This document summarizes a report about medical malpractice in Rhode Island. It finds that:
1) Preventable medical errors cost Rhode Island residents $63-108 million annually in lives lost and healthcare costs, far exceeding the $21.6 million annual cost of malpractice insurance for doctors.
2) Malpractice payouts by Rhode Island doctors have decreased 21% from 1997-2001 when adjusted for inflation, and million-dollar payouts have remained flat, contradicting claims of a litigation crisis.
3) A small proportion of doctors are responsible for half of malpractice payouts, yet two-thirds of those with multiple payouts have not faced discipline, indicating a failure to adequately
Home care has been provided in the US since the 1880s and currently over 7.6 million people receive care from 83,000 home care providers. Medicare's enactment in 1965 accelerated growth in home care agencies. By the end of 2001, the number of Medicare-certified home health agencies declined to 6,861 due to changes in Medicare home health coverage and reimbursement. However, the number of agencies rebounded to 9,284 by the end of 2007 with the introduction of the home health prospective payment system in 2000. Total national health expenditures were projected to be $2.2 trillion in 2007, with home care expenditures estimated at $47.5 billion in 2005.
Affordable Care Act The Decision Is In Pbc Partnership For Agingcschoolmaster
Affordable Care Act - The Decision Is In (What is included, what is not and how much does it all cost.)
A presentation for the Palm Beach County Partnership for Aging by Paul Gionfriddo of
Our Health Policy Matters.
705 South Palmway
Lake Worth FL 33460
561-307-5588
Elucidates the governing laws (U.S., Canada, U.K), restrictions and extensions of the advance-directives (living wills) in obstetrics. DOI: 10.13140/RG.2.1.3671.4321
This report analyzes the US elder care services industry, providing historical data from 2001-2011 and forecasts through 2021. It finds that revenues will grow 5.2% annually to $319.5 billion by 2016, driven by an aging population and baby boomers retiring. Home and community-based services are projected to have the fastest growth due to efforts to shift Medicaid payments from nursing facilities to lower-cost options. Nonprofits are expected to slightly outpace for-profits through 2016. Medicaid will remain the leading payment source despite efforts to curb spending, while Medicare payments will experience the fastest annual growth. The report also profiles major industry players.
This document discusses a hypothetical case study for a Micro-Health Impact Bond (Micro-HIB) program at Howard University Hospital aimed at reducing readmissions and emergency room visits for patients with cardiovascular diseases. The program would implement low-cost therapies like smile therapy, mindfulness meditation and non-cognitive development training. It provides details on program objectives, structure through a Howard University Non-Cognitive Development Institute and Alliance, financial projections estimating over $445,000 in cost savings over 3 years from reduced readmissions and emergency visits, and an annual budget of $500,000 to fund the program. The goal is to test innovative healthcare financing and achieve improved health outcomes and cost efficiencies.
Discusses the intersection of bankruptcy and health care, and why lack of adequate health care is the number one reason people are forced to file bankruptcy.
Obamacare in Pictures: Visualizing the Effects of the Patient Protection and ...The Heritage Foundation
“Obamacare in Pictures: Visualizing the Effects of the Patient Protection and Affordable Care Act” shows in detail the impact of the sweeping health care law for Americans.
This document provides an overview and review of critical illness insurance. It discusses how critical illnesses like cancer and heart disease can impact finances through lost income and medical costs. It then outlines sources of funds people may have like health insurance, disability insurance, and savings, but notes their limitations. The document proposes critical illness insurance as a potential solution, explaining that it pays a lump sum that can be used flexibly upon diagnosis of a covered critical illness. This allows focusing on treatment instead of finances. The document also clarifies what critical illness insurance is not, such as health care insurance.
Home care has been provided in the US since the 1880s and currently over 7.6 million people receive care from 83,000 home care providers. Medicare's enactment in 1965 accelerated growth in home care agencies. By the end of 2001, the number of Medicare-certified home health agencies declined to 6,861 due to changes in Medicare home health coverage and reimbursement. However, the number of agencies rebounded to 9,284 by the end of 2007 with the introduction of the home health prospective payment system in 2000. Total national health expenditures were projected to be $2.2 trillion in 2007, with home care expenditures estimated at $47.5 billion in 2005.
Affordable Care Act The Decision Is In Pbc Partnership For Agingcschoolmaster
Affordable Care Act - The Decision Is In (What is included, what is not and how much does it all cost.)
A presentation for the Palm Beach County Partnership for Aging by Paul Gionfriddo of
Our Health Policy Matters.
705 South Palmway
Lake Worth FL 33460
561-307-5588
Elucidates the governing laws (U.S., Canada, U.K), restrictions and extensions of the advance-directives (living wills) in obstetrics. DOI: 10.13140/RG.2.1.3671.4321
This report analyzes the US elder care services industry, providing historical data from 2001-2011 and forecasts through 2021. It finds that revenues will grow 5.2% annually to $319.5 billion by 2016, driven by an aging population and baby boomers retiring. Home and community-based services are projected to have the fastest growth due to efforts to shift Medicaid payments from nursing facilities to lower-cost options. Nonprofits are expected to slightly outpace for-profits through 2016. Medicaid will remain the leading payment source despite efforts to curb spending, while Medicare payments will experience the fastest annual growth. The report also profiles major industry players.
This document discusses a hypothetical case study for a Micro-Health Impact Bond (Micro-HIB) program at Howard University Hospital aimed at reducing readmissions and emergency room visits for patients with cardiovascular diseases. The program would implement low-cost therapies like smile therapy, mindfulness meditation and non-cognitive development training. It provides details on program objectives, structure through a Howard University Non-Cognitive Development Institute and Alliance, financial projections estimating over $445,000 in cost savings over 3 years from reduced readmissions and emergency visits, and an annual budget of $500,000 to fund the program. The goal is to test innovative healthcare financing and achieve improved health outcomes and cost efficiencies.
Discusses the intersection of bankruptcy and health care, and why lack of adequate health care is the number one reason people are forced to file bankruptcy.
Obamacare in Pictures: Visualizing the Effects of the Patient Protection and ...The Heritage Foundation
“Obamacare in Pictures: Visualizing the Effects of the Patient Protection and Affordable Care Act” shows in detail the impact of the sweeping health care law for Americans.
This document provides an overview and review of critical illness insurance. It discusses how critical illnesses like cancer and heart disease can impact finances through lost income and medical costs. It then outlines sources of funds people may have like health insurance, disability insurance, and savings, but notes their limitations. The document proposes critical illness insurance as a potential solution, explaining that it pays a lump sum that can be used flexibly upon diagnosis of a covered critical illness. This allows focusing on treatment instead of finances. The document also clarifies what critical illness insurance is not, such as health care insurance.
Untreated mental illnesses and substance use disorders increase state spending significantly. They account for 15% of total state spending on criminal justice, Medicaid, transportation, and public safety. For every $1 invested in addiction treatment, $7.46 is saved in costs. Providing community-based mental health services and supportive housing reduces costs compared to incarceration, emergency rooms, and hospitals. Shifting treatment to outpatient settings has the potential to significantly lower state expenditures.
This document is a letter from Republican physicians in Congress providing 10 facts about the challenges facing the Medicare program. It summarizes that Medicare costs have grown unsustainably, the program will face insolvency in the near future, and reforms are needed to strengthen and protect Medicare for current and future seniors. The letter aims to further an informed discussion about adopting bipartisan solutions to these issues.
Dr. Pam Silberman, President and CEO of the N.C. Institute of Medicine, provides an overview of the Affordable Care Act in North Carolina as part of a NCACC Annual Conference workshop on Aug. 24, 2013.
This document provides information about various insurance policies offered by My FamilyProtect including accident, critical illness, cancer, accidental death & dismemberment, hospital indemnity, and funeral expense policies. The accident policy provides coverage for medical expenses from covered accidents. The critical illness policy provides a lump sum payment for heart attacks, strokes, or invasive cancer diagnoses. The cancer-only critical illness similarly provides payments for cancer diagnoses. The accidental death & dismemberment policy provides payments for accidental death or dismemberment. Details are given on benefit amounts, coverage options, eligibility, and coordination of benefits for each policy type.
This document discusses medical malpractice laws and legal challenges to caps on noneconomic damages in malpractice cases. It provides background on the medical malpractice crisis, including rising costs of malpractice insurance that have led some states to impose caps on damages. The document then examines various court rulings that have both upheld and struck down such caps in different states, with differing arguments made on both sides of the debate. In conclusion, it notes that while caps may help slow insurance premium increases, there are also drawbacks, but alternative approaches are unproven and action is needed to address the crisis.
