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Abstract:
Enacted caps on malpractice awards and proposed early offer reform address the sometimes excessive verdicts of conventional liability and its very high overhead costs. However, such reforms greatly benefit medical defendants while doing too little for claimants or patients in general. Caps and early offer only affect current claims' far broader reforms are therefore needed to improve the woeful performance of liability as a general promoter of patient safety and injury compensation. Broad reforms, however desirable, seldom surmount high political and practical hurdles. A good, more evenhanded start would seek to make claims resolution faster, more accurate, more predictable, and less expensive, while separately promoting medical quality and safety as well as greater transparency for law, medicine, and insurance.

Abstract:
Policy on medical injury would benefit from a new, "third way" to blend the traditional approach of professional responsibility, espoused by lawyers and most doctors, and newer systems solutions emphasized by patient safety advocates. Both worldviews have merit, the authors conclude, but full implementation of either policy undercuts the other. A better approach would rely more on systematic incentives created by demanding patients, payers, and regulators, and less on case-by-case sanctions from litigation and peer review.

Abstract:
Injuries caused by medical care are far too common, and policy makers are finally noticing. As the three first-person accounts in this symposium suggest, however, creating a useful policy response is difficult. Two influential camps are at loggerheads. On one side, the litigators and regulators who have always run our traditional injury system blame injuries on incompetence or carelessness, and urge yet more and stronger external rules, investigations, litigation, and sanctions. On the other, a growing provider-generated patient safety movement blames errors not on medical caregivers but rather on their complex, high-stress, and poorly organized work environment. This camp wants to create a new culture of safety inside medical institutions, seeking to fix problems, not blame. They want practitioners to be able to report errors without fear of retribution, investigate contributing factors, then craft specific interventions.

Each approach has some merit, but neither is sufficient on its own, and the two are inconsistent when applied together. One demands open disclosure and punitive response, which drives information underground. The other wants to coax out information but lacks reliable motivation to overcome the traditional medical impulse to secrecy.

A third way is needed, emphasizing the interests of patients, not those of lawyers or doctors. External legal interventions should be toned down, but patients and payers should be far more demanding of enhanced safety information and better safety management inside medical institutions. Ideally, caregivers would routinely tell patients about injuries, and reasonable compensation would follow for those that were avoidable. Then safety management would constantly be informed by experience. Patients should not need to sue, and practitioners should worry more about patient outcomes than legal outcomes.

Abstract:
National policy makers focus on insurance coverage from a national perspective-expanding it (or not) or re-engineering it (or not). Because "the era of big government is over," they often act through mandates or incentives on states, as for Medicaid and the new children's health insurance programs. Increasingly, national policy makers also micro-manage Medicare's national insurance. Interest in fully national health insurance has for the moment waned, though the number of uninsured Americans has generally increased for over a decade. The ultimate backstop for uninsured access is the local safety net, dominated by hospitals and clinics with a mission to serve the underserved. Federal policy mandates limited hospital access to emergency hospital care, but only indirectly influences general provision of care. General safety net access is left for local provision of care, and often, local funding. Insurance policy, public and private, is pressuring the hospital-based safety net through payment cuts and managed care shifts in patterns of delivery. Some localities are experimenting with new organizational arrangements. Their experience suggests some policy options for the twenty-first century. The safety net ought to get more policy attention.

Abstract:
Advocates for and against running public hospitals dispute who can best provide "safety net" care. To understand the issues in practice, we studied three localities that stopped running public hospitals in the 1990s (Milwaukee, Boston, Tampa). Two older sites provided comparative perspective (San Diego, Philadelphia).

Implementation
Decisions to privatize were political. Decisions were based partly on health policy concerns, but mainly on local public finance, state support, and budgetary tradeoffs.
Transitions were more successful where:
? a private hospital took over for the public facility
? policy makers articulated a clear and plausible strategy for continuing to serve the poor
? change was planned over time rather than suddenly implemented
? stakeholders, especially unions, were consulted and their concerns addressed Efficiency and better value were key goals; the 1990s shifts replaced episodic public hospital care with a full continuum of private care, overseen by primary-care clinics under new programs. The programs created locally managed indigent health care, a new hybrid between public support for one local hospital and broad payment for most providers via health insurance or Medicaid. The programs feature local design and control, emphasize efficient delivery of care, and fund private systems of care with public monies. Benefits are broad, but provider payments and eligibility are limited.
Clinics play a key role. The earlier shifts also came to rely on clinics, without integrating services.

