of their products to include other professions within healthcare – such as nurse practitioners, nurse midwives, physician assistants and others – that are playing a more prominent role in care delivery, as well as institutions, hospitals and health systems. Many companies are expanding the scope of the providers they insure...  They are also looking at new areas of risk that are emerging now and determining how they can continue to contribute to the evolution of patient safety.  Because, ultimately, promoting quality healthcare distinguishes PIAA companies from other MPL insurers. Along those lines, I think it’s going to be very important how we evaluate the changing risks in the delivery of medicine in this country. We’ve had a number of great panels today that have touched on this theme. To borrow an expression from Wayne Gretsky, you don’t want to go to where the puck is, you want to go to where the puck is going to be. That is our goal when we put together our programs—whether it be this yearly conference, one of our educational workshops, or a webinar.  We strive to help people assess where the puck is going to be in the next few years, so to speak. Laura Jacobs, our luncheon speaker, captured it well when she was talking about people who are saying, “Oh well, you saw this migration towards acquiring or employing physicians 10 or 15 years ago and then it undid itself.” Some people say that may happen again and others say there is no way that is going to happen again. It was refreshing to hear her say, “You know, no one really knows.” We are in such different, changing times. As our keynote speaker Leonard Schaffer said this morning, the economics and the financials are much different now than ever before, and those factors will drive much of our healthcare system in the future. The sessions we’ve been putting on will stimulate a lot of good discussions and provide people with some insights into where these changes are taking us. MLM: That’s interesting. Last year’s keynote speaker at the PIAA Medical Liability Conference, Ian Morrison, had said that the healthcare reforms have left the station and we’re definitely not turning back. Here, Laura Jacobs is saying that nobody really knows what is and isn’t definite. BA: Absolutely. We know that things will never be exactly the same as they were before, but what we don’t exactly know is where things are going. People need to embrace change. That can mean different things to different individuals, but at a minimum, people need to build-in versatility and flexibility into their business models because healthcare will be delivered differently in the future. For example, there have been many articles written and some of the economic modeling conducted showing there simply will not be enough doctors in the future. However, when you speak to people in the nurse practitioner community, they point out there are not going to be enough nurse practitioners to meet projected needs, either. We know that in the future nurse practitioners, certified nurse anesthetists, nurse midwives and others are going to have greater authority and responsibility in terms of ordering tests or writing prescriptions, and we have no doubt that that will translate into greater liability. It’s a natural sort of evolution, and people need to be prepared for that. MLM: The healthcare delivery system is changing and the medical professional liability industry will change in response to those changes. How is the PIAA and its function going to change? BA: That’s a really good question. As you know, we announced the results of our rebranding efforts today. In many respects, what we’ve really done is updated our brand to better reflect what we have already become over the last 10 to 20 years. It surprises people when we tell them that our members already insure close to 3,000 hospitals, about 2,000 of those in the United States and the others around the world. Our members are not just mutuals anymore. They are reciprocals, exchanges, trusts, risk retention groups, captives, privately held stock companies, publicly held stock companies. There is no one type of PIAA member. What we have started to do in this past year, and we plan to do even more of in the future, is to ensure that our programs – whether they be in-person workshops, the yearly Medical Liability Conference, the many   webinars we are hosting or educational sessions that are available to be played back from our website – provide education, training, and tools for all of our members. That includes self-insured health systems and hospitals. We have health systems whose captives are members; we have risk retention groups that represent groups of hospitals or health systems. Many of their needs and their goals are the same as a mutual or a reciprocal or a cooperative. We are working to ensure that our programs encompass issues and topics that are just as valuable and relevant for them as they are for the traditional member company. We have the unique capability to bring together the greatest expertise in the medical professional liability community, regardless of the shape or size of the organization, the type of healthcare providers, or institutions they are insuring. Implementing our strategic plan over the last year and a half has provided us with a good opportunity to step back and look at the organization in a different light.  