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Medical Experts Learning to Live with Medco 2018 - Dr Mark Burgin

22/06/18. Dr Mark Burgin considers the main challenges facing Medco dealing with medical experts and suggests possible solutions from the point of view of a medical expert.

Medco has been highly successful and pioneered the use of business techniques such as criteria, metrics and randomisation in a legal field and has improved many aspects of PI.

Medco delivers against the Government's policy objectives and aims to ensure high standards of professional conduct to maintain confidence in the MedCo Service.

The IT system has successfully disrupted unhealthy relationships between experts and their instructing parties and ensured that experts have passed an examination.

Medco has provided a forum where poor practice can be discussed and appropriate steps are taken to resolve the issues with warning letters and sanctions.

Medco recognised the differences between high volume and regional MROs and took an inclusive approach by running two tiers in parallel.

Medco has not considered whether PI requires more than one type of medical expert to provide a comprehensive service that can reach rural communities and deal with unusual cases.

The MedCo Mandatory Accredited Training was highly successful in setting a benchmark for expertise in personal injury but created a two-tier system of experts.

Alienation of those experts who have not undergone the training was seen as a necessary evil but the distance between the two groups has been growing larger.

The lack of a medical expert representative on the board and reluctance to commission views from experts has led to persisting conflicts of interest.

Medco has also had problems with cost containment partly due to complex audit process but also the failure to obtain high level IT competence.

The main challenges to Medco are conflicts of interest in their panel, recognising different services that PI experts provide to the industry and the cost of running the Medco system.


Different experts for different roles

You can have high quality, rapid service and low cost but you cannot have all three so experts vary in their business model depending on their individual skills and strengths.

High volume experts and moderate volume experts are different from each other in more ways than simply the number of claimants that they see.

High volume experts typically work in large urban areas with frequent clinics and produce a simplified standardised product that allows solicitors to streamline their processes.

They often use assistants to collect data and have ten-minute appointments completing the report during the consultation so that they can meet the MRO’s SLAs.

Moderate volume experts typically work in multiple clinics in semi-rural areas or on the edges of large urban areas and take on the more complex or specialised cases which take more time.

They usually take more notes during the examination and will complete the medical report in stages over the next few days or even a week or two in complex cases.

The moderate volume experts are more likely to have claimants that travel further than 30 miles to reach the expert although the distance would be less than the nearest large urban area.

They may have developed a broader expertise (e.g. children, LVI, psychological, disability) and are less likely to recommend a separate report for every injury.

Without high volume experts able to work long hours at speed waiting times would increase and without moderate volume experts less claims would be concluded proportionately.

Recognising that diversity has benefits and ‘different’ does not mean worse will help Medco devise criteria that value the contributions of all types of experts.


Conflicts of interest

Medco’s problems with conflict of interest appear to arise inter alia from difficulties that the board has had with defining its role as evidenced by its own words.

“It is not MedCo’s function to interpret the Civil Procedure Rules [CPR], neither does MedCo have the power to intervene in breaches of the relevant rules, directions and guidance.”

“MedCo recognises that this is a rapidly evolving market and that some aspects of behaviour may undermine the original policy intention and takes misuse of the system seriously.

As such, if you have concern about either another MedCo user or the way in which the system is working please complete the feedback form and submit it to This email address is being protected from spambots. You need JavaScript enabled to view it. .”

It is difficult to see how Medco will achieve its purpose if it cannot intervene when an expert is instructed to interfere with the fair and efficient processing of a case.

Long-term it is impractical for Medco to micromanage recurrent disputes, but investigations could be used as a basis for guidance and recommendations for the MROs and experts.

Medco could usefully liaise with the relevant regulatory body(ies) on behalf of the industry where further clarification is required on a particular point e.g. solicitors asking for longer prognoses.

Statistics generated automatically and pseudonymised reduces outlier behaviours e.g. claimants in a day, distance travelled, average prognosis, number of instructions, length of examinations.

When addressing issues around experts an independent report from a senior expert would avoid conflicts and increase cooperation and reduce the risk of further disenfranchisement.


Increasing costs

Medco has used a high cost approach both for auditing the MROs and within its structure (there are Board Subgroups on Education and Training, Operations, Audit, IT and Expert and Peer Review).

Maintaining the difference between tier one and tier two MROs will continue to be a large cost for Medco as the difference in profit between the two tiers is large.

High volume MROs could provide operational data in real time with creating the system to provide this information being part of tier one MRO criteria.

Medco would then have killed two birds with one stone, the MROs who can provide the data and the system would reduce Medco’s audit costs.

The cost of inspecting every medical expert in the way outlined by the agreement will need a doubling or more of the budget and would take too many years to make the process effective.

The alternative is to focus on audits of medical reports and qualitative data from solicitors and MROs to provide an overview of all expert’s performance.

This information would give the Medco audit team a short list of experts who can be targeted for prompt action at much lower costs.

It is important to get experts to buy into the idea of their reports being regularly audited as most experts have never received any feedback on their reports.

I recommend that audits are performed on an anonymised report by an expert independent of the MRO and the expert and scored in a systematic way with detailed recommendations.

This way the audits could support further training and be evidence for the professional appraisal process which all professionals have to undertake and the results could be uploaded to Medco.


Conclusions

This article has reflected both the successes and challenges of a quasi-governmental organisation working to regulate lawyers and medical professionals.

Medco has developed the reputation of an open and powerful influencer in personal injury litigation and its decisions are respected and backed up in the courts.

For an organisation that has grown rapidly from a standing start in 2015 its performance has not come without some growing pains but it has been successful.

This is the right time to reassess the situation and plan to build for the future by identifying the key challenges and finding solutions.

This article has considered the issue of conflict of interest and the danger of damage to Medco’s reputation if systems that can be used independently are not created.

Alienation of groups of experts needs addressing as Medco risks spiralling costs if visits from Medco are seen as synonymous with Medco wanting to remove the expert.

Two methods have been suggested – an audit process independent of MROs and containing detailed advice that can support the expert’s training.

Recognising the strengths of high volume expert and the importance of these workhorses in delivering a large bulk of reports means they need to be assessed differently from other experts.

The medium volume expert who may provide regular clinics in underserved locations or has special skills may be important to the PI industry in a different way.

One thing that few disagree upon is the need to contain costs and there is a need to find less time intensive approaches to monitoring performance.

In conclusion I believe that Medco is trying to future proof medical experts and the PI industry by improving standards and encouraging professional behaviour.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted for audits on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

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