Modern American Health Care: Balancing Performance and Compliance in the Curr...Craig B. Garner
This presentation provides an overview of the Affordable Care Act three years after its passage. It explains how the landmark legislation evolved, what provisions are in place today, and what can we expect in the years to come. The implications for patients, providers and payers are massive, and this presentation is designed to provide a comprehensive overview for anyone interested to learn about health care reform.
Fqhc statistics growth, region, performance and revenue - federally qualifi...GaryRichards30
The document provides statistics on Federally Qualified Health Centers (FQHCs) in the United States, including their growth over time, regional distribution, performance, and sources of revenue. It notes that FQHCs have grown exponentially since the 1960s from only 8 centers to over 1,400 organizations today serving around 25 million patients annually. The document also shares data on FQHC revenues by state and payer source, with the largest sources being Medicaid, Medicare, federal grants, and private insurance. It concludes that FQHCs have the potential to serve more patients by improving quality of care through investments in technology.
Health Care Reform Goes Live: Day Three in the Current Climate of ReformCraig B. Garner
The document provides a history of healthcare reform in the United States from the 1800s to present day. It discusses the shift from home care to hospital care over time and key acts like the Hill-Burton Act and Medicare. It then summarizes provisions of the Affordable Care Act including essential health benefits, exchanges, the individual and employer mandates, and ways to deliver care like accountable care organizations.
The Affordable Care Act: Taking a New Approach to DamagesRachel Hamilton
Presented at ACI's 13th Annual Advanced Forum on Obstetric Malpractice Claims by Caryn L. Lilling Mauro Lilling Naparty LLP and Thomas R. Shimmel Kitch Drutchas Wagner Valitutti & Sherbrook.
Tom Wong: Public Charge: Immigrant Health Under Trump’s New Rulereportingonhealth
Prof. Tom Wong's slides from the Center for Health Journalism webinar, "Public Charge: Immigrant Health Under Trump’s New Rule" 9.11.19
More info: https://www.centerforhealthjournalism.org/content/employee-health-insurance-failing-americans
The Social Security Administration announced a 1.7% cost-of-living adjustment for 2013 benefits, one of the lowest increases since 1975. This will increase the average monthly retirement benefit from $1,240 to $1,261. The maximum taxable earnings also increased slightly. Involving an attorney early in the disability claims process can improve chances of approval, as initial claims have around a 63% denial rate. Common medical conditions like musculoskeletal disorders and mental illnesses are most likely to be awarded disability benefits.
This document provides an overview of the Stark Law, including:
- The Stark Law prohibits physician self-referrals of Medicare patients for designated health services if the physician has a financial relationship with the entity providing those services.
- It addresses questions about who enforces the law, why the law was created, what activities it prohibits, and differences between it, the Anti-Kickback Statute, and the False Claims Act.
- The document outlines penalties for Stark Law violations and lists 17 areas of compliance risk identified by the Office of Inspector General related to healthcare fraud and abuse.
- The document discusses long-term care insurance, explaining what long-term care is, the rising costs of care, and options for paying for care such as Medicaid, private pay, and long-term care insurance.
- It provides details on factors to consider when purchasing long-term care insurance like benefits, discounts, inflation protection, and when to buy.
- The earlier you purchase insurance, the lower the premiums tend to be and the more likely you are to pass underwriting given health risks increase with age.
Serious misgivings medicaid expansion and house bill 148akame2015
House Bill 148 proposes expanding Medicaid in Alaska, but Rep. Liz Vazquez has serious misgivings. If passed, the bill would cost an uncertain amount due to unreliable enrollment projections. It could drain hundreds of millions from Alaska's $3.5 billion budget deficit. There are concerns that promised federal funding may not continue as expected, existing Medicaid groups could face cuts, and the expansion may increase emergency room usage contrary to goals.
The document summarizes recent legal developments from Supreme Court decisions and appellate court rulings that have implications for healthcare providers. Key points include: the Supreme Court ruling in North Carolina Board of Dental Examiners v. FTC that state licensing boards composed primarily of market participants do not enjoy automatic antitrust immunity; developments in case law around the False Claims Act and what constitutes a "claim"; and implications of cases related to the Anti-Kickback Statute and Stark Law on compensation arrangements between physicians and healthcare entities.
SUD and Health Care Reform: Key Changes Being Considered by Congress and the ...Epstein Becker Green
Epstein Becker Green Webinar with Attorney Jackie Selby - Substance Use Disorders Crash Course Webinar Series - June 13, 2017.
Discussion Points:
* How would the American Health Care Act impact SUD services?
* What is the U.S. Department of Health and Human Services doing differently regarding SUD services?
* How does the executive budget proposal impact SUDs?
* Are parity requirements for SUD services going to change?
Take a coffee break every Tuesday in June at 2 p.m. ET to join us for a 15-minute webinar covering substance use disorder (SUD) issues!
http://www.ebglaw.com/events/sud-and-health-care-reform-what-are-the-key-changes-being-considered-by-congress-and-the-trump-administration-substance-use-disorders-crash-course-webinar-series/
These materials have been provided for informational purposes only and are not intended and should not be construed to constitute legal advice. The content of these materials is copyrighted to Epstein Becker & Green, P.C. ATTORNEY ADVERTISING.
The document summarizes bills passed by the 2010 Virginia General Assembly related to health care, the state budget, and health care workforce needs in Virginia. Key points included the creation of the Virginia Health Workforce Development Authority, requiring insurers to cover telemedicine, prohibiting requirements for individuals to have health insurance, cuts to the state budget including Medicaid rate reductions and closure of mental health units, and shortages of physicians, dentists, and mental health professionals in certain areas of the state.
Text of speech (associated PowerPoint is at http://www.slideshare.net/stevelevine/protecting-texas-medical-liability-reforms-piaa-2014) delivered to PIAA Medical Liability Conference in Toronto, May 14, 2014
This document discusses Medicaid eligibility rules and planning for long-term care costs. It notes that long-term care can be expensive, with nursing home care costing $9,000-$17,000 per month on Long Island. Medicaid is a means-tested program that can help cover long-term care costs. The document outlines Medicaid eligibility requirements around income, resources, transfers of assets, and penalty periods for gifts made during the 60-month lookback period. Protecting the homestead through sale, transfer, life estate, or trust is also discussed.
Webinar: “Making It Work—Physician Compensation During the COVID-19 Pandemic”PYA, P.C.
What to do with your physician compensation plan in the face of the COVID-19 pandemic? It’s a question that leaves administrators searching for answers.
PYA Principal Angie Caldwell and Senior Manager Katie Culver introduced several key considerations for provider compensation during and after the COVID-19 pandemic. In PYA’s complimentary webinar, they:
Summarized the current environment impacting physician compensation associated with the pandemic.
Provided an overview of the Stark Blanket Waivers and opportunities created for physician compensation.
Described restoration and recovery strategies for physician resources.
PYA hosted this one-hour webinar Tuesday, April 28, 2020, at 11 a.m. EDT in conjunction with the Florida Hospital Association.
Untreated mental illnesses and substance use disorders increase state spending significantly. They account for 15% of total state spending on criminal justice, Medicaid, transportation, and public safety. For every $1 invested in addiction treatment, $7.46 is saved in costs. Providing community-based mental health services and supportive housing reduces costs compared to incarceration, emergency rooms, and hospitals. Shifting treatment to outpatient settings has the potential to significantly lower state expenditures.
This document is a letter from Republican physicians in Congress providing 10 facts about the challenges facing the Medicare program. It summarizes that Medicare costs have grown unsustainably, the program will face insolvency in the near future, and reforms are needed to strengthen and protect Medicare for current and future seniors. The letter aims to further an informed discussion about adopting bipartisan solutions to these issues.
Dr. Pam Silberman, President and CEO of the N.C. Institute of Medicine, provides an overview of the Affordable Care Act in North Carolina as part of a NCACC Annual Conference workshop on Aug. 24, 2013.
This document provides information about various insurance policies offered by My FamilyProtect including accident, critical illness, cancer, accidental death & dismemberment, hospital indemnity, and funeral expense policies. The accident policy provides coverage for medical expenses from covered accidents. The critical illness policy provides a lump sum payment for heart attacks, strokes, or invasive cancer diagnoses. The cancer-only critical illness similarly provides payments for cancer diagnoses. The accidental death & dismemberment policy provides payments for accidental death or dismemberment. Details are given on benefit amounts, coverage options, eligibility, and coordination of benefits for each policy type.
This document discusses medical malpractice laws and legal challenges to caps on noneconomic damages in malpractice cases. It provides background on the medical malpractice crisis, including rising costs of malpractice insurance that have led some states to impose caps on damages. The document then examines various court rulings that have both upheld and struck down such caps in different states, with differing arguments made on both sides of the debate. In conclusion, it notes that while caps may help slow insurance premium increases, there are also drawbacks, but alternative approaches are unproven and action is needed to address the crisis.
