Medical Liability Reform
This Position Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.
The AAOS is committed to safe, accessible, cost effective and quality patient care. The AAOS believes that the structure of the current medical liability system limits the ability of physicians to provide the highest quality patient care. Systematic medical liability reform is necessary to improve the overall health care system.
Challenges of the Current Medical Liability System
Fails to Fairly Compensate Injured Patients in a Timely Manner
The medical liability system fails to fairly compensate those injured through medical negligence.1,2 Injured patients receive only 28 cents on the dollar of all the money paid into the liability system.3 Sixty (60) percent of patient compensation goes to administrative expenses, primarily legal fees.4
Medical liability lawsuits average five years in duration and are costly.5 Eighty-three (83) percent of claims do not involve a negligent injury.2,6 Just 6 percent of lawsuits go to trial,4 and in only 1 percent of all closed claims is the verdict in favor of the plaintiff.5 Compensation amounts are unpredictable and inconsistent from case to case and not necessarily related to negligence or adverse events.6
Interferes with the Patient-Physician Relationship
The adversarial nature of the medical liability system disrupts the empathic patient-physician relationship and communication at a time when patients need it most- after an injury.10,11,12,13,14,15,16,17,18
Prevents Analysis of Medical Errors and Impedes Lessons Learned
The issue of patient safety should be about system improvement.19 Analyzing errors, unexpected outcomes, and near misses are seminal tools to improving patient safety.
Under the current system, medical errors and negative outcomes are frequently underreported due to fear of punitive action or exploitation without explanation. Failure to report medical errors prevents physicians from learning from mistakes thus endangering future patients.19 Quality improvement is essential to improving patient care and an absolute necessity in educating future physicians.
Compromises Quality by Encouraging Defensive Medicine
Evidence indicates that areas with greater medical liability pressure experience a higher practice of defensive medicine.20,21,22,23,24,25 Defensive medicine is driven by the intensity of conflict, the duration of tort action, the emotional drain on the physician, and the threat of a large jury award.26
Defensive medicine includes assurance behavior, the practice of ordering excessive or unnecessary tests, procedures, visits, or consultations solely for reducing liability risk to the physician, and/or avoidance behavior, the practice of avoiding high-risk patients or procedures.24 With over 120,000 pending liability actions against physicians on any day in the US,25 the threat of frivolous lawsuits places significant pressure on physicians to request or perform unnecessary tests including invasive ones.27,29
Quality of care is reflected by appropriate tests and treatments,30,32 efficient use of resources,29 and treatment that is consistent with current medical knowledge.30 Defensive medicine detracts from quality of care.34,35,36,37 Avoidance behavior limits access to care, especially for high risk patients.27
Escalates the Cost of Health Care
The cost of litigation and defensive medicine increased national health care spending by ten percent annually.38 In 2007, an estimated $210 billion of health care costs can be attributed to defensive medicine. Liability reform could reduce defensive medicine practices and result in an estimated 5 to 9 percent savings in overall health care expenditures. In 2005, a 5 to 9 percent reduction in the nation’s health care expenditures would have amounted to $100 to 178 billion.36
Reduces Patient Access to Care by Decreasing Physician Supply
Forty-three (43) percent of physicians have reduced or eliminated high-risk aspects of their practice and nearly 50 percent of others plan to do so.40 Critical specialists are becoming less available to provide emergency trauma care as specialists face higher medical liability exposure.41 Patients in need of high-risk services, uninsured patients, and patients whose insurance minimally reimburses specialists are most affected.40
One sixth of the approximately 650,000 practicing physicians report a medical liability claim annually.28 Fifty (50) percent of America’s neurosurgeons and more than 30 percent of orthopaedists, obstetricians, trauma surgeons, emergency department physicians, and plastic and reconstructive surgeons are sued each year.28 In 86 percent of cases, the jury finds the doctor not negligent, yet the cost of defense can range from $24,000 to $90,000.8
Principles for Medical Liability Reform
The AAOS believes that broad reforms are necessary to compensate negligently injured patients promptly and equitably, enhance patient-physician communication, facilitate improvement of patient safety and quality of care, reduce defensive medicine and wasteful spending, decrease liability costs, and improve patient access to care.