To use a familiar analogy, much like an automobile, we put the organization up on the lift to give it a tune-up. That applies to our programs as well. The strategic plan development was a collaborative undertaking between the board of directors and PIAA staff. It was the perfect opportunity for us to analyze the organization and truly assess our position within the MPL industry and also determine how well we are meeting the needs of our members. Every organization, big or small, should do this sort of thing every few years; it helps you become proactive as opposed to reactive. As the new guy in the organization, I found it fascinating to work with the board of directors to collectively step back, go offsite – we did it with our staff for a couple of days, then we did it with the board – and acknowledge that people sometimes – all of us –don’t see the trees through the forest. It’s been a long time since this organization was just “physicians insuring physicians,” and yet when I was talking with people about potentially joining this organization, if I talked to eight or nine friends, colleagues about the organization, by and large it was viewed as the physician mutuals insuring physicians. It had not been that organization in a long time. We had some fascinating discussions among the board of directors, really the best and brightest in this industry, about who we are, who we think we are, and who we want to be. It was really surprising to many of us that who we wanted to be – to some extent – was who we already were. We just hadn’t updated our brand; we hadn’t updated how we described ourselves. So this was a significant undertaking. [PIAA director of public relations and marketing] Eric Anderson and his team did a fantastic job of carrying out the rebranding effort, but it was made simpler because we were just trying to better articulate who the organization already was. As we framed it, certain things became apparent. At a time of dramatic change, it was also a good thing to provide the perception of a bigger tent for those who still think of us in the old vernacular of just physicians insuring physicians. What does PIAA stand for? Everyone on our staff, everyone on our board is now ready and able to collectively say that we are the insurance trade association that represents the entire MPL community who support the quality delivery of healthcare and the practice of medicine. That’s who we are. Probably 50 percent of the time, when we ask others that question, someone is going to say, “You mean you are the group whose members insure physicians.” Old perceptions die-hard. So, we understand the perception is not going to change right away. This is a situation where the brand is catching up with the reality of the organization. We are really excited to have this opportunity to convey our message a little more clearly and have a name and a brand that we can speak to. Of course, we are never going to forget our roots and the founders of this association. The physician component will always be a bedrock element of our organization as we take on a broader role in the evolving healthcare industry. As we addressed the question of whether or not to keep the name, use the acronym or come up with a whole new name, it was interesting how many of the organizations that are in our membership have already gone down this road. There are a lot of companies that have rebranded over the last 10 or 20 years. It takes a little while before the whole world starts referring to you by the new brand, but we’re sure that they will. We’re excited about that. MLM: Your answer reminds me of a conversation I had three weeks ago with Neil Morrell, the president of MagMutual in Atlanta. He said that when he came onboard in April of 2012, the first thing he did was sit down with his team to clearly define what they stand for and what drives what they do. BA: It’s oftentimes just a question of taking the time to step back, turn off the telephones and get your people together to ask, “Who are we?” That was one of the best parts about doing this rebranding. Our staff is about 20 people, and they were all involved in the process.   And I must say that taking this approach  reaffirmed my belief that sometimes it is the most junior people in your organization that have the clearest perception of who you are and what you do. The first day we spent a lot of time asking, “Who are our members? And who do we serve?” We settled on the wording, “We promote. We protect. We educate.” We thought we had it, but at the five o’clock hour, after a late afternoon break, the consultant we worked with came over and told me, “The new junior IT guy, Justin, made an observation that resonated with me. I’d like him to run it by you and the group.” Justin joined the organization only eight weeks earlier. He said, “It seems like a big part of what this organization does – from what I’ve learned so far – is you connect this industry.” We all sat there and realized, “Bing!” So now in everything promotional, you will see, “We promote, protect, educate and connect.” It is a big part of what PIAA has always done. Going back to the early days of PIAA, the purpose was exactly to connect the people who were providing medical professional liability insurance. Before the internet and all the technology that now links everyone together, PIAA literally brought people together to connect. And we still do.