Modern American Health Care: Balancing Performance and Compliance in the Curr...Craig B. Garner
This presentation provides an overview of the Affordable Care Act three years after its passage. It explains how the landmark legislation evolved, what provisions are in place today, and what can we expect in the years to come. The implications for patients, providers and payers are massive, and this presentation is designed to provide a comprehensive overview for anyone interested to learn about health care reform.
Fqhc statistics growth, region, performance and revenue - federally qualifi...GaryRichards30
The document provides statistics on Federally Qualified Health Centers (FQHCs) in the United States, including their growth over time, regional distribution, performance, and sources of revenue. It notes that FQHCs have grown exponentially since the 1960s from only 8 centers to over 1,400 organizations today serving around 25 million patients annually. The document also shares data on FQHC revenues by state and payer source, with the largest sources being Medicaid, Medicare, federal grants, and private insurance. It concludes that FQHCs have the potential to serve more patients by improving quality of care through investments in technology.
Health Care Reform Goes Live: Day Three in the Current Climate of ReformCraig B. Garner
The document provides a history of healthcare reform in the United States from the 1800s to present day. It discusses the shift from home care to hospital care over time and key acts like the Hill-Burton Act and Medicare. It then summarizes provisions of the Affordable Care Act including essential health benefits, exchanges, the individual and employer mandates, and ways to deliver care like accountable care organizations.
The Affordable Care Act: Taking a New Approach to DamagesRachel Hamilton
Presented at ACI's 13th Annual Advanced Forum on Obstetric Malpractice Claims by Caryn L. Lilling Mauro Lilling Naparty LLP and Thomas R. Shimmel Kitch Drutchas Wagner Valitutti & Sherbrook.
Tom Wong: Public Charge: Immigrant Health Under Trump’s New Rulereportingonhealth
Prof. Tom Wong's slides from the Center for Health Journalism webinar, "Public Charge: Immigrant Health Under Trump’s New Rule" 9.11.19
More info: https://www.centerforhealthjournalism.org/content/employee-health-insurance-failing-americans
The Social Security Administration announced a 1.7% cost-of-living adjustment for 2013 benefits, one of the lowest increases since 1975. This will increase the average monthly retirement benefit from $1,240 to $1,261. The maximum taxable earnings also increased slightly. Involving an attorney early in the disability claims process can improve chances of approval, as initial claims have around a 63% denial rate. Common medical conditions like musculoskeletal disorders and mental illnesses are most likely to be awarded disability benefits.
This document provides an overview of the Stark Law, including:
- The Stark Law prohibits physician self-referrals of Medicare patients for designated health services if the physician has a financial relationship with the entity providing those services.
- It addresses questions about who enforces the law, why the law was created, what activities it prohibits, and differences between it, the Anti-Kickback Statute, and the False Claims Act.
- The document outlines penalties for Stark Law violations and lists 17 areas of compliance risk identified by the Office of Inspector General related to healthcare fraud and abuse.
- The document discusses long-term care insurance, explaining what long-term care is, the rising costs of care, and options for paying for care such as Medicaid, private pay, and long-term care insurance.
- It provides details on factors to consider when purchasing long-term care insurance like benefits, discounts, inflation protection, and when to buy.
- The earlier you purchase insurance, the lower the premiums tend to be and the more likely you are to pass underwriting given health risks increase with age.
Serious misgivings medicaid expansion and house bill 148akame2015
House Bill 148 proposes expanding Medicaid in Alaska, but Rep. Liz Vazquez has serious misgivings. If passed, the bill would cost an uncertain amount due to unreliable enrollment projections. It could drain hundreds of millions from Alaska's $3.5 billion budget deficit. There are concerns that promised federal funding may not continue as expected, existing Medicaid groups could face cuts, and the expansion may increase emergency room usage contrary to goals.
The document summarizes recent legal developments from Supreme Court decisions and appellate court rulings that have implications for healthcare providers. Key points include: the Supreme Court ruling in North Carolina Board of Dental Examiners v. FTC that state licensing boards composed primarily of market participants do not enjoy automatic antitrust immunity; developments in case law around the False Claims Act and what constitutes a "claim"; and implications of cases related to the Anti-Kickback Statute and Stark Law on compensation arrangements between physicians and healthcare entities.
SUD and Health Care Reform: Key Changes Being Considered by Congress and the ...Epstein Becker Green
Epstein Becker Green Webinar with Attorney Jackie Selby - Substance Use Disorders Crash Course Webinar Series - June 13, 2017.
Discussion Points:
* How would the American Health Care Act impact SUD services?
* What is the U.S. Department of Health and Human Services doing differently regarding SUD services?
* How does the executive budget proposal impact SUDs?
* Are parity requirements for SUD services going to change?
Take a coffee break every Tuesday in June at 2 p.m. ET to join us for a 15-minute webinar covering substance use disorder (SUD) issues!
http://www.ebglaw.com/events/sud-and-health-care-reform-what-are-the-key-changes-being-considered-by-congress-and-the-trump-administration-substance-use-disorders-crash-course-webinar-series/
These materials have been provided for informational purposes only and are not intended and should not be construed to constitute legal advice. The content of these materials is copyrighted to Epstein Becker & Green, P.C. ATTORNEY ADVERTISING.
The document summarizes bills passed by the 2010 Virginia General Assembly related to health care, the state budget, and health care workforce needs in Virginia. Key points included the creation of the Virginia Health Workforce Development Authority, requiring insurers to cover telemedicine, prohibiting requirements for individuals to have health insurance, cuts to the state budget including Medicaid rate reductions and closure of mental health units, and shortages of physicians, dentists, and mental health professionals in certain areas of the state.
Text of speech (associated PowerPoint is at http://www.slideshare.net/stevelevine/protecting-texas-medical-liability-reforms-piaa-2014) delivered to PIAA Medical Liability Conference in Toronto, May 14, 2014
This document discusses Medicaid eligibility rules and planning for long-term care costs. It notes that long-term care can be expensive, with nursing home care costing $9,000-$17,000 per month on Long Island. Medicaid is a means-tested program that can help cover long-term care costs. The document outlines Medicaid eligibility requirements around income, resources, transfers of assets, and penalty periods for gifts made during the 60-month lookback period. Protecting the homestead through sale, transfer, life estate, or trust is also discussed.
Webinar: “Making It Work—Physician Compensation During the COVID-19 Pandemic”PYA, P.C.
What to do with your physician compensation plan in the face of the COVID-19 pandemic? It’s a question that leaves administrators searching for answers.
PYA Principal Angie Caldwell and Senior Manager Katie Culver introduced several key considerations for provider compensation during and after the COVID-19 pandemic. In PYA’s complimentary webinar, they:
Summarized the current environment impacting physician compensation associated with the pandemic.
Provided an overview of the Stark Blanket Waivers and opportunities created for physician compensation.
Described restoration and recovery strategies for physician resources.
PYA hosted this one-hour webinar Tuesday, April 28, 2020, at 11 a.m. EDT in conjunction with the Florida Hospital Association.
Positive word of mouth and brand advocacy are important to any organization. But for nonprofits, groups that are typically challenged by strict budgets, limited human resources and government regulations, word-of-mouth and advocacy marketing are key strategies. Enter social media and the abundance of wide-open channels (most of them free to use) and communities of socially and ethically conscious millions. For many nonprofits, the opportunity to identify and tap into groups of like-minded citizens helps the organization not only share its mission and mandate, but use the common collective of fans and followers to spread those messages far and wide. Let’s look at ten nonprofits doing just that.
The document discusses several people, places, and events. It provides clues about notable figures like Samuel Beckett, Conrad Hunte, PJ Antony, and Jamsetji Tata. It also identifies structures like Mysore Palace and locations like Florence. Events mentioned include the Suez Canal crisis and the Sino-Indian War of 1962. Works and concepts discussed include Hitopadesha, Dante's Divine Comedy, and the UN peacekeeping force.
Virtualization provides several benefits for businesses including more efficient use of computing resources which reduces costs, increases flexibility and improves disaster recovery capabilities. It allows multiple virtual machines to run on a single physical server sharing processors, memory, storage and network resources. This consolidation improves hardware utilization rates and reduces infrastructure costs like data center space, power and cooling needs while maintaining isolation between virtual systems. Virtualization also simplifies management, upgrades and compliance efforts for IT organizations.
This business presentation describes the Aaachoo! opportunity, a digital product business with a low $29.95/month investment, no inventory requirements, and global market reach. It claims participants can earn $80,000 per month through Aaachoo!'s compensation plan which involves recruiting others into a matrix structure to earn commissions. The presentation encourages viewers to enroll now on the free trial and upgrade their account to get started sharing the opportunity with others.