The AAOS believes that efforts for comprehensive medical liability reform should include the following core principles:
Compensation: Compensate patients for injury caused by negligent care promptly, fairly, equitably, and reliably.42,43,44,45,46
- Encourage early and free dialogue and advance the primacy of empathic patient-physician relationship10,11,12,13,14,15,16,17,18,44,45,46
- Develop more equitable and less adversarial mechanisms for dispute resolution while minimizing costs26,44,45,46
Encourage a Culture of Safety and Quality:
- Encourage voluntary reporting of unanticipated occurrences and open dialogue through confidentiality laws19
- Establish firewalls between discipline and voluntary reporting systems
- Enhance data collection and analysis efforts to enable effective system-wide and individual improvement2,19,44,45,46,47 ,48
- Enhance peer review to prevent abuse, ensure due process, and focus on learning in order to improve patient safety and quality of care48,49
- Encourage system-wide responsibility for clinical safety and improvement47,48,50
Reduce Defensive Medicine and Excess Health care Costs
- Eliminate and/or minimize factors that promote the practice of defensive medicine
- Reduce assurance behavior to avoid the expense of unnecessary tests and treatment20,21,22,23,24,25,26,27,38,39,52
Increase Patient Access
- Eliminate and/or minimize factors which promote the practice of defensive medicine (avoidance behavior) in order to increase availability of care22,23,24,25,26,27,38,39,43,45,46,51
Components of Successful Medical Liability Reform
The AAOS believes that the following programmatic components of reform should be among those considered to achieve these principles.
- Early tender to compensate for economic losses
- Alternative Dispute Resolution
- Arbitration; Mediation; Pre-arranged patient-physician agreement
- Enterprise (the organization, e.g. hospital, and the professionals as an accountable unit) Liability to encourage shared responsibility and system-wide improvement; and eliminate blame and shame44
- “Safe harbor” from liability for following established and approved clinical practice guidelines46
- Medical Courts with specially trained judges to allow a case to be evaluated by experienced professionals in the medical and legal arena
- Scheduled payments for certain typical injuries
- Administrative compensation system using an evidence-based and expert-developed predetermined list of compensable injuries resulting from negligent care and compensation amount
- Modify punitive and National Practitioner Data Bank reporting requirements to provide incentive for open communication, prompt resolution and compensation, and the improvement of patient safety through confidential data collection
The AAOS believes that no federal legislation pertaining to liability reform should include provisions that would undermine effective state tort reform provisions or the ability of states to enact tort reform tailored to local needs. In recognizing that broad reform requires pilots and time before widespread application, it is critical to provide interim relief within the current system through proven measures by state and/or federal legislation, including:
- A specific per claimant cap on non-economic damages
- Mandatory offset of collateral sources of payment
- Periodic payment of future damage awards
- Establishment of basic requirements to qualify an expert witness in medical malpractice cases and accountability to license board/medical specialty board
- Expansion of the Good Samaritan laws to allow volunteers and charitable organizations to serve the public without the threat of litigation
- Shorter duration for the statute of limitations for minors and/or a statute of repose
- Implementation of a uniform system of several, and not joint liability that holds physicians liable only to the extent he or she is responsible
- “Safe harbor” from liability for following best practice guidelines46
The AAOS believes that there is an urgent need to improve patient safety and access to care, decrease defensive medicine and reduce the cost of health care through medical liability reform.
1. Joint Economic Committee; United States House of Representatives: The Perverse Nature of the Medical Liability System; March, 2005. Accessed July 3, 2009 at: http://www.house.gov/jec/publications/109/03-21-05.pdf
2. Studdert DM, Mello MM, Brennan TA: Medical malpractice. N Engl J Med 2004;350:283-292.
3. Weinstein SL: Medical liability reform crisis 2008. Clin Orthop Relat Res 2009;467:392-401.
4. Kakalik JS, Pace NM: Costs and compensation paid in tort litigation. R-3391-ICJ. Santa Monica, Calif.:Institute for Civil Justice, RAND, 1986.
