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XL Insurance (Bermuda) Ltd. has announced a partnership with The Sullivan Group, a leading provider of clinical risk management and patient safety services for hospitals, doctors and nurses. XL and TSG anticipate serving more clients together as healthcare reform in the United States increases demands on healthcare providers. XLIB’s Wesly Guiteau and TSG’s founder, Dr. Daniel Sullivan, recently explained how the partnership will help hospitals mitigate and protect against risks.


What led XL and The Sullivan Group to seek this partnership in healthcare risk management?

Guiteau: XL’s objective was to partner with the best clinical loss prevention service provider available with a track record of success in helping hospitals improve their risk profile. TSG met those criteria. They have a proven track record of success with over 800 hospitals and more than 16,000,000 patient visits. We also wanted a service provider to match our unique underwriting platform.

Healthcare reform is bringing about greater utilization of the healthcare system, and that is going to impact the risk profile of most providers. For example, 30 million to 40 million individuals will gain access to health insurance without having any history of interaction with the healthcare system. Most healthcare providers want to see their patients’ medical history so they can treat them appropriately, but the risk profile of this pool of new insureds is as different as it is new.  That is a big challenge for healthcare providers, so it’s extremely important that they identify and mitigate the risks associated with this change. The Sullivan Group is very active in this area.

Our partnership with TSG will provide our clients with a variety of services from an enterprise risk management approach to specific clinical areas, such as labor and deliver, emergency medicine and others. The package also includes web based courses for all the clinicians on key risk issues. This is cutting edge and more comprehensive than any other products currently available in the medical malpractice insurance sector.

Sullivan: Our interest in partnering with XLIB stemmed from XL’s desire to provide hospitals with the best risk management services. We have a symbiotic relationship. TSG has been providing clinical risk management and loss control programs for over 16 years. Together, our offering can provide the most sophisticated risk management programs in the industry, and working together we can greatly assist hospitals and health care organizations reduce medical errors and improve patient safety.

What are some of the biggest drivers of clinical risk today?

Sullivan: Many of the biggest drivers of clinical risk today were prevalent even 30 years ago. There are some new opportunities and challenges including national quality initiatives, electronic health record regulations and the development of evidence-based practices. In primary care specialties, emergency and urgent care medicine, the biggest risk driver remains the failure to diagnose. In many instances, a deep dive is required to understand the many variables that result in a delay or failure to diagnose. TSG is focused on creating education and research related to the key contributors to ’failure to diagnose, such as human bias and certain cognitive issues. Not all practitioners are aware of the impact of human bias (i.e., heuristics) on clinical decision making, and so some may anchor early onto a diagnosis, and do not consider alternative possibilities. The cognitive issues include faulty memory, inadequate knowledge base and faulty judgment. In obstetrics, we often find issues relating to inadequate training and faulty judgment, such as Pitocin guidelines based on evidence that are not being followed. Another driver, inadequate communication, is consistently cited in summaries of adverse outcome events, such as inadequate informed consent and failure to maintain a team approach in patient handoffs, transfers and patient discharge after admission.

The rapid integration of electronic health records into medicine is having a dramatic impact on clinical care.  Although the large enterprise systems have been around for decades, we are at the very beginning stages of optimizing and aligning provider workflow with clinical decision support technology in medicine.  Electronic health records are a key part of the risk equation, but they are incomplete and have not yet adequately addressed workflow and decision support for the various medical specialties.   It’s the advent of a new day, and there is tremendous potential in reducing risk through appropriate development of the electronic medical record, bringing risk management and patient safety to the bedside. 

What is XL’s appetite for healthcare risk?

Guiteau: XL has been an active healthcare underwriter for the last 27 years; we have been active in the hospital market for a long time. Over the years, healthcare buyers’ philosophy on insurance capacity changed, and most now are diversifying their portfolio and retaining more of their own risks. We at XL are realigning our platform to meet current demand, and our partnership with The Sullivan Group is part of the strategy.