Soc Marketing Stronger Bottom Line Presentationguest9ae81dca9
The document discusses the importance of appreciation and relationship marketing for building strong relationships with clients that lead to greater customer retention and referrals. It emphasizes that treating customers well through appreciation, gratitude, and creating memorable experiences leads to clients becoming "raving fans" who continue to purchase and refer others. The document also promotes using greeting cards and gifts as a cost-effective way to show appreciation and strengthen relationships on a regular basis.
This is a listing for a 53-foot triple expandable trailer from eventpro.com. The trailer has an expandable width that allows it to be configured in three different sizes. Eventpro.com sells and rents various types of event equipment including trailers.
CitySt.Paul heinous Civil,Criminal,Constitutional Rights to Shut off Sharon Water, www.sharonanderson.org
then Steal Sharons Cars,Trailers,Propertys, but Theft,Trespass,Treason, must be abated,Damages Award
This document discusses two theories for why legal origin influences financial development:
1) The "political" channel argues that legal traditions differ in the priority they give to private property rights versus state power, and common law traditions better protect private contracting rights and financial development.
2) The "adaptability" channel holds that legal traditions differ in their ability to adapt efficiently to changing economic conditions, and common law systems can more flexibly evolve case-by-case while civil law systems rely more on statutory changes. The document assesses the empirical validity of these two channels influencing the relationship between legal origin and financial development.
Construction Of Gendered Legal Personhood In The History Oflegal5
This document provides an introduction to a paper about the historical construction of gendered legal personhood in Finnish law. It discusses how women were not fully recognized as legal persons until the 20th century in many legal systems. It reviews feminist critiques of how the concept of the legal person is inherently gendered and excludes women. It also discusses different understandings of legal personhood, including substantive views that see elements like rationality as integral versus more formal views of it as an empty category. The document aims to analyze how Finnish law constructed norms and gender through its representations of legal persons over time.
This compensation plan offers several bonuses for new members including a welcome bonus and fast start bonus. It pays a dual team building cycle bonus weekly and cuts checks every Thursday without a earnings cap. Members can also earn matching bonuses on retail profits and through infinity generational matching. Leadership pools provide additional compensation.
This document discusses how Gruvi helps film companies engage fans on social media through Facebook app development, advertising, and community management. They create engaging Facebook apps for films that convert visitors to fans through games, videos, and sharing features. Gruvi also runs targeted Facebook ad campaigns and manages fan pages to optimize engagement. Their services are effective at driving fans, interactions, and sharing for film companies.
Healing Pathways Foundation on Health Care ReformJacob Garlick
The document discusses perspectives on health care reform from various stakeholders. It outlines some of the conflicting interests between attorneys, doctors, hospitals, HMOs/PPOs, insurance companies, and drug companies. While many blame rising costs on medical malpractice lawsuits, the document notes studies showing malpractice insurance is a small percentage of physician revenues and most claims do not result in payouts. Overall, the document aims to balance all stakeholder interests with the needs of society and injured citizens.
This document discusses legal barriers to implementing international medical providers into workers' compensation medical provider networks in the United States. It notes that medical costs associated with workers' compensation claims have risen steadily in recent decades and implementing international providers could help control costs. However, there are currently legal and regulatory barriers preventing foreign medical providers from treating work-related injuries abroad. The document examines considerations around the quality of care provided by international medical tourism destinations and notes some top hospitals abroad that provide comparable or better care than U.S. hospitals. It aims to start a discussion on including medical tourism in workers' compensation to take advantage of globalization in healthcare.
This document summarizes New Jersey's efforts to reform its health care system and preserve the Affordable Care Act. It discusses the state's high health care costs and rates of uninsured prior to the ACA. The new law in New Jersey requires residents to have minimum essential health coverage, establishes a state-run health insurance exchange, provides reinsurance to insurance companies, and levies a tax on commercial policies to fund the exchange. However, the reforms do little to control escalating health care spending or prices in New Jersey. Challenges remain such as the potential for insurers to cherry-pick healthier customers through the use of stop-loss insurance.
The document discusses Medicare spending in the United States. It reports that Medicare spending was reduced to 0.2% in 2013 compared to 1.8% between 2009-2012. This decrease may have resulted from the recession limiting spending, delivery system reforms to improve quality while reducing local costs, or a focus on patient-centered care. Statistical data from Medicare budget reports is cited to support the claims around reduced spending.
Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.
ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.
Please send your email address to info [at] anesthesiallc [dot] com if you would like to join the Communique mailing list!
Visit www.anesthesiallc.com for more information!
1_2012 Rhode Island Hospital Payment Study FinalKim Paull
This study analyzes patterns of hospital payment variation in Rhode Island. It finds substantial variation in payments for similar care, with commercial plans generally paying hospitals higher rates than Medicaid or Medicare. Payments also varied significantly between hospitals, with larger hospitals like Lifespan and Care New England receiving higher payments from commercial plans. The study aims to inform policies around rising healthcare costs by examining a key driver of spending - the price of hospital care.
1. Entities mentioned Chris Hann and Classic Auto Sales Problem.docxSONU61709
1. Entities mentioned: Chris Hann and Classic Auto Sales
Problem 1-29 Accounting entities
The following business scenarios are independent from one another:
1. Chris Hann purchased an automobile from Classic Auto Sales for $10,000.
2. Sal Pearl loaned $15,000 to the business in which he is a stockholder.
3. First State Bank paid interest to Strong Co. on a certificate of deposit that Strong Co. has invested at First State Bank.
4. Cindy’s Restaurant paid the current utility bill of $135 to Midwest Utilities.
5. Sun Corp. borrowed $50,000 from City National Bank and used the funds to purchase land from Carriage Realty.
6. Sue Wang purchased $10,000 of common stock of International Sales Corporation from the corporation.
7. Chris Gordon loaned $6,000 cash to his daughter.
8. Motor Service Co. earned $20,000 in cash revenue.
9. Poy Imports paid $4,000 for salaries to each of its four employees.
10. Borg Inc. paid a cash dividend of $4,000 to its sole shareholder, Mark Borg.
Required
A. For each scenario, create a list of all of the entities that are mentioned in the description.
B. Describe what happens to the cash account of each entity that you identified in requirement a.
Exercise 2-5 Missing information related to accruals
Panoramic Inc. had a beginning balance of $2,000 in its Accounts Receivable account. The ending balance of Accounts Receivable was $2,400. During the period, Panoramic recognized $40,000 of revenue on account. Panoramic’s Salaries Payable account has a beginning balance of $1,300 and an ending balance of $900. During the period, the company recognized $35,000 of accrued salaries expense.
Required
A. Based on the information provided, determine the amount of net income.
B. Based on the information provided, determine the amount of net cash flow from operating activities.
Exercise 2-11 Prepaid items on financial statements
Therapy Inc. experienced the following events in 2014, its first year of operation:
1. Performed counseling services for $18,000 cash.
2. On February 1, 2014, paid $12,000 cash to rent office space for the coming year.
3. Adjusted the accounts to reflect the amount of rent used during the year.
Required
Based on this information alone
A. Record the events under an accounting equation.
C. Ignoring all other future events, what is the amount of rent expense that would be recognized in 2015?
Exercise 2-13 Unearned items on financial statements
Interior Design Consultants (IDC) experienced the following events in 2014, its first year of operation:
1. On October 1, 2014, IDC collected $24,000 for consulting services it agreed to provide during the coming year.
2. Adjusted the accounts to reflect the amount of consulting service revenue recognized in 2014.
Page 79
Required
Based on this information alone
A. Record the events under an accounting equation.
C. Ignoring all other future events, what is the amount of service revenue that would be recognized in 2015?
Exercise 2-17 Prep ...
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Here is a draft outline for a research paper on the Affordable Care Act and its impact on the health care industry:
I. Introduction
A. Background on the state of healthcare in the U.S. prior to the ACA
B. Thesis: The Affordable Care Act has significantly impacted the U.S. health care industry through its provisions aimed at expanding coverage, regulating insurance practices, and controlling costs.
II. Expanding Coverage
A. Individual mandate
B. Medicaid expansion
C. Impact: More insured Americans, reduced uncompensated care
III. Regulating Insurance Practices
A. Banning pre-existing condition exclusions
B. Ending annual/lifetime limits
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Chapter 2Fraud and Abuse StarkPhysician Self-Referral and EstelaJeffery653
Chapter 2
Fraud and Abuse: Stark/Physician Self-Referral and Anti-Kickback
Learning Objectives
Physician Self-Referral (Stark) Law and Anti-Kickback Statute (AKS)
Services, individuals, organizations, and transactions affected by these laws.