5. Studdert DM, Mello MM, Gawande AA, et al: Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med 2006;354:2024-33.
6. Localio AR, Lawthers AG, Brennan TA, et al: Relation between malpractice claims and adverse events due to negligence: results of the Harvard Medical Practice Study III. N Engl J Med 1991;325:245-51.
7. DeMaria AN. Medical malpractice insurance: a multifaceted problem. J Am Coll Cardiol. 2003;42:1683-1684.
8. 8 Smarr LE: Statement of the Physician Insurers Association of America Before a joint hearing of the United States Senate Judiciary Committee and Health, Education, Labor and Pensions Committee Regarding: Patient Access Crisis: The Role of Medical Litigation. February 11, 2003. At page 17. Accessed on April 8, 2009 at http://www.piaa.us/pdf_files/February_11_Testimony.pdf. PIAA’s Claims Trend Analysis, 2009 Edition (cumulative data from 1985 to 2008) also bears out that 1 percent of closed claims resulted in a verdict for the plaintiff.
9. Brennan TA, Soc CM, Burstin HR: Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med 1996;335:1963-7.
10. Sheridan SE: Medical liability: New ideas for making the system work better for patients, a hearing before the US Senate Health Education, labor and Pension Committee. June 22, 2006. Accessed on July 3, 2009 at http://www.help.senate.gov/Hearings/2006_06_22/sheridan.pdf
11. Sheridan SS, Hatlie MJ: We’re not your enemy. Patient Safety & Quality Healh care. July/August 2007: 22-26.
12. Delbanco T, Bell SK: Guilty, afraid, and alone – struggling with medical error. N Engl J Med 2007;357:1682-3.
13. Hickson GB et al: Factors that prompted families to file medical malpractice claims following perinatal injuties. JAMA 1992;267:1359-1363.
14. Levinson W et al: Physician-patient communication: The relationship with malpractice claims among primary care Physicians and surgeons. JAMA 1997;277:553-559.
15. Wu AW, et al: To tell the truth: Ethical and practical issues in disclosing medical mistakes to patients. Journal of General Internal Medicine 1997;12:770-775.
16. Gallagher TH et al: Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA 2003;289:1001-1007.
17. Liebman CB, Hyman CS: A mediation skills model to manage disclosure of errors and adverse events to patients. Health Aff (Millwood) 2004;23:22-32.
18. Vincent C, Young M, Philips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994;343:1609-13.
19. Institute of Medicine. To Err is Human: Building a Safer Health System. National Academies Press: 2000.
20. Rock, SM: 1988 Malpractice premiums and primary Cesarean section rates in New York and Illinois. Public Health Reporter CVIII, 459–468.
21. Harvard Medical Practice Study. Patients, doctors, and lawyers: medical injury, malpractice litigation, and patient compensation in New York. Report of the Harvard Medical Practice Study to the State of New York. The President and Fellows of Harvard College, Cambridge, MA, 1990.
22. Localio AR: Relationship between malpractice claims and cesarean delivery. JAMA 1993;269:366–373.
23. Kessler D, McClellan M: Do doctors practice defensive medicine? Quarterly Journal of Economics, 1996; 111:353–390.
24. Kessler D, McClellan M: Malpractice law and health care reform: optimal liability policy in an era of managed care. NBER WP 7537, 2000.
25. Dubay L, Kaestner R, Waidmann T: The impact of malpractice fears on cesarean section rates. Journal of Health Economics 1999;18:491–522.
26. Kessler DP, McClellan MB: How liability law affects medical productivity. Journal of Health Economics 2002;21:931-955.
27. Studdert DM, Mello MM, Sage WM, et al: Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA 2005;293:2609-16.
28. Anderson RE: Defending the practice of medicine. Arch Intern Med. 2004;164:1173-1178.
29. Hartwig RP: Medical Malpractice Insurance Jury Verdict Research; Insurance Information Institute volume 1 #1 June 2003, on page 5.
