Public and Private Options in Practice: The Military Health System.

Recent debates over health care reform, including in the context of the Military Health System (MHS) and Veterans Administration, highlight the dispute between public and private provision of health care services. Using novel data on childbirth claims from the MHS and drawing on the combination of plausibly exogenous patient moves and heterogeneity across bases in the availability of base hospitals, we identify the impact of receiving obstetrical care on versus off military bases. We find evidence that off-base care is associated with slightly greater resource intensity, but also notably better outcomes, suggesting marginal efficiency gains from care privatization.

Investing in Ex Ante Regulation: Evidence from Pharmaceutical Patent Examination.

We explore how the Patent Office may improve the quality of issued patents on "secondary" drug features by giving examiners more time to review drug-patent applications. Our findings suggest that current time allocations are causing examiners to issue low quality secondary patents on the margin. To assess the merits of expanding ex ante scrutiny of drug-patent applications at the agency, we set forth estimates of the various gains and losses associated with giving examiners more time, including reduced downstream litigation costs and added personnel expenses, along with both the static gains and dynamic innovation losses associated with earlier generic entry.

Malpractice Liability and Health Care Quality: A Review.

IMPORTANCE: The tort liability system is intended to serve 3 functions: compensate patients who sustain injury from negligence, provide corrective justice, and deter negligence. Deterrence, in theory, occurs because clinicians know that they may experience adverse consequences if they negligently injure patients. OBJECTIVE: To review empirical findings regarding the association between malpractice liability risk (ie, the extent to which clinicians face the threat of being sued and having to pay damages) and health care quality and safety. DATA SOURCES AND STUDY SELECTION: Systematic search of multiple databases for studies published between January 1, 1990, and November 25, 2019, examining the relationship between malpractice liability risk measures and health outcomes or structural and process indicators of health care quality. DATA EXTRACTION AND SYNTHESIS: Information on the exposure and outcome measures, results, and acknowledged limitations was extracted by 2 reviewers. Meta-analytic pooling was not possible due to variations in study designs; therefore, studies were summarized descriptively and assessed qualitatively. MAIN OUTCOMES AND MEASURES: Associations between malpractice risk measures and health care quality and safety outcomes. Exposure measures included physicians' malpractice insurance premiums, state tort reforms, frequency of paid claims, average claim payment, physicians' claims history, total malpractice payments, jury awards, the presence of an immunity from malpractice liability, the Centers for Medicare & Medicaid Services' Medicare malpractice geographic practice cost index, and composite measures combining these measures. Outcome measures included patient mortality; hospital readmissions, avoidable admissions, and prolonged length of stay; receipt of cancer screening; Agency for Healthcare Research and Quality patient safety indicators and other measures of adverse events; measures of hospital and nursing home quality; and patient satisfaction. RESULTS: Thirty-seven studies were included; 28 examined hospital care only and 16 focused on obstetrical care. Among obstetrical care studies, 9 found no significant association between liability risk and outcomes (such as Apgar score and birth injuries) and 7 found limited evidence for an association. Among 20 studies of patient mortality in nonobstetrical care settings, 15 found no evidence of an association with liability risk and 5 found limited evidence. Among 7 studies that examined hospital readmissions and avoidable initial hospitalizations, none found evidence of an association between liability risk and outcomes. Among 12 studies of other measures (eg, patient safety indicators, process-of-care quality measures, patient satisfaction), 7 found no association between liability risk and these outcomes and 5 identified significant associations in some analyses. CONCLUSIONS AND RELEVANCE: In this systematic review, most studies found no association between measures of malpractice liability risk and health care quality and outcomes. Although gaps in the evidence remain, the available findings suggested that greater tort liability, at least in its current form, was not associated with improved quality of care.

The effect of malpractice law on physician supply: Evidence from negligence-standard reforms.

We explore whether the composition of the physician workforce is impacted by the clinical standards imposed on physicians under medical liability rules. Specifically, we explore whether the proportion of non-surgeons practicing in a region decreases-and thus whether the proportion of surgeons increases-when liability standards are modified so as to expect that physicians practice more intensively. For these purposes, we draw on a quasi-experiment made possible by states shifting from local to national customs as the basis for setting liability standards. Using data from the Area Health Resource File from 1977 to 2005, we find that the rate of non-surgeons among practicing physicians decreases by 2-2.4 log points (or by 1.4-1.7 percentage points) following the adoption of national-standard laws in initially low surgery-rate regions-i.e., following a change in the law that effectively expects physicians to increase their use of surgical approaches.

Review of Neurosurgery Medical Professional Liability Claims in the United States.

BACKGROUND: Due to disparaging costs and rates of malpractice claims in neurosurgery, there has been significant interest in identifying high-risk specialties, types of malpractice claims, and characteristics of claim-prone physicians. OBJECTIVE: To characterize the malpractice claims against neurosurgeons. METHODS: This was a comprehensive analysis of all malpractice liability claims involving a neurosurgeon as the primary defendant, conducted using the Physician Insurers Association of America Data Sharing Project from January 1, 2003 and December 31, 2012. RESULTS: From 2003 to 2012, 2131 closed malpractice claims were filed against a neurosurgeon. The total amount of indemnity paid collective between 1998 to 2002, 2003 to 2007, and 2008 to 2012 was $109 614 935, $140 031 875, and $122 577 230, respectively. Of all the neurosurgery claims, the most prevalent chief medical factor was improper performance (42.1%, $124 943 933), presenting medical condition was intervertebral disc disorder (20.6%, $54 223 206), and operative procedure performed involved the spinal cord and/or spinal canal (21.0%, $62 614 995). Eighty-five (22.91%) of the total neurosurgery claims resulted in patient death, resulting in $32 067 759 paid. Improper performance of the actual procedure was the most prevalent and highest total paid cause for patient death ($9 584 519). CONCLUSION: From 2003 to 2012, we found that neurosurgery malpractice claims rank among one of the most costly and prevalent, with the average indemnities paid annually and the overall economic burden increasing. Diagnoses and procedures involving the spine, along with improper performance, were the most prevalent malpractice claims against neurosurgeons. Continued medical malpractice reform is essential to correct the overall health care cost burdens, and ultimately improve patient safety.