Specific behaviors prohibited.
Exceptions and “safe harbors” for avoiding liability.
Anticipating and preventing violations.
Physician Self-Referral Law (Stark)
Initial law (Stark I) sponsored by Congressman Pete Stark enacted in 1989 and applied only to clinical laboratory services.
Omnibus Budget Reconciliation Act of 1993 (Stark II) expanded law to additional 10 types of clinical services.
Patient Protection and Affordable Care Act of 2010 added restrictions on physician-owned hospitals and required the issuance of a self-referral disclosure protocol.
Stark Prohibition
“... If a physician (or an immediate family member of such physician) has a financial relationship with an entity ..., then the physician may not make a referral to the entity for the furnishing of designated health services for which payment otherwise may be made” under Medicare (also applicable to Medicaid). (underlining added).
“Physician”
The person making the referral may be a(n)
MD
Osteopath
Dentist
Podiatrist
Optometrist, or
Chiropractor
“Immediate family member”
Besides the referring physician herself, this person may be a
spouse;
parent, child, or sibling (by birth or adoption);
stepparent, stepchild, step-brother, or step-sister;
father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, or sister-in-law;
grandparent or grandchild; or
spouse of a grandparent or grandchild.
“Entity”
The entity with which there is a financial relationship must be one that bills CMS for designated health services (DHS) or that furnishes all or most of the components of the DHS.
This includes the person or entity that actually performs the DHS, or presents a claim for DHS services to the Medicare program.
7
“Financial relationship”
Direct or indirect ownership of an entity:
Equity stock, interest in a limited liability company, holding debt in an entity.
Direct or indirect compensation from an entity:
Physician’s compensation from an entity, lease between physicians and health care facilities, medical director agreements, and independent contract with physicians.
“Designated health services” (I)
Clinical laboratory services.
Physical therapy services.
Occupational therapy services.
Outpatient speech-language pathology services.
Radiology and certain other imaging services.
Radiation therapy services and supplies.
“Designated health services” (II)
Durable medical equipment and supplies.
Parenteral and enteral nutrients, equipment, and supplies.
Prosthetics, orthotics, and prosthetic devices and supplies.
Home health services.
Outpatient prescription drugs.
Inpatient and outpatient hospital services.
Penalties for Stark Violations
Payment for services in response to prohibited referral must ...
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Chapter 2Where Are WeAmerican health care is in a state of flJinElias52
Chapter 2
Where Are We?
American health care is in a state of flux as new scientific knowledge and clinical experience continue to change our definitions of illness and wellness. As a society, we respond by changing the ways health care is delivered. Health services increasingly impact our society—from health status to employment to budgetary economics to recreation to professional concerns to our perceptions of our own well-being.
American health care is also in flux because now that it has grown to more than one-sixth of our economy it threatens to squeeze out public goods such as education and infrastructure maintenance. People have wanted to do something about cost and access to care problems for a long time. The 2010 Affordable Care Act (ACA) is doing much to address access issues, but opposition to certain provisions is strong. Employers are steadily shifting more risk to employees and their families, and there is a real tension between Washington and the state capitols over Medicaid expansion. Medicare trust funds are forecast to disappear over the next decade or so. Washington is unlikely to tolerate another major health reform battle, although major changes may come as a side effect of a “grand” government overhaul of spending and tax policies. The future is highly uncertain, and still we must plan and act as we go along.
This chapter reviews the current status of the U.S. health care system from several points of view:
• Current outcomes and costs
• Quality
• Leadership
• Complexity
• Industrializing structures for delivery
• Medicalization of our society
• Redistribution of wealth
2.1 Current Outcomes and Costs
Previous section
Next section
2.1 CURRENT OUTCOMES AND COSTS
Health care expenditures were projected to rise to close to 20% of the U.S. gross domestic product (GDP) by 2015 (Borger et al., 2006), but more recent estimates from the Centers for Medicare & Medicaid Services (CMS) project it to be 18.2% for 2015 and 19.5% by 2021 (CMS, 2012). Average annual family health insurance premiums were estimated for 2012 at $15,745, with $11,429 paid by employers. The 4% growth rate for 2012 was slow by historical standards but still more than twice the growth rate of wage income. The comparable total insurance cost for a single individual was $5,615. Large employers (98%) offered health care benefits to workers but were cutting back on retiree health benefits. Only 50% of firms with 3 to 9 workers and 73% with 10 to 24 workers offered health benefits. Many small companies do not provide health benefits. At the same time, control of health care by health professionals is being threatened by outsiders calling for more reliance on government programs, more consumer-centered care, or both.
High Comparative Costs and Low Comparative Outcomes
The United States spends far more on health care per capita and as a percentage of GDP than other developed countries, yet does not seem to be much better off for it. Table 2-1 illustrates this ...
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2) This power of attorney will be in effect from the dated signed (6) until (5), or unless ended earlier by either party.
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3. The Facts About Medical Malpractice in Rhode Island
Table of Contents
Executive Summary ......................................................................................................................1
Introduction: Overstating Problems and Undermining Patients’ Legal Rights ........................7
Costs of Medical Malpractice to Rhode Island’s Patients & Consumers.................................8
Figure 1 ....................................................................................................................................8
Rhode Island Doctor’s Medical Malpractice Payouts: Reliable Sources vs. Rhetoric............9
Figure 2: Total Malpractice Payouts, R.I. Physicians, 1992-2002 ..................................9
Figure 3: Number of Malpractice Payouts in Rhode Island, 1997-2001 ......................10
Figure 4: Malpractice Payouts Exceeding $500,000 in Rhode Island, 1992-2001 .....11
Rhode Island Doctor’s Medical Malpractice Premiums: Rising Less than Inflation Rate .....12
Figure 5: Total Medical Malpractice Premiums Paid in Rhode Island, 1996-2001 .....12
Figure 6: Annual Malpractice Premuims, Rhode Island Compared with
Neighboring States ............................................................................................13
No Evidence of Doctors Abandoning Rhode Island.................................................................14
Figure 7: Licensed Physicians and Osteopaths with Rhode Island Addresses ..........14
Repeat-Offender Doctors Are Responsible for Half of Medical Malpractice Payouts ..........15
Figure 8: Number of Medical Malpractice Payouts and Amounts Paid by
Rhode Island Doctors 1990 - 2002 ..................................................................15
Two-Thirds of Doctors with Four or More Malpractice Payouts Have not
Been Disciplined....................................................................................................................16
Where’s the Doctor Watchdog?.................................................................................................18
Medical Liability Premium Spike Is Caused by the Insurance Cycle and
Mismanagement, Not the Legal System.............................................................................19
Caps on Damages Are a False “Solution” ................................................................................21
Insurance Companies and Their Lobbyists Admit Caps on Damages Won’t Lower
Insurance Premiums.............................................................................................................22
Rather than Facing “Runaway Litigation,” Doctors Benefit from a Claims Gap....................24
Figure 9: Malpractice Claims Gap: Ratio of Medical Errors to Claims Filed ................25
Figure 10: Florida Malpractice Claims Gap: 1996-1999 Ratio of Medical Errors to
Claims Filed........................................................................................................25
Few Malpractice Lawsuits Are “Frivolous” ................................................................................26
Empirical Evidence Does not Confirm the Existence of “Defensive Medicine” – Patient
Injuries Refute It.....................................................................................................................28
Solutions to Reduce Medical Errors..........................................................................................30
Solutions to Make Insurance Rates More Predictable ............................................................34
Appendix: Public Citizen’s “Questionable Doctors” Database..........................................36
4. Executive Summary
The Rhode Island Medical Society and its political allies have made dire predictions about an
impending malpractice “crisis” in their state. These worries are based on the experiences of other
states, where some doctors have faced significantly increased malpractice insurance premiums
over the past two years. Rhode Island’s medical establishment may be reacting to the potential
for a temporary “crisis” – but its arguments that this is being triggered by “frivolous”
malpractice claims or an explosion of “meritless” lawsuits have no basis in fact.
This Public Citizen study, which examines statistics from numerous government agencies and
other reputable sources, has two principal findings:
1) The most significant, long-term malpractice “crisis” faced by Rhode Island residents
is the unreliable quality of medical care being delivered by a relatively small
proportion of doctors – a problem that health-care providers have not adequately
addressed. Restricting access to legal remedies for patients who seek compensation
for injuries, as is proposed under legislation introduced in Rhode Island, would only
decrease deterrence and reduce the quality of care.
2) The medical malpractice premium “crisis” that Rhode Island doctors have seen in
other states is not a long-term problem nor is it being caused by the legal system. It is
a short-term problem triggered by a brief spike in medical malpractice insurance
premiums for some physicians. This spike in rates is a result of the cyclical
economics of the insurance industry and investment losses caused by the country’s
economic slowdown.