Impacts
Efficiency of services has improved, as intended. Enrollees in the programs have better access through clinics and referral providers than they had at the prior public hospital alone. Quality is said to be as good as before or better, and the localities have all achieved budgetary savings. Successor hospitals are also said to be operationally more efficient. Overall access for the uninsured remains as good as before-not ideal, just no worse , at least in the early years after privatization. This success is due not just to the new programs, which fall well short of reaching all the uninsured, but also to continued private hospital charity. Access remains concentrated at traditional core safety net providers, especially the successor hospitals. Reliance on so few providers makes the safety nets vulnerable to further fiscal shocks. Clinics and hospitals report increasing difficulty in maintaining charitable care. Local support has not increased because of the programs' good performance, and program successes have prompted little expansion. Local funding is strictly limited under the new plans, which draw on state or federal support as well. Over a longer period in the comparison sites, local funding dwindled.
State and federal funding has become more important in guaranteeing continued access, given limited local funding and enrollment.

Implications
Localities can innovatively restructure safety net care as states or federal authorities seldom can. However, the effort needed is substantial, the new programs remain relatively small, and local funding is problematic. Replicability is unknown.
The need for a facility-based safety net persists because so many remain uninsured, and local funding contributes little there. State and federal support has been significant but current policy calls for cutbacks. Robust local safety nets thus need non-local funding. On reflection, this is unsurprising because the poor and the uninsured are geographically concentrated, but the tax base is not.

Safety net policy needs to be made at both local and higher levels of government.

Abstract:
This article presents new administrative and empirical evidence from a multi-year study of the only two operational medical no-fault programs in the U.S. Virginia and Florida in the late 1980s began covering children with severe birth-related neurological injuries on a no-fault basis. The study surveyed the two programs, affected parties, and observers, drawing empirical comparisons with tort performance using Florida's unusual data base of all closed malpractice claims. Background is provided on both the theory of no fault and prior experience in Workers' Compensation and auto no fault.

No fault theory promises to improve both compensation and deterrence. Compensation, by lowering administrative costs, speeding resolution of claims, and covering more injuries. Deterrence, at least in some forms of no fault, by clarifying standards of responsibility, reducing the perceived erraticness of determinations, and by experience rating premiums. For Virginia and Florida, however, the primary goal was akin to tort reform--to maintain affordable obstetrical liability coverage for physicians, which in the late 1980s was jeopardized by very expensive "bad baby" cases.

Success was achieved by taking a narrowly defined category of expensive neurological injuries out of tort. Almost all physicians participate, voluntarily paying assessments for tort protection. Malpractice premiums have dropped relative to the nation at large. Other achievements include delivering higher compensation relative to need than do comparable tort claims; doing so at extremely low overhead cost, especially for attorneys' fees on both sides; and resolving claims filed far faster than for tort. Moreover, no-fault administration functions reasonably well, and cases do not normally seem to be difficult to resolve even with minimal process. Most physicians and claimants express satisfaction with the no fault experience, but the same is true for similar obstetrical claimants under tort.

On the negative side, the programs have remained even smaller than expected for their narrow design. More claims come forward than for comparable earlier tort cases, but many fewer than the number of families with severe birth-related neurological injuries, especially cerebral palsy--and minuscule relative to medical injuries more generally. Caseload is far too small to permit experience rating or any activist approach to risk management or quality assurance. Further, the programs have not eliminated tort, even for costly obstetrical injuries, and no-fault claimants' continue to rely on plaintiffs' attorneys to guide their choice of forum. Indeed, the Supreme Court of Florida authorized claimants to go straight to courts, an approach understandably favored by trial attorneys. (A 1998 legislative amendment sought to reassert the primacy of no fault.)

Thus, no fault failed to make compensation broadly available, and its small size also prevents experience rating and risk management to improve deterrence. Moreover, the continuation of tort for uncovered obstetrical injuries continues incentives for defensive practices and may well inhibit practitioners from referring injuries to no fault lest they wind up in court. As often happens, success or failure depends on the details of implementation. Better understanding should allow others to refine no-fault programs to better meet their proponents' objectives.

Abstract:
"No-fault" is the leading alternative to traditional liability systems for resolving medically caused injuries, but the U.S. has only two operational examples: In the late 1980s, Virginia and Florida created non-tort compensation systems for newborns with severe birth-related neurological impairments, largely on the model of Workers Compensation. This paper offers the first detailed evidence on the administrative performance of these pioneering programs over seven years. For both states, it presents results from legislative history, executive interviews, as well as administrative and claims data. Using Florida's unusual data base on closed malpractice claims, it also compares no-fault speed of resolution and level of administrative cost with those of similar obstetrical tort cases. Key empirical findings are that < Both programs are small relative either to predictions or to injuries < Many Florida cases featured little dispute, but half involved major issues of eligibility/severity of injury or causality < No fault cases are resolved a third faster than tort, saving a full year < All of the time savings occur after filing, not before; it appears that lawyers take just as long to file no-fault as tort cases < No fault's "overhead" costs above benefits payments and reserves are far lower than tort's, especially with regard to attorneys' fees on both sides.

