Debates about medical malpractice have recurring themes, with tort reformers emphasizing the threat that liability crises pose to the cost and availability of medical services and tort defenders emphasizing the importance of liability to medical quality, according to background information in the article. Effects on access to health care are of particular concern during "malpractice crises," when rising liability insurance premiums and uncertain coverage are said to induce physicians to avoid high-risk patients or procedures, relocate to other communities, or leave practice altogether. Even between such crises, however, malpractice climate remains one of many factors determining how many physicians enter the medical profession, what specialties they choose, and where they practice.
Daniel P. Kessler, Ph.D., J.D., of the Stanford University Graduate School of Business, Hoover Institution, and the National Bureau of Economic Research, Stanford, Calif., and colleagues investigated whether and how liability pressure affects long-term trends in physician supply from state to state. The researchers used data from the American Medical Association's Physician Masterfile on the number of physicians in active practice in each state for each year from 1985 through 2001, and matched this with data on state tort laws and state demographic, political, population, and health care market characteristics.
The researchers found that the adoption of "direct" malpractice reforms that reduce the size of awards (such as caps on damages) led to greater growth in the overall supply of physicians. Three years after adoption, direct reforms increased physician supply by 3.3 percent, controlling for fixed differences across states, population, states' health care market and political characteristics, and other differences in malpractice law. Direct reforms had a larger effect on the supply of nongroup vs. group physicians, on the supply of most (but not all) specialties with high malpractice insurance premiums, on states with high levels of managed care, and on supply through retirements and entries than through the propensity of physicians to move between states. Direct reforms had similar effects on less experienced and more experienced physicians.
(JAMA. 2005;293:2618-2625. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: This work was supported by the Project on Medical Liability in Pennsylvania funded by The Pew Charitable Trusts.
Editorial: Tort Reform and the Patient Safety Movement - Seeking Common Ground
In an accompanying editorial, Peter P. Budetti, M.D., J.D., of the University of Oklahoma Health Sciences Center, Oklahoma City, discusses the studies on defensive medicine and tort reform in this week's issue of JAMA.
"Perhaps the foremost lesson emerging from the work of Studdert et al and Kessler et al is that medicine's 30-year pursuit of piecemeal tort reform has had some results, but not all the consequences have been positive and serious problems with the quality of medical care have not been ameliorated. While some physicians apparently prefer to practice in states that have enacted certain liability law changes, the tort system still seems to engender perverse behaviors such as widespread, sometimes serious, and often costly deviations from accepted medical practice, and internal self-monitoring by the medical profession evidently permits such behavior to occur on a large scale. Most important, the pattern of tort reforms pursued to date has not led to innovative legal approaches that serve both the profession and patients by tying liability law restructuring to systemic, evidence-based changes in medical practice that ensure adherence to not deviate from good medical care."
"What is needed is to link new approaches to legal accountability with mandatory active participation in advanced, systematic measures to ensure high-quality care. Plaintiffs' attorneys, physicians, and patient safety proponents need to work toward achieving their stated central motivation (i.e., protecting patients from medical errors and fairly compensating the unfortunate few who nevertheless sustain avoidable injuries). Even as states continue to reform tort law and the patient safety movement makes progress toward its goals, health care generates large numbers of avoidable injuries from medical errors--most of which the legal system fails to compensate. Regardless of how fanciful this may sound in the face of entrenched contrary experience, now is the time for the disparate and opposing forces to find a way to focus together on 'the large number of patients who die unnecessarily each year from medical errors' rather than a continuance of actions reflecting the visceral antipathy of many physicians and lawyers to one another," Dr. Budetti writes. (JAMA. 2005;293:2660-2662. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: Dr. Budetti is serving as a paid expert in a lawsuit against a number of health maintenance organizations in which his contribution is focused on issues related to medical necessity and also is performing malpractice-related research funded by the Henry J. Kaiser Family Foundation.
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