Highlights of this report include:
• The cost of medical negligence to Rhode Island patients and consumers is
considerable, especially when measured against the cost of malpractice
insurance to Rhode Island doctors. Extrapolating from Institute of Medicine (IOM)
findings, we estimate there are 164 to 365 deaths in Rhode Island each year that are due to
preventable medical errors. The costs resulting from preventable medical errors to Rhode
Island residents, families and communities are estimated at $63 million to $108 million each
year. But the cost of medical malpractice insurance to Rhode Island doctors is only $21.6
million a year.
• There has been a decrease in the annual malpractice payouts by Rhode
Island’s doctors when inflation is considered. According to the National Practitioner
Data Bank (NPDB), the total value of malpractice payouts made to patients in Rhode Island
in 2001 was $22.8 million, up from $21.1 million in 1992. This increase of $1.7 million
represents a change of only 8 percent over nine years, or 0.9 percent a year. During this
same period, costs of medical care increased 47 percent nationwide, an average of 5.2
percent a year.
Public Citizen’s Congress Watch 1 Medical Malpractice in Rhode Island
5. • There has been a significant decrease in the number of malpractice payouts
made in Rhode Island. NPDB statistics contradict suggestions by Rhode Island doctors
and their political allies that malpractice payouts have grown much more frequent. NPDB
data show that the number of payouts actually declined 21 percent from 73 in 1997 to 58 in
2001 (the most recent five years for which statistics are complete).
• Million-dollar malpractice payouts have remained flat. Proponents of legislation to
impede the legal access of injured patients assert that “verdicts and settlements in medical
malpractice actions exceeding $1 million have increased steadily over the past 20 years.” In
fact, payouts reported to the National Practitioner Data Bank show that Rhode Island has
experienced no such recent pattern. From 1992 through 2001, the average number of
malpractice payouts of a million dollars or more was less than two per year, and never
exceeded three in any of those years. In 2001, the total number of payouts of $1 million or
more was three, the same as in 1992. Additionally, the number of malpractice payouts
between $500,001 and $1 million showed no steady, upward trend during these years,
averaging just over eight per year. In 2001, the total number of payouts in this range was 11,
less than the 13 in 1992.
• As a group, Rhode Island doctors have seen a decrease in their liability
insurance premiums, when inflation is considered. According to data from the
National Association of Insurance Commissioners (NAIC), the total amount that Rhode
Island doctors paid in malpractice insurance premiums in 2001 was $21.6 million, compared
with $19.5 million in 1996. This is an increase of only 11 percent during this period (the
most recent five years for which data is complete). When adjusted for medical inflation,
which was 19.8 percent during this same period, and the growing number of physicians in the
state, this represents a significant decline in actual dollars.
• Malpractice insurance premiums are lower in Rhode Island than in
neighboring states. A comparison of medical malpractice premiums charged by one
insurance group that serves Rhode Island, Connecticut and Massachusetts shows that Rhode
Island doctors generally pay less – in some cases, much less – than their counterparts in
neighboring states. And one of these two adjacent states, Massachusetts, imposes a $500,000
cap on malpractice awards. According to data from Medical Liability Monitor, rates for
general surgeons ranged from 14 percent to 40 percent less in Rhode Island than in
Connecticut or Massachusetts; rates for Ob/Gyns ranged from 6 percent to 23 percent less in
Rhode Island than in the other two states; and rates for internists ranged from 2 percent to 23
percent less in Rhode Island than in the other states.
• Malpractice payouts are insignificant when compared with the state’s overall
healthcare expenditures. Total spending on health care in Rhode Island was $4.5 billion
in 1998. In that year, doctors’ malpractice payouts made to patients in Rhode Island totaled
$14.5 million – the equivalent of only 0.32 percent of healthcare expenditures in the state.
• There is no sign that doctors are abandoning Rhode Island. Rhode Island’s
medical environment has attracted a steady increase in physicians. In 2002, there were 2,915
practicing physicians and osteopaths with Rhode Island addresses, compared with 2,623 in
Public Citizen’s Congress Watch 2 Medical Malpractice in Rhode Island
6. 1999, an increase of 11 percent. According to the American Medical Association, Rhode
Island had 277 doctors per 100,000 residents in 1990. By 2001, that ratio had increased to
365 doctors per 100,000 residents. This is the seventh highest ratio in the nation.
• Repeat-offender doctors are responsible for half of medical malpractice
payouts. According to the NPDB, which covers malpractice judgments and settlements
since September 1990, 4.8 percent of Rhode Island’s doctors have made 52.7 percent of all
payouts. These repeat-offender doctors are responsible for two or more malpractice payouts
to patients and they have paid out $104.7 million in damages. Even more disturbing, just 1.6
percent of Rhode Island’s doctors, each of whom has paid three or more malpractice claims, are
responsible for nearly 26 percent of all payouts.
• Less than a third of doctors with four or more malpractice payouts have been
disciplined. According to the National Practitioner Data Bank and Public Citizen’s analysis
of NPDB data, 19 Rhode Island physicians have made four or more malpractice payouts, but
only 31.6 percent of those doctors have been disciplined by the Rhode Island State Board of
Medical Licensure and Discipline.
• The medical board is among the nation’s less stringent when it comes to
disciplining doctors. Rhode Island ranks 35th among all states and the District of
Columbia when its diligence in taking disciplinary actions against doctors is measured. In
2002, the state Board of Medical Licensure and Discipline levied serious sanctions against
only 10 doctors for incompetence, misprescribing drugs, sexual misconduct, criminal
convictions, ethical lapses or other offenses, according to an ongoing Public Citizen project
that tracks “Questionable Doctors” nationwide. Nationally in 2002, there were 3.6 serious
actions taken for every 1,000 physicians. The rate of serious actions by the Rhode Island
Board of Medical Licensure and Discipline – 2.6 per 1,000 physicians – was roughly one-
fifth the rate in Wyoming, which is the top-ranked state with 11.9 serious actions per 1,000
physicians.
• Five years after a disclosure law was adopted, consumers still can’t get vital
data. Rhode Island has yet to fully implement a 1997 law that called for public disclosure
of profiles containing information about individual physicians. Although some profiles are
available online, they omit two crucial categories: malpractice information and criminal
convictions. The system is scheduled for an update this summer, but the profiles still will not
contain data on doctors’ malpractice payouts.
• Spike in medical liability premiums is caused by the insurance cycle, not by
“skyrocketing” malpractice awards. J. Robert Hunter, one of the country’s most
knowledgeable insurance actuaries and director of insurance for the Consumer Federation of
America, recently analyzed the growth in medical liability premiums. He found that amounts
charged for premiums do not track losses paid, but instead rise and fall in concert with the
state of the economy. When the economy booms and investment returns are high, companies
maintain premiums at modest levels; however, when the economy falters and interest rates
fall, companies increase premiums.
Public Citizen’s Congress Watch 3 Medical Malpractice in Rhode Island
7. • Rhode Island doctors have endured insurance cycles for 28 years. As recently as
February, the Rhode Island Medical Society’s board of directors acknowledged that the state
had witnessed up-and-down cycles in the medical liability insurance industry since the mid-
1970s. In an advisory to members, the board recounted major problems that occurred with
medical liability insurers in 1975, when coverage became largely unavailable; for a number
of years beginning in 1987, when nine different “risk retention groups” began going
bankrupt; and again in 1993, when a large, unrated carrier, Premier Alliance, became
insolvent. The primary cause for these problems, the board concluded, has been “under-
reserving” of funds by the insurance companies.
• Insurance companies and their lobbyists admit caps on damages won’t lower
malpractice premiums. Caps on “non-economic damages” are not part of Rhode Island’s
current legislative proposal, but they are included in a federal bill that the state’s U.S.
senators and representatives are considering. These caps, which limit compensation for pain
and suffering resulting from severe injuries such as brain damage, paralysis, loss of a limb,
loss of reproductive capacity, disfigurement, blindness or deafness, significantly reduce
awards paid to catastrophically injured patients. But, because such truly severe cases
comprise a small percentage of medical malpractice claims and because the portion that pays
for defense lawyer fees dwarfs the portion of the insurance premiums that pay for
compensation, caps do not lead to lower premiums. Insurance companies and their lobbyists
understand this, and have said so on numerous public occasions.
• So-called “non-economic” damages are real and not awarded randomly. “Non-
economic” damages aren’t as easy to quantify as lost wages or medical bills, but they
compensate for the pain and suffering that accompany any loss of normal functions (e.g.
blindness, paralysis, sexual dysfunction, lost bowel and bladder control, loss of a limb) and
inability to engage in daily activities or to pursue hobbies, such as hunting and fishing. This
category also encompasses damages for disfigurement and loss of fertility. According to the
PIAA, the average total payout between 1985 and 2001 for a “grave injury,” which
encompasses paralysis, was only $454,454.