We believe there are a number of areas where we have the opportunity to bring XL’s focus on risk management to different segments of the healthcare marketplace and form more symbiotic relationships with clients. XL is looking to become a lead market for buyers and a market of choice for hospitals of varying sizes and risk profiles. We are broadening our risk appetite to include smaller hospital systems, community hospitals, single-state facilities -- the full range of health care providers.

What sets XL apart as a writer of healthcare risk?

Guiteau: We have an established record of service excellence. Prompt, efficient and amicable claims resolution and a flexible and innovative underwriting approach to risk transfer, plus a very strong balance sheet. These are valuable assets to healthcare buyers in this age of uncertainty.

How do XL and TSG see the healthcare risk landscape changing over the next 3-5 years?

Guiteau: Over the next few years, we will see a continuation or perhaps an acceleration of mergers and acquisitions; as various actors seek greater alignment with vendors, payers and other service providers. The end result will be fewer players but a fully integrated healthcare delivery model. The Affordable Care Act will continue to put a lot of emphasis on quality and safety, and the risk profile of many facilities will change for the better. But along with that, there will be far greater utilization of the healthcare system. The healthcare industry is in a transition period now but we foresee a much more accountable, service oriented healthcare system with stronger commitment to patient safety and quality.

Sullivan: One trend that has become evident over the past several years is the lack of focus on primary care – medical students are almost all going into specialties. There is a huge need for primary care, even more so following the Affordable Care Act.  Without filling the primary care need, we have noticed a dramatic increase in the development of free-standing urgent care centers. More patients are going to urgent care centers and free-standing emergency departments.  Where will the 30 million or so patients entering the healthcare system under the recent reforms go for care? We believe hospitals will be looking at that question, and their response in many cases will be to make mega-emergency departments. There are some interesting clinical risks related to that. The secondary response, hopefully, will be an increase in primary care access.

Another trend that we have noticed is the rapid employment of physicians by hospitals and health systems.   In the next 3 to 5 years, we anticipate this trend will continue, and the healthcare organization’s desire to integrate the physician staff will result in the centralization of clinical risk and liability.  At the same time, we are hearing from many hospitals that they are simply not prepared to manage physician risk. TSG recognized this phenomenon several years ago and in response, we began to partner with clinical champions across the spectrum of medicine to form the organizations in our RSQ® Collaborative.  This group meets frequently to discuss emerging patient safety and clinical risk issues in their specialty. To learn more about XL's product and to access The Sullivan Group's Newsletter, go here.


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Global Asset Protection Services, LLC, and its affiliates (“AXA XL Risk Consulting”) provides risk assessment reports and other loss prevention services, as requested. This document shall not be construed as indicating the existence or availability under any policy of coverage for any particular type of loss or damage. AXA XL Risk. We specifically disclaim any warranty or representation that compliance with any advice or recommendation in any publication will make a facility or operation safe or healthful, or put it in compliance with any standard, code, law, rule or regulation. Save where expressly agreed in writing, AXA XL Risk Consulting and its related and affiliated companies disclaim all liability for loss or damage suffered by any party arising out of or in connection with this publication, including indirect or consequential loss or damage, howsoever arising. Any party who chooses to rely in any way on the contents of this document does so at their own risk.

US- and Canada-Issued Insurance Policies

In the US, the AXA XL insurance companies are: AXA Insurance Company, Catlin Insurance Company, Inc., Greenwich Insurance Company, Indian Harbor Insurance Company, XL Insurance America, Inc., XL Specialty Insurance Company and T.H.E. Insurance Company. In Canada, coverages are underwritten by XL Specialty Insurance Company - Canadian Branch and AXA Insurance Company - Canadian branch. Coverages may also be underwritten by Lloyd’s Syndicate #2003. Coverages underwritten by Lloyd’s Syndicate #2003 are placed on behalf of the member of Syndicate #2003 by Catlin Canada Inc. Lloyd’s ratings are independent of AXA XL.
US domiciled insurance policies can be written by the following AXA XL surplus lines insurers: XL Catlin Insurance Company UK Limited, Syndicates managed by Catlin Underwriting Agencies Limited and Indian Harbor Insurance Company. Enquires from US residents should be directed to a local insurance agent or broker permitted to write business in the relevant state.