Based on its qualitative and quantitative review, the paper concludes that: 1. No-fault operations are feasible even in this contentious area of tort, notwithstanding the predictions of some no-fault opponents. 2. Even with limited scope, the programs achieve major gains in efficiency compared with tort (speed and cost). 3. Reaching the eligible population requires more than just legislating benefits and a claims process; outreach is needed, and attention must be paid to administrative mechanisms, incentives, and financing. 4. The survival of tort remedies is an Achilles heel for no-fault. 5. An expanded no-fault program could be more satisfactory in terms of compensation and injury prevention. 6. Larger no-fault programs, however, would have to operate under more formal rules and would face more attacks from the trial bar and more judicial scrutiny. Larger size could achieve some new economies of scale, but there might also be new costs of inevitable bureaucratization.

Abstract:
This article contributes to the current debate over Indiana's malpractice statute of limitations, now on appeal to the state's highest court. This statute, most recently reformed during the mid 1970s "crisis" in liability coverage, is unusually stringent in seeking to bar late-discovered injuries.

We blend a literature search and legal reasoning with new empirical analysis of pre-reform claims. The data suggest that such stringency probably does bar a significant number of potential claimants, disproportionately those with severe injuries, although available information does not permit precise conclusions. However, not all late-discovered injuries are equally likely to require "stale" evidence and hence risk unjust results. Factual claims (e.g., foreign body retained after surgery) are less troublesome than cases that crucially rely on accurate recollection of contemporary medical expertise (e.g., "failure to diagnose" cases).

Finally, we argue that judicial record keeping should be improved, to maintain more detailed data on lawsuits, so as to inform future decisions involving the effect of legal rules on litigants and courts.

Abstract:
Health care competition has arrived. Market changes affect all consumers of health care, perhaps the low-income population most of all. This paper presents evidence from six states and draws general conclusions about current impacts and emerging policy issues.

The stimulus for rapid change in the 1990s has been buyers' demands for lower prices. In insurance markets, this means more managed care. In provider markets, this means less professional control over services and prices. Price pressure in turn stimulates hospital budget cutting -- along with downsizing, consolidation into larger provider entities, conversions of ownership status, and, potentially, less service for non-paying patients.

The case studies found that states are generally supportive of price competition. State policy makers credit managed care with reducing inflation, to the benefit of large purchasers. This pleases states as big Medicaid buyers. As general overseers of health markets, however, policy makers are more ambivalent. Concerns are voiced, for example, about market concentration through mergers and the extent of patient rights.

Did the poor benefit from market change along with states and other big buyers of coverage? The report offers three conclusions:

* Price competition seems to have increased coverage by giving buyers better value for money. Many states have expanded eligibility for Medicaid or other public coverage.

* Both good and bad effects on quality of care are reported. Developments are too new to assess in most places.

* Hospitals' traditional ability to support charity care is threatened by new competition. Significant cuts in access for the poor are feared, though most states report no major impacts as yet. An emerging issue is whether and how to craft a competition-era safety net for the growing share of poor Americans who lack coverage, despite expansions in public plans. Several state or local mechanisms exist.

Abstract:
This case study examined the District of Columbia's 11 acute-care, short-term, nonmilitary hospitals, how they are being affected by market change, and what this means for the city's poor. Information came from interviews with hospital executives and others, hospital association filings, and literature review.

The District has a high level of uninsured residents, at 19% about three points above the US average, despite high average incomes and a large Medicaid program. Fully a quarter of the population is below the poverty line, almost double the national average. DC hospitals are overbedded relative to the nation at large, even allowing for their serving a share of suburban residents. The hospitals face increasing fiscal pressure from private market competition, despite the predominance in the DC area of relatively lightly managed care, as well as from public cutbacks.

In response, hospitals have cut expenditures through downsizing and operating efficiencies and raised revenue by finding market niches. Hospital responsiveness to market signals is generally good for insured buyers of care, who get better value. It is, however, threatening to the uninsured, as funds to subsidize uncompensated care are squeezed.

Uncompensated acute care (including bad debt as well as charity) has already declined over 12% in real terms between 1991 and 1996 and has become more concentrated at quasi-public DC General and three other top safety net hospitals. The burden of charity is thus unevenly distributed, and theoretical legal obligations of charity care are very hard to enforce. The current approach does not provide incentives to hospitals to serve individual patients nor to operate cost effectively, and non-hospital care has little safety net support.

Thus far, all 11 hospitals have survived. Only one merger has occurred, very recently, joining the city's biggest hospital with a Maryland system. Large realignments in the sector are expected, including merger or closure(s) of hospitals, and could occur rapidly. The report concludes that the city should establish policy on the uininsured before any crisis in access to care, so as to guide market development and level the currently uneven playing field.