• Capping damages hurts women in particular. Limiting medical malpractice awards
for non-economic injury has a disproportionate impact on women. The largest part of
economic damages in many tort claims is lost wages, and women earn on average less money
than men do. Additionally, the most significant effect of many medical injuries inflicted on
women is harm to reproductive capacity, which does not entitle them to receive economic
damages, according to a study by the director of the Insurance Law Center at the University
of Connecticut School of Law.
• Rather than facing “runaway litigation,” doctors benefit from a claims gap. A
landmark Harvard Medical Practice Study and other studies have found that only a small
percentage of medical errors result in lawsuits. Twelve years ago, Harvard researchers found
that only one in 7.6 preventable medical errors committed in hospitals resulted in a
malpractice claim. Researchers replicating this study made similar findings in Utah and
Colorado. From 1996 through 1999, Florida hospitals reported 19,885 incidents but only
3,177 medical malpractice claims. In other words, for every six medical errors only one
claim is filed.
Public Citizen’s Congress Watch 4 Medical Malpractice in Rhode Island
8. • Malpractice insurance costs amount to only 3.2 percent of the average
physician's revenues. According to experts at the Medicare Payment Advisory
Commission (MedPAC), liability insurance premiums make up just a tiny part of a
physician’s expenses and have increased by only 4.4 percent over the past year. The increase
in this expense is noticeable primarily because of the decreases in reimbursements that
doctors are receiving from HMOs and government health programs.
• The small number of claims pursued to a defense verdict are not frivolous.
Researchers at the American Society of Anesthesiologists arranged for pairs of doctors to
review 103 randomly selected medical negligence claims files. The doctors were asked to
judge whether the anesthesiologist in question had acted reasonably and prudently. The
doctors only agreed on the appropriateness of care in 62 percent of the cases; they disagreed
in 38 percent of cases. The researchers concluded, “These observations indicate that neutral
experts (the reviews were conducted in a situation that did not involve advocacy or financial
compensation) commonly disagree in their assessments when using the accepted standard of
reasonable and prudent care.”
• No evidence supports the claim that jury verdicts are random “jackpots.”
Studies conducted in California, Florida, North Carolina, New York and Ohio have found
that jury verdicts bear a reasonable relationship to the severity of the harm suffered. In total
the studies examined more than 3,500 medical malpractice jury verdicts and found a
consistent relationship between the severity of the injury and the size of the verdict.
Uniformly the authors concluded that their findings did not support the contention that jury
verdicts are frequently unpredictable and irrational.
• Empirical evidence does not confirm the existence of “defensive medicine” –
and patient injuries refute it. The Congressional Budget Office was asked to quantify
the savings from reduced “defensive medicine” if Congress passed H.R. 4600. This bill,
which passed the House in 2002, contained very stringent restrictions on a patient’s ability to
recover damages. CBO declined, saying that any such “estimates are speculative in nature,
relying, for the most part, on surveys of physicians’ responses to hypothetical clinical
situations, and clinical studies of the effectiveness of certain intensive treatments.
Compounding the uncertainty about the magnitude of spending for defensive medicine, there
is little empirical evidence on the effect of medical malpractice tort controls on spending for
defensive medicine and, more generally, on overall health-care spending. Using broader
measures of spending, CBO’s initial analysis could find no statistically significant connection
between malpractice tort limits and overall health care spending.” In addition, numerous
studies continue to document preventable medical errors ranging from invasive procedures
performed on the wrong patients, medication errors, misreading of test results and unsanitary
conditions – all mistakes that any widespread practice of “defensive” medicine could have
been expected to reduce.
• Action could be taken on a national level to reduce medical errors. The only way
to reduce the cost of medical injuries is to reduce negligence and mistakes – and the best way
to accomplish this is by reforming the regulatory oversight of the medical profession. Public
Citizen recommends opening up the National Practitioner Data Bank to empower consumers
Public Citizen’s Congress Watch 5 Medical Malpractice in Rhode Island
9. with information about their doctors. It also recommends implementing the “systems
approach” advocated by the Institute of Medicine to establish mandatory nationwide error
reporting systems, identify unsafe practices and raise performance standards. And Public
Citizen recommends that Congress encourage better oversight of physicians through grants to
state medical boards, tied to the boards’ agreements to meet performance standards.
• States should improve oversight of health-care providers. When negligent doctors
are disciplined, it is rarely for inferior care. Instead, state medical boards frequently respond
to more easily documented things such as prescription drug violations, fraud convictions or
disciplinary actions taken in other states. Governance of physicians would improve if
medical and licensing boards were required to sever formal links with state medical societies.
And legislatures could help ensure that medical boards have enough revenue to hire more
investigators and legal staff to perform effective oversight. In addition, Rhode Island is
demonstrating how medical errors can be addressed on the state level by considering two
bills to reduce overwork among nurses. This is a constructive step, in light of studies that
identify fatigue among nurses and medical residents as a significant contributing factor to
patient injuries and deaths.
• State regulators could make insurance rates more predictable. J. Robert Hunter,
Director of Insurance for the Consumer Federation of American, on behalf of Americans for
Insurance Reform, has recommended a number of steps to state insurance regulators. These
include thoroughly auditing insurance companies’ pricing and profitability data; regulating
excessive prices; freezing “stressed rates” until prices and jumps in loss reserves can be
analyzed; and requiring medical malpractice insurers to use claims history as a rating factor.
He also advocates creating a standby public insurer to write risks during “hard markets,” and
asking the National Association of Insurance Commissioners to stop the implementation of
the deregulation of commercial rates and forms, which it is unwisely pushing.
Public Citizen’s Congress Watch 6 Medical Malpractice in Rhode Island
10. Introduction:
Overstating Problems and Undermining
Patients’ Legal Rights
There is no dispute that doctors are concerned about the prospect of rising medical malpractice
premiums. And no one wants to see doctors forced to pay more to insure themselves against
liability, even if they are surgeons earning $500,000 a year. It is important, however, that public
policy regarding medical malpractice be guided by solid facts and a clear understanding of the
situation – not by an artificial sense of “crisis” exaggerated to serve narrow interests.
Rhode Island’s medical establishment has used dire language in its campaign to change state
laws to inhibit injured patients from seeking compensation for negligence. “Access to quality
health care services is already shrinking,” warned the president of the Rhode Island Medical
Society in a letter to members. “The word is out that Rhode Island is not a great place to be a
doctor.”1
In an advertisement distributed statewide, the Rhode Island Medical Society delivered the
unsettling assessment that financial pressures on doctors are “intensifying” and that “no one can
predict how doctors will respond to these pressures or what the impact on patients will be.” The
ad also suggested, “The next time you see your doctor for a routine appointment, you might turn
the tables on him or her and ask, ‘Hey, Doc, how’s it going?’”2
In effect, Rhode Island’s physicians have become the “victims” of malpractice, according to this
advertisement. Meanwhile, the doctors and their political allies have firmly placed the blame on
patients who, they allege have brought “many meritless claims” for steadily increasing amounts
of money. 3
In fact, as this report shows, conditions in Rhode Island do not constitute a “crisis,” and litigation
does not seriously threaten the cost of liability insurance or consumer access to health care in the
state. Rhode Island doctors openly acknowledge that the insurance industry has experienced
economic fluctuations 4 – and it is these pricing and profitability problems, not patient lawsuits
that put sporadic pressure on malpractice insurance premiums.
The real long-term threat to quality health care in Rhode Island is the frequency of medical
mistakes, and the lack of oversight and discipline against the very small number of medical
professionals who commit most of the state’s malpractice. This report provides suggestions for
averting these problems in the future.
Public Citizen’s Congress Watch 7 Medical Malpractice in Rhode Island
11. Costs of Medical Malpractice to
Rhode Island’s Patients & Consumers
In 2000, the Institute of Medicine (IOM) estimated that from 44,000 to 98,000 Americans die in
hospitals every year from preventable medical errors. 5 The IOM also estimated the costs to
individuals, their families and society at large for these medical errors at $17 billion to $29
billion a year. These costs include disability and health-care costs, lost income, lost household
production and the personal costs of care.
The true impact of medical malpractice in Rhode Island should be measured by the cost to
patients and consumers, not the premiums paid by doctors to their insurance companies.
