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ReformingMedicalLiabilityConventionalApproachesandBeyondRandallR.Bovbjerg,J.D.(Bó-berg)TheUrbanInstitute

††Standarddisclaimerapplies1Who’sMissing?PatientsPayers2“RoadMap〞ofTalkAbitofhistoryProblemstoday:insurance“crisis,〞safetyCausesandimplicationsConventionalsolutions,mainlytortreformMorefundamentalchangestoimprovecompensationandsafety3ABitofHistorySeriesofcrisesthathavechangedindustryTwolesserknowncrisesin50s&60s:risingclaims,thenbetterrating,medicalsocietyplansFirstnationalcrisisinmid-70s:higherclaims,availabilityproblems,mutualsenter,tortreformSecondinmid-80s:higherclaims,affordability,otherlinestoo,shifttoclaims-made,tortreformThirdfromY2K:describedbelowRegulationbystates―solvency&rates exception:FederalRiskRetentionAct‘81,‘86.4LatestInsuranceCrisisInsurerwithdrawal,retrenchmentPriceincreasesandselectiveunderwriting;variesbystateBigforsomeMD’s,can’tpassthroughLimitedaccessproblems―high-riskprovidersinhigh-riskregions,perhapslong-termshifts5TrendsinPhysicianPremiumsSource:CBOanalysisofMedLiabilMonsurveys6FactorsUnderlyingRiseLawyerssayit’sallinsurancecycle,interestratesandinsurermisbehaviorDoctorsandinsurersagreethere’scycle,buttrendinclaimspayoutswentupinmid-90sinsomestates,claimsupreinsuranceupBothpartlyright,doctors/insurersmore7Crises:Cycles&CostsUnderlyingtrendin“true”claimsandothercostsSuperimposedpricefluctuationfromcompetitivecycle$$$$$$Time8Problems&ImplicationsMaincostofmalpracticeinsuranceismalpracticeclaims[Duh]Interestearningshaveeffectbecausethey’reanegativecostbutdon’tdrivecycleCrisisseemstobeabating,not“normalcy〞BigdifferencesacrossStates,evenwithinState9NationalMalpracticeCostsTotalPhysiciansSource:Tillinghast(2004)$billions10PotentialSolutionsToday’stopthree:tortreform,tortreform,andtortreformInsurancemarketinterventions,othernear-termreformsBroaderreforms―replacepartorallofcurrentliabilitysystem11Conventional“TortReforms〞Goals:insuranceavailability,affordabilityLegalcutbacksCapsonawards,shortertimestosue,nodoublerecovery,cutattorneyfees,etc.Worktocutclaimscosts,alsopremiums;calmsinsurancemarkets(somewhat)As“takeaways,〞facechallengesincourtImproveinsuranceperformanceSometimesaddqualityorsafetyregulation12CapsAreCenterpieceDesigntotalaward,only“painandsuffering〞Doctorsonlycapsaremorethan“band-aids〞Lawyersunconstitutional,theworsthurtarehurtworstInsurerslikecaps,tradepremiumvolumeforclaimspredictabilityScorecardinabout1/2ofStates,pushfornational13CaliforniaMICRA&FederalBillsOtherprovisionsPeriodicpaymentsSlidingscaleforattorneyfeesMultipledefendantspaybypercentageofresponsibilityCA90-daynoticeofclaim,physiciandisciplineFederalPunitivedamagelimits,drug/deviceprovisions,asbestosreforms,classactionreform“Bigthree〞$250Kcaponpain&sufferingCollateralsourceoffsetShortertimetosueMICRA=MedicalInjuryCompensationReformActof1975Federal,HR4600&successors,administrationproposalsN.B.FederalbillwouldaltertraditionalFederal/Staterolesinthisfield14InsuranceChanges―PublicRegulation/antitrust(lawyers’preferences)StateprovisionofinsuranceInsureroflastresort―JointUnderwritingAssociationHigh-endrisk―PatientCompensationFundorreinsuranceSomesubsidiesofphysicianpremiumsOldNYrequirementthathospitalsprovidetoplayerPAforcatastrophiccoverageMDsubsidy―endedHMOsexemptionfrompremiumtax15InsuranceChanges-PrivateAlternativeRiskMechanisms(ARMs)Mainlyhospitals,seemmorecommonthiscrisisHospital-physiciancollaborationMaysubsidizerates―starkissues“Channeling〞programsatacademicmedicalcentersBroaderhospital-physiciancollaborationcould:Createnewriskpool,withpositiveattributesSaveoninvestigation,defensePromptnewmodeofcooperationonsafetyMultistatearrangements?16What’sMissing?Moreeven-handedness,notjusttakeawaysMajorunderperformanceoflaw’s3keygoals:CompensationDeterrenceJusticeThesearepersistentproblems,notcrisesHereafter,possiblealternativestoCA’sMICRAandproposednationalmega-MICRA17KeyGoal1:FairerCompensation“It’satreasuremap〞18KeyGoal2:Better“Signals〞/Safety“It’sfrommyattorney.