Effect of Increasing Malpractice Insurance Cost and Subsequent Practice of Defensive Medicine on Out-of-Hospital Birth Rates in the United States.

BACKGROUND: Across the United States, the burden of malpractice litigation has influenced obstetricians and obstetric institutions to avoid high-risk patients, favor cesarean delivery, and decrease availability of trial of labor after cesarean. Recently, the United States has experienced an increase in out-of-hospital (OOH) births. OBJECTIVE: The main purpose of this article is to investigate the association between malpractice insurance premium (MIP) and OOH births in the United States from 2000 to 2014. STUDY DESIGN: We analyzed changes in OOH birth rates and MIP from 2000 to 2014 using birth data from the National Vital Statistics System and Medical Liability Monitor's annual survey, respectively. The change in OOH birth rates was then compared with the change in MIP. RESULTS: Between 2000 and 2014, there has been approximately 60% increase in MIP from national average of $40,949 to $65,210 (p < 0.05). OOH births increased 57% from 39,398 births to 59,674 births (p < 0.05). There was a significant positive correlation between increase in MIP and increase in OOH births (p < 0.05, R 2 = 0.14). CONCLUSION: MIP and OOH birth rates have a significantly associated increase from 2000 to 2014. Given that malpractice climate affects other aspects of obstetric practice, we cautiously propose that increasing MIP may be associated with an increase in OOH births.

Rethinking the Obvious: Time for New Ideas on Medical Malpractice Tort Reform.

States have engaged in medical malpractice litigation reforms over the past 30 years to reduce malpractice insurance premiums, increase the supply of physicians, reduce the cost of health care, and increase efficiency. These reforms have included caps on noneconomic damages and legal procedural changes. Despite these reforms, health care costs in the United States remain among the highest in the world, provider shortages remain, and defensive medicine practices persist. The purpose of this study was to determine how successful traditional medical malpractice reforms have been at controlling medical costs, decreasing defensive medicine practices, lowering malpractice premiums, and reducing the frequency of medical malpractice litigation. Research has shown that direct reforms and aggressive damage caps have had the most significant impact on lowering malpractice premiums and increasing physician supply. Out of the metrics that were improved by malpractice reforms, similar improvements were shown because of quality reform measures. While traditional tort reforms have shown some targeted improvement, large-scale, system-wide change has not been realized, and thus it is time to consider alternative reforms.

Defensive medicine among neurosurgeons in the Netherlands: a national survey.

OBJECTIVE: In defensive medicine, practice is motivated by legal rather than medical reasons. Previous studies have analyzed the correlation between perceived medico-legal risk and defensive behavior among neurosurgeons in the United States, Canada, and South Africa, but not yet in Europe. The aim of this study is to explore perceived liability burdens and self-reported defensive behaviors among neurosurgeons in the Netherlands and compare their practices with their non-European counterparts. METHODS: A survey was sent to 136 neurosurgeons. The survey included questions from several domains: surgeon characteristics, patient demographics, type of practice, surgeon liability profile, policy coverage, defensive practices, and perception of the liability environment. Survey responses were analyzed and summarized. RESULTS: Forty-five neurosurgeons filled out the questionnaire (response rate of 33.1%). Almost half (n = 20) reported paying less than 5% of their income to annual malpractice premiums. Nearly all respondents view their insurance premiums as a minor or no burden (n = 42) and are confident that in their coverage is sufficient (n = 41). Most neurosurgeons (n = 38) do not see patients as "potential lawsuits". CONCLUSIONS: Relative to their American peers, Dutch neurosurgeons view their insurance premiums as less burdensome, their patients as a smaller legal threat, and their practice as less risky in general. They are sued less often and engage in fewer defensive behaviors than their non-European counterparts. The medico-legal climate in the Netherlands may contribute to this difference.

Defensive medicine and outcomes for medical malpractice liability.

Defensive medicine is a significant force driving the high costs of healthcare systems and has a substantial influence on physicians' behavior because they primarily concern about malpractice liability and not patient's health protection. This attitude disagrees with deontological duties and could impair physicians' ability of judgment and clinical reasoning. Reducing defensive medicine also could mean improving the quality in healthcare systems and eliminating unnecessary costs.

