1: Interesting
A good book on a contentious topic. Written by an experienced health care economist and an attorney, the authors attempt to provide a broad perspective on medical malpractice. Sloan and Chepke agree that there are serious problems with medical malpractice, but not the problems generally discussed in most public forums. The intermittant public attention paid to this issue is driven often by intermittant malpractice 'crises' in which insurers withdraw from markets, premiums escalate sharply, and there is fear of consequent physician withdrawal from states with sharply rising premiums. A common popular perception of these crises is that they are driven by excessive tort litigation and awards. In fact, there is little evidence for this explanation and recurrent malpractice insurance crises apparently have their roots in other phenomena, notably cyclical features of the insurance industry. Another common public point of discussion is that malpractice litigation is a significant contributor to rising health care costs. The available evidence, however, suggests that malpractice torts have at best a modest effect on health care costs.
Where Sloan and Chepke see major problems with malpractice torts is their apparent failure to have an impact on the high rate of serious medical errors in the USA. In addition, the data cited by Sloan and Chepke indicates that the tort system does a poor and inefficient job of compensating individuals injured through negligence. Sloan and Chepke discuss the first generation of tort reforms which are mainly caps on awards. The major effects of these reforms has been indeed to reduce awards, claims, and insurance premiums with the primary beneficiaries being physicians and insurers. It appears that first generation reforms are a stereotypical example of successful interest group lobbying of state legislatures with modest general public benefits.
Much of the book is a systematic discussion of proposed reforms including such topics as alternative dispute resolution, specialized health courts, no-fault procedures, and a number of others. These discussions are generally thorough, contain nice summaries of the usually limited evidence, and discouraging in the sense that Sloan and Chepke demonstrate the uncertainties that any proposed reforms will work and point out the pragmatic political obstacles to most of these proposed reforms.
Sloan and Chepke conclude with a chapter proposing a series of modest reforms, particularly focused on making hospitals or hospital systems the focus on malpractice litigation in the hope that this will produce incentives to improve patient safety. This is reasonable and approaches like the one proposed are used by some academic hospital systems where physicians are employees.
Sloan and Chepke may make a couple of errors. As they point out, the tort system does a poor job of identifying and compensating meritorious claims. At the same time, a lot of claims pursued do lack merit. But this irrational element is one of the things that physicians most dislike about the present system. While the tort system may not be the 'lottery' claimed by many critics, its irrational enough to be worrisome to health care providers. There is also some recent evidence that some forms of torts do reduce medical errors. Nonetheless, Sloan and Chepke's analysis is convincing and their modest suggestions for reform quite reasonable.
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