30. Palmer RH: Considerations in defining quality of health care. In:Palmer RH, Donabedian A, Povar GJ, eds. Striving for quality in health care: an inquiry into policy and practice. Ann Arbor, Mich.: Health Administration Press, 1991:1-53.
31. Donabedian A: Explorations in quality assessment and monitoring. Vol.1. The definition of quality and approaches to its assessment. Ann Arbor, Mich.: Health Administration Press, 1980.
32. American Medical Association, Council on Medical Service. Quality of care. JAMA 1986:256:1032-4.
33. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. National Academies Press: 2001.
34. Fisher ES, Welch HG: Avoiding the unintended consequences of growth in medical care. JAMA 1999;281:446-453.
35. Verrilli D, Welch HG: The impact of diagnostic testing on therapeutic interventions. JAMA 1996;275-1189-91.
36. Black WC, Welch HG: Advances in diagnostic imaging and overestimations of disease prevalence and benefits of therapy. N Engl J Med 1993;328:1237-1243.
37. Blumenthal D: Quality of health care Part 1: Quality of care-What is it? N Engl J Med 1996; 335-891-4.
38. The Price of Excess: Identifying waste in health care spending. Price Waterhouse Coopers. 2008. Accessed on July 4, 2009.
39. Weinstein SL: The Cost of Defensive Medicine. AAOS Now. November, 2008. Accessed on March 3, 2009 at http://www.aaos.org/news/aaosnow/nov08/managing7.asp
40. Mello MM, Studdert DM, DesRoches CM, Peugh J, Zapert K, Brennan TA, Sage WM: Effects of a malpractice crisis on specialist supply and patient access to care. Ann Surg. 2005;242:621-628.
41. Emergency medical services at the crossroad, Committee on the Future of Emergency Care in the United States Health System, Board on Health care Services. Washington, D.C.: Institute of Medicine; June 2006.
42. O’Connell J: Offers That Can’t Be Refused: Foreclosure of Personal Injury Claims by Defendants’ Prompt Tender of Claimants’ Net Economic Losses. Northwestern University Law Review 1982;77:589–632.
43. Tancredi L, Bovbjerg R: Rethinking Responsibility for Patient Injury: Accelerated-Compensation Events, a Malpractice and Quality Reform Ripe for a Test. Law and Contemporary Problems 1991;54:147–177.
44. Boothman RC: Medical Justice: Making the System Work Better for Patients and Doctors. Testimony before themUnited States Senate Committee on Health, Education, Labor and Pensions. Thursday, June 22, 2006. Accessed on July 4, 2009 at http://help.senate.gov/Hearings/2006_06_22/boothman.pdf
45. Clinton HR, Obama B: Making Patient Safety the Centerpiece of Medical Liability Reform. N Engl J Med 2008;354:2205-2208.
46. Mello MM, Brennan TA: The role of medical liability reform in Federal health care reform. N Engl J Med 2009;361:1-3.
47. Sage WM, Hastings KE, Berenson RA: Enterprise Liability for Medical Malpractice and Health Care Quality Improvement. American Journal of Law and Medicine 1994;20:1–28.
48. Sage WM: Medical liability and patient safety. Health Aff (Millwood) 2003;22(4):26-36.
49. Massachusetts Medical Society’s Model Principles for Incident-Based Peer Review for Health Care Facilities. Accessed on July 5, 2009.
50. Abraham KS, Weiler PC: Enterprise Medical Liability and the Evolution of the American Health Care System. Harvard Law Review 1994;108:381–436.
51. The Factors Fueling Rising Health care Costs. Prepared for America’s Health Insurance Plans, Price Waterhouse Coopers. 2006. Accessed on March 3, 2009.
April 1995 American Association of Orthopaedic Surgeons.
Revised February 2001 and September 2009.
This material may not be modified without the express written permission of the American Association of Orthopaedic Surgeons.
Position Statement 1118
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