Defensive medicine in the emergency department: increasing health care costs without increasing quality?

Defensive medicine is taxing our health care system more and more each year. Emergency departments are at more risk of malpractice claims due to their quick pace, lack of patient-physician relationship, and patient expectations and demands. It can be assumed that this results in unnecessary, expensive care. There are health risks and monetary and emotional consequences that result from the use of defensive medicine. Eradication of defensive medicine can begin with the use of evidence-based medicine and by ensuring that hospital policies and procedures are followed.

Opportunities for cost reduction of medical care: part 3.

The level of health care spending in the United States and other developed nations is rising at a disturbingly rapid rate. However, in the United States, these increases are not justified by superior performance. Rather, most other wealthy countries' inhabitants live longer and suffer from fewer medical problems than the average American. This paper demonstrates the continued abundance of opportunities for substantially reducing health care costs without decreasing the quality of care. In particular, it emphasizes the need to reduce the practice of defensive medicine and to enlarge the cadre of non-specialist physicians who educate future doctors. Such cost-saving opportunities are not rare phenomena but are widely available and offer the United States opportunities to move toward the markedly lower cost levels that have been achieved in other countries.

The current state of health care reform: the physicians' burden.

Congress has passed expansive legislation to "fix" health care. US health care, however, is not "broken"; rather, it functions according to purpose. The legal standard sets health care's purpose as high-quality care, not care at a pervasive quantity or low cost. Juries focus on quality irrespective of cost, and the court's concern is not cost but whether the defendant physician has met the standard of care. As the US health system does deliver high-quality (albeit high-cost) care, it is not broken; instead, the system that defines it is broken. The legal system defines the standard of care as the care that an average physician would deliver under similar circumstances. As 91% of physicians admit to practicing defensively excessive care, the legal care standard is therefore excessive care. However, the new health care legislation passed by Congress does not address tort reform. Instead, it reduces physician remuneration and increases penalty-driven cost care control regulations. Caught between a care standard that demands high quality regardless of cost and penalty-driven federal mandates demanding low-cost care regardless of the legal care standard, physicians bear the new law's ultimate burden. US health care should not continue to focus on quality over cost and quantity; more important, the law should not continue to dictate that it do so. Rather, the system must import cost-effective care, and the law must so direct. To reduce health care costs, the legal system must first recognize a standard of care that respects cost-or tort reform that protects those physicians who do.

Diagnostic imaging rates for head injury in the ED and states' medical malpractice tort reforms.

OBJECTIVE: Physicians' fears of being sued may lead to defensive medical practices, such as ordering nonindicated medical imaging. We investigated the association between states' medical malpractice tort reforms and neurologic imaging rates for patients seen in the emergency department with mild head trauma. METHODS: We assessed neurologic imaging among a national sample of 8588 women residing in 10 US states evaluated in an emergency setting for head injury between January 1, 1992, and December 31, 2001. We assessed the odds of imaging as it varied by the enactment of medical liability reform laws. RESULTS: The medical liability reform laws were significantly associated with the likelihood of imaging. States with laws that limited monetary damages (odds ratio [OR], 0.63; 95% confidence interval [CI], 0.40-0.99), mandated periodic award payments (OR, 0.64; 95% CI, 0.43-0.97), or specified collateral source offset rules (OR, 0.62; 95% CI, 0.40-0.96) had an approximately 40% lower odds of imaging, whereas states that had laws that limited attorney's contingency fees had significantly higher odds of imaging (OR, 1.5; 95% CI, 0.99-2.4), compared to states without these laws. When we used a summation of the number of laws in place, the greater the number of laws, the lower the odds of imaging. In the multivariate analysis, after adjusting for individual and community factors, the total number of laws remained significantly associated with the odds of imaging, and the effect of the individual laws was attenuated, but not eliminated. CONCLUSION: The tort reforms we examined were associated with the propensity to obtain neurologic imaging. If these results are confirmed in larger studies, tort reform might mitigate defensive medical practices.