〞19FiveAlternativesAkintoconventionalreformMoreeven-handedliabilityreformsBroaderreforms,aimatallmedicalinjuriesRadicaldisclosure,full“transparency〞Reward(only)disclosurewithtortreformTrialrunforadministrativecompensationsystemCreateadvancelistsof“avoidableclassesofevents〞201.MoreEven-HandednessWithincurrentsystemImproveliabilityprocess,notjustprospectsforonepartyorotherAddressspecificproblemsUnpredictable/inaccurateliabilitydeterminationsUnpredictablepayouts,notjustintangiblesbutalsofuture“economic〞losses,discountrates21ElementsofImprovementExpertwitnessesNotjust“tighter〞qualifications(e.g.,<20%ofincome)butalsoavailability,objectivityEvidence-basedmedicine?Capsotherthanflat,one-size-fits-all“Stacked〞caps,slidingscales,orrangesRoutinizeelementsoffuturelossdeterminationsImprovelegalperformanceMoreactivejudicialmanagement,trackingofdata(timeliness,costs,awards,lawyers’performance)22WhyDoMoreThanThis?Tapintonewcapabilitiesin“patientsafety〞Fixtheproblem,nottheblameRegulation,punishmentcanhelp,butfallshort“Surface〞problems,analyze,changeprocesses,monitor,repeatEarlysuccessesinmedicineBUTfearofblameandliabilitykeepsproblemshidden(andclaims,too)232.GreaterTransparencyMore“transparent〞disclosuretopatientsRisksbeforethefact,unanticipatedoutcomesafterRemediation,settlementofferMotivationsTreatpatientsethicallyImprovetrust,cutlitigiousnessEaseproviders’malpracticefearsFacilitatesystemicimprovements24GreaterTransparency,cont’dManysayingthisshouldhappen,includingAMA,JointCommissiononAccreditationofHealthcareOrganizationActualpracticelessclear,manysaytheydoMaybegoodbusiness/liabilitystrategySomeindicationfromVAthatit’sfiscallyfeasibleIncreasinglybecomingconventionalwisdomMayhelpsafetyanalysis,tooFearsmaylinger253.Early-OfferReformDefendantspromptlyofferingtopayfutureout-of-pocketlossescannotbesuedforpainandsufferingPlusesRewardsfastdisclosure,potentiallyincreases##MuchfasterandloweroverheadAssuresfundsforfutureneedsNocomplexchangestolaworliabilityinsuranceMinusesMaybe“gamed〞―onlyofferforbigcasesLawyershate,insurersuneasyaboutongoingrisk26NewSystems“Wewouldliketorequestachangeinvenuetoanentirelydifferentlegalsystem.〞274.AdministrativeCompensationCoverpreventableinjuries(notfull“nofault〞),controlpayoutsSimilartoWorkersCompensation,othernationsPlusesFiscalincentivesforsafetypractices,dataHighspeed,lowoverhead,moreconsistencyMinusesHardtolegislateasgoodpackage―cf.no-faultautoStilldependentonclaimsbroughtbypatientsNotwell-groundedinoperationsofmedicalentities28AdminComp,cont’dEvidencefromVAandFLbirth-relatedneurologicalinjurycompensationSuccesses:feasibletorunprogramwithonelistedeventmaintainedaccesstoobstetricianliabilityinsurancecutOBs’premiums2.5timesbelowtrend settlesin1/3time,1/5theadministrativecostscomparablecompensation,satisfactionBut:toosmall,somevariabilityinapplicationpoliticalandlegalattacks295.ACEs&ProviderGroupsListpreventableinjuriesinadvanceasACEs(avoidableclassesofevents)Paystructureddamagesautomatically,likedisabilityinsurance,withoutliabilityprocessResolvedisputes,othercasesthroughnonjudicialprocess30ACEs,cont’dImplementthroughprivatecontractprovider-patientcontractsemployer/healthplan-enrolleecontract(akintoKaisermandatedarbitrationbutwithnewrules)potentialforchoiceattimeofservice,PPOmodelNatureofoversightanopenissue(sanctionedbyState,inIOMmodel)Couldalsobeusedtopromotecase-finding,resolutionunderotherreforms 31ACEs,cont’dEvidencefromresearchlistingsarefeasiblewouldcoveralotofcurrentsystem(1/2hospitalOBcasesbut3/4of$$)Potentialisgreatbutunproven;needdemonstrationinwillinglocale 32NeedStateExperimentationProposedNovember2002inIOMreporttoDHHSNonjudicial,patient-centered,safety-friendlynewinjuryresolutionsystemFederallia