Trends: Effects of the malpractice crisis on access to and incidence of high-risk procedures: Evidence from Florida - Will the recent upsurge in malpractice premiums drive obstetricians and neurosurgeons away from "crisis states"?

Health Affairs

Volumn 24, Issue 3, 2005, Pages 802-810

  Dranove, David ^a   Gron, Anne ^b  

^a NORTHWESTERN UNIVERSITY   (United States)

^b NORTHWESTERN UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CONTROLLED STUDY; CRANIOTOMY; DELIVERY; HEALTH CARE ACCESS; HUMAN; INCIDENCE; MALPRACTICE; NEUROSURGERY; OBSTETRICS; PATIENT CARE; PHYSICIAN ATTITUDE; RISK ASSESSMENT; SURGICAL RISK; UNITED STATES; ECONOMICS; FEMALE; HEALTH CARE DELIVERY; INSURANCE; MALE; MANPOWER; OBSTETRIC OPERATION; PREGNANCY; RISK; STATISTICS; UTILIZATION REVIEW;

FEMALE; FLORIDA; HEALTH SERVICES ACCESSIBILITY; HUMANS; INSURANCE, LIABILITY; MALE; MALPRACTICE; NEUROSURGERY; OBSTETRIC SURGICAL PROCEDURES; OBSTETRICS; PREGNANCY; RISK;

EID: 20044375799     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.24.3.802     Document Type: Article

References (20)

1. American Medical Association, "America's Medical Liability Crisis: A National View," 15 March 2005, www.ama-assn.org/ama/noindex/category/ 11871.html (21 March 2005). This was up from twelve states reported by the AMA in mid-2002. The twenty states in crisis as of March 2005 were Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Massachusetts, Mississippi, Missouri, Nevada, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Texas, Washington, West Virginia, and Wyoming.
2. This is measured as the annual change in medical malpractice net written premiums. See A.M. Best Company, Best's Aggregates and Averages Property/Casualty (Oldwick, N.J.: A.M. Best Company, 2004). These include premiums reported to the National Association of Insurance Commissioners (NAIC), but not all entities selling medical malpractice insurance report to this group.
3. AMA, "Dying for Help: Are Patients Needlessly Suffering due to the High Cost of Medical Liability Insurance?" Statement of the AMA to the House Government Reform Subcommittee on Wellness and Human Rights, by John C. Nelson, 1 October 2003, www.ama-assn.org/ama/pub/category/12988.html (22 March 2005).
4. U.S. Government Accountability Office, Medical Malpractice: Implications of Rising Premiums on Access to Health Care, Pub. no. GAO-03-836 (Washington: GAO, 2003).
5. The Insurance Information Institute reports that Florida doctors are sued twice as often as those in other states. See R. Hartwig and C. Wilkinson, "Medical Malpractice Insurance," Insurance Issues Series 1, no. 1 (2003).
6. Medical Liability Monitor (Chicago: Medical Liability Monitor, 1997-2002). The median changes for Florida by year are as follows: 1997-98, 0 percent; 1998-99, 0 percent; 1999-2000, 10.5 percent; 2000-01, 12.7 percent; and 2001-02, 50.7 percent. Nationally, the median percentage changes in premiums for these years were 7.3, 10, 9.6, 14.6, and 29.1 percent.
7. It is worth noting that Florida does not require physicians to carry liability insurance. This might limit exit in times of rapidly increasing premiums. However, most Florida hospitals have required physicians with privileges to have liability insurance.
8. We included all patients with a diagnostic code in International Classification of Diseases, Ninth Revision (ICD-9) categories 640-469, "Complications mainly related to pregnancy," as well as multiple gestations.
9. An increase in upcoding might imply that patients reported to have preexisting conditions in later years were less severely ill, on average, than patients with preexisting conditions in earlier years. To avoid the resulting potential bias, we proceeded with the analysis based upon DRGs.
10. Roughly 75-85 percent of patients in DRGs 370 and 372 reported one or more preexisting complications, versus only about 30-40 percent of patients in DRGs 371 and 373.
11. For tables with physicians by percentiles, see www.kellogg.northwestern. edu/faculty/gron/htm/Percentile%20Tables-ALL.pdf (15 February 2005).
12. The 1997-2000 changes in numbers of physicians are more difficult to interpret since a number of observations in 1997 have missing data or are coded simply as "resident" (code RES000), while this coding is less prevalent in subsequent years. The increase in physicians from 1997 to 2000 might be the result of having more physicians precisely identified. This is unlikely to be the case for neurosurgery, where physicians with missing or resident codes accounted for eight high-risk procedures in 1997, two in 2000, and none in 2003. The obstetrics data are less clear; there are 1,157 high-risk deliveries for 1997 that have missing or resident physician codes, 293 such observations in 2000, and 50 in 2003. Thus, without some information on the average number of high-risk deliveries by residents, it is difficult to speculate on whether the number of physicians performing such deliveries increased from 1997 to 2000 and by how much. Given the data, however, the decreases from 2000 to 2003 are clear.
13. See Note 12 for a description of the missing physician identifiers. Because these physicians are most likely low-volume physicians, our 1997-2000 changes in low-volume activity levels may be quite "noisy."
14. We used the online travel time calculator in Mapquest and measured time from ZIP code centroid to centroid. For patients who receive care in their own ZIP code, we set travel time equal to one minute. We also set the maximum travel time equal to 200 minutes to minimize the impact of outliers. This does not materially affect our findings. We acknowledge that the state population was increasing over the time period studied. However, we do not believe that the growth trend for 1997-2000 is markedly different than that for 2000-2003, so we used the early period as a benchmark for comparing incidence trends.
15. We did examine incidence rates for deliveries and found no effects of the "crisis."
16. Rural ZIP codes were defined as those with greater than 40 percent of the population classified as rural by the Bureau of the Census.
17. M. Glabman, "Bare Bones," Trustee 56, no. 3 (2003): 8-13.
18. P.M. Danzon, A.J. Epstein, and S. Johnson, "The 'Crisis' in Medical Malpractice Insurance" (Presentation at the Brookings-Wharton Conference on Public Policy Issues Confronting the Insurance Industry, Philadelphia, 4 March 2003), found that premium increases were six percentage points higher in states without caps on noneconomic damages of $500,000 or less.
19. A 2003 study by the Pew Charitable Trusts argued that patients receiving large payments in the current system are generally those injured by medical errors or negligence. Quoted in M. Romano, "Keeping the Cap," Modern Healthcare 33, no. 25 (2003): 25, 28.
20. For example, subsidies for malpractice insurance, stronger disciplinary procedures for negligent or incompetent physicians, and toughening reporting of any malpractice settlements are among the measures considered by the Illinois State Legislature in addition to caps on noneconomic damages. G. Hinz, "No Jury Cap for Doctors in Lawsuits," Crain's Chicago Business 27, no. 13 (2004): 3, 34.