Effect of fear of litigation on obstetric care: a nationwide analysis on obstetric practice.

The aim of our study was to investigate the influence of malpractice premiums paid by obstetricians on obstetric care across the United States. We conducted a retrospective cross-sectional population-based study using patient-level data obtained from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample on every woman who delivered in 2006. Mode of delivery was compared with the average state medical liability insurance premium paid by obstetricians (Medical Liability Monitor and the National Association of Insurance Commissioners) using a generalized estimating equation to calculate crude and adjusted odds ratios. Our cohort included 890,266 women who delivered across 37 states in 2006. Average state malpractice premium of over $100,000 was associated with higher incidences of total cesarean deliveries (odds ratio [OR] 1.17, 95% confidence interval [CI]: 1.02, 1.35); lower incidences of vaginal births after cesarean deliveries (OR 0.60, 95% CI: 0.37, 0.98); and lower rates of instrumental deliveries (OR 0.72, 95% CI: 0.63, 0.83) compared with when the average state malpractice premium was less than $50,000. Fear of litigation appears to have a marked effect on obstetric practice, particularly total cesarean delivery, vaginal birth after cesarean, and instrumental delivery, when malpractice premiums rise above $100,000 per annum.

Defensive medicine, cost containment, and reform.

The role of defensive medicine in driving up health care costs is hotly contended. Physicians and health policy experts in particular tend to have sharply divergent views on the subject. Physicians argue that defensive medicine is a significant driver of health care cost inflation. Policy analysts, on the other hand, observe that malpractice reform, by itself, will probably not do much to reduce costs. We argue that both answers are incomplete. Ultimately, malpractice reform is a necessary but insufficient component of medical cost containment. The evidence suggests that defensive medicine accounts for a small but non-negligible fraction of health care costs. Yet the traditional medical malpractice reforms that many physicians desire will not assuage the various pressures that lead providers to overprescribe and overtreat. These reforms may, nevertheless, be necessary to persuade physicians to accept necessary changes in their practice patterns as part of the larger changes to the health care payment and delivery systems that cost containment requires.

The fear factor. Malpractice reforms haven't done much to end defensive medicine and the costs it adds to the system.

The latest flurry of research seems to show that malpractice reforms haven't done much to stop defensive medicine. The solution depends on whom you ask. "The focus ought to be on preventing medical errors--and not on taking away people's rights and capping their damages once they've been injured," says Todd Smith, left, of the Illinois Trial Lawyers Association.

The problem of defensive medicine.

Defensive medicine--the use of diagnostic and end-treatment measures explicitly for the purposes of averting malpractice suits--is frequently cited as one of the least desirable effects of the current rise in medical litigation. Many physicians and policy-makers claim that defensive medicine is responsible not only for the increasing costs of health care but the exposing of patients to significant risks of harm from unnecessary procedures. Very little solid information is available about defensive medicine. The studies that have been conducted have been fraught with statistical difficulties and are by no means definitive. Even more important than the issue of defensive medicine is the more basic problem of our system of compensation for medical injuries.

Is there empirical evidence for "Defensive Medicine"? A reassessment.

Proponents of tort reform applied to medical malpractice argue for change partly on the premise that the threat of lawsuits has made medical care more costly. Using U.S. longitudinal data from the National Long-Term Care Survey merged with Medicare claims and other data for 1985-2000, this study assesses whether tort reforms have reduced Medicare payments made on behalf of beneficiaries and the survival probability following an index event. Direct reforms (caps on damages, abolition of punitive damages, eliminating mandatory prejudgment interest, and collateral source offset) did not significantly reduce payments for Medicare-covered services in any specification. Indirect reforms (limitations on contingency fees, mandatory periodic payments, joint-and-several liability reform, and patient compensation funds) significantly reduced Medicare payments only in a specification based on any hospitalization, but not in analysis of hospitalization for each of four common chronic conditions. Neither direct nor indirect reforms had a significant effect on the health outcomes, with one exception. The overall conclusion is that tort reforms do not significantly affect medical decisions, nor do they have a systematic effect on patient outcomes.