Extrapolating from the IOM findings, we estimate that there are 164 to 365 preventable deaths in
Rhode Island each year that are due to preventable medical errors. The costs resulting from
preventable medical errors to Rhode Island’s residents, families and communities are estimated
at $63 million to $108 million each year. But the cost of medical malpractice insurance to Rhode
Island’s doctors is only $21.6 million a year. 6 [See Figure 1]
Figure 1
164 - 365
Preventable Deaths Due to Medical Errors Each Year
$63 million - $108 million
Costs Resulting from Preventable Medical Errors Each Year
$21.6 million
Cost of Rhode Island Doctors’ Annual Medical Malpractice Premiums
Sources: Preventable deaths and costs are prorated based on population and based on estimates in To Err Is
Human, Institute of Medicine, November 2000. Malpractice premiums are based on “Medical Malpractice Net
Premium and Incurred Loss Summary,” National Association of Insurance Commissioners, July 18, 2001.
Public Citizen’s Congress Watch 8 Medical Malpractice in Rhode Island
12. Rhode Island Doctors’ Medical Malpractice Payouts:
Reliable Sources vs. Rhetoric
Medical leaders in Rhode Island have made gloomy pronouncements that the state is on the brink
of a crisis that could “erode” health care and cost almost every doctor in the state “many
thousands of dollars” in malpractice insurance premiums.7 Mirroring this rhetoric, legislation
introduced in the General Assembly describes the prospect of “soaring” premiums resulting from
“meritless claims” and steadily increasing malpractice awards. 8 These assertions, by doctors and
politicians alike, are not supported by government statistics or other reliable sources.
• There has been a decrease in the amounts of Rhode Island’s annual
malpractice payouts. According to the federal government’s National Practitioner Data
Bank (NPDB), the total value of malpractice payouts made to patients in Rhode Island in
2001 was $22.8 million, up from $21.1 million in 1992. 9 [See Figure 2] This increase of $1.7
million represents a change of only 8 percent over nine years, or 0.9 percent a year. During
this same period, costs of medical care increased 46.7 percent nationwide, an average of 5.2
percent a year. 10 (Health-care costs, which directly affect health insurance premiums, make
up the lion’s share of most medical malpractice awards.)
Figure 2
Total Malpractice Payouts, R.I. Physicians, 1992-2002
Malpractice Payouts,
Year
R.I. Physicians
1992 $21,148,750
1993 18,457,750
1994 12,205,800
1995 13,969,800
1996 10,685,750
1997 17,338,000
1998 14,522,750
1999 19,930,750
2000 15,428,800
2001 22,805,250
Source: National Practitioner Data Bank, Sept. 1, 1990 – Sept. 30, 2002.
Public Citizen’s Congress Watch 9 Medical Malpractice in Rhode Island
13. • There has been a significant decrease in the number of malpractice payouts
made in Rhode Island. Statistics from the National Practitioner Data Bank contradict
suggestions by Rhode Island doctors and their political allies that malpractice payouts have
become much more frequent. NPDB data show that the number of annual malpractice
payouts to patients declined by 21 percent, from 73 in 1997 to 58 in 2001, during the most
recent five years for which complete statistics are available. 11 [See Figure 3]
• Million-dollar malpractice payouts have remained flat. Proponents of Rhode
Island’s legislation to limit the legal rights of injured patients assert that “verdicts and
settlements in medical malpractice actions exceeding $1 million have increased steadily over
the past 20 years, resulting in losses to many malpractice insurers.”12 In fact, data reported to
the National Practitioner Data Bank show that the state has experienced no such recent
pattern. From 1992 through 2001, the average number of malpractice payouts of a million
dollars or more was less than two per year, and never exceeded three in any of those years. In
2001, the total number of payouts of $1 million or more was three – the same as in 1992.
Additionally, the number of malpractice payouts between $500,001 and $1 million showed
no steady, upward trend during these years, averaging 9.4 per year. In 2001, the number of
payouts in this range was 11, less than the 13 in 1992. 13 [See Figure 4]
Figure 3
Number of Malpractice Payouts in Rhode Island, 1997-2001
80
Number of Payments
73
70
67 65
63
60
58
50
40
1997 1998 1999 2000 2001
Year
Source: National Practitioner Data Bank, Sept. 1, 1990 – Sept. 30, 2002.
Public Citizen’s Congress Watch 10 Medical Malpractice in Rhode Island
14. Figure 4
Malpractice Payouts Exceeding
$500,000 in Rhode Island, 1992-2001
Number of
Number of
Payouts
Payouts
Year Between
More Than
$500,001 –
$1,000,000
$1,000,000
1992 13 3
1993 9 2
1994 8 0
1995 8 1
1996 3 0
1997 11 0
1998 5 1
1999 13 3
2000 13 1
2001 11 3
Average 9.4 1.4
Source: National Practitioner Data Bank, Sept. 1, 1990 – Sept. 30, 2002.
• Malpractice payouts are insignificant when compared with the state’s overall
healthcare expenditures. Total spending on health care in Rhode Island was $4.5 billion
in 1998, the last complete year for which data is available from government sources. 14 In that
year, doctors’ malpractice payouts made to patients in Rhode Island totaled $14.5 million. 15
Thus, doctors’ malpractice payouts were equivalent to only 0.32 percent of healthcare
expenditures in the state.
Public Citizen’s Congress Watch 11 Medical Malpractice in Rhode Island
15. Rhode Island Doctor’s Medical Malpractice
Premiums: Rising Less than Inflation Rate
As a group, Rhode Island doctors have seen a decline in the premiums they pay, when inflation
is considered. According to the National Association of Insurance Commissioners (NAIC), the
total amount that Rhode Island doctors paid in malpractice insurance premiums in 2001 was
$21.6 million, compared with $19.5 million in 1996. This is an increase of only 11 percent
during this period (the most recent five years for which statistics are complete). When adjusting
for medical inflation, which was 19.8 percent for this same period) and the growing number of
physicians in the state, this represents a significant decline in actual dollars. 16 [See Figure 5]
Figure 5
Total Medical Malpractice Premiums
Paid in Rhode Island, 1996-2001
Direct
Year Premiums
Earned
1996 $19,478,952
1997 22,358,738
1998 22,196,884
1999 25,102,502
2000 21,777,121
2001 21,581,983
Source: National Association of Insurance Commissioners, “Medical
Malpractice Insurance Net Premium and Incurred Loss Summary,” July 2001.
• Malpractice insurance premiums are lower in Rhode Island than in
neighboring states. A comparison of medical malpractice premiums charged by one
insurance group that serves Rhode Island, Connecticut and Massachusetts shows that Rhode
Island doctors generally pay less – in some cases, much less – than their counterparts in
neighboring states. And one of these two adjacent states, Massachusetts, imposes a $500,000
cap on malpractice awards. According to data published by the insurance industry magazine,
Medical Liability Monitor, rates for general surgeons ranged from 14 percent to 40 percent
less in Rhode Island than in Connecticut or Massachusetts; rates for Ob/Gyns ranged from 6
percent to 23 percent less in Rhode Island than in the other two states; and rates for internists
ranged from 2 percent to 23 percent less in Rhode Island than in the other states. 17 [See
Figure 6]
Public Citizen’s Congress Watch 12 Medical Malpractice in Rhode Island
16. Figure 6
Annual Malpractice Premiums,
Rhode Island Compared with Neighboring States
State Company General Internal
Surgery Ob/Gyn Medicine
Connecticut ProSelect (ProMutual Group) $43,438 $69,499 $7,405
Massachusetts ProMutual 30,246 84,566 9,356
Rhode Island ProSelect (ProMutual Group) 26,040 65,307 7,243
Source: “Trends in 2002 Rates for Physicians’ Medical Professional Liability Insurance,”
Medical Liability Monitor, October 2002.
Public Citizen’s Congress Watch 13 Medical Malpractice in Rhode Island
17. No Evidence of Doctors Abandoning Rhode Island
In published comments, the president of the Rhode Island Medical Society described his state as
“an increasingly hostile environment” and proclaimed: “The word is out that Rhode Island is not
a great place to be a doctor.”18 Statistics indicate, however, that Rhode Island’s medical
environment has attracted a steady increase in physicians. And a lawyer for the Board of Medical
Licensure and Discipline has observed, “Rhode Island has more doctors today than at any time in
the state's history. The residency training program is larger than it has ever been.”19
• The number of doctors residing and practicing in state has grown steadily. In
2002, there were 2,915 practicing physicians and osteopaths with Rhode Island addresses,
compared with 2,623 in 1999, an increase of 11 percent. 20 [See Figure 7]
• The number of licensed doctors also has risen. Many doctors from Connecticut and
Massachusetts also are licensed to practice in Rhode Island. In the past two years alone, the
number of licensed doctors active in Rhode Island increased by nearly 6 percent, from 3,624
in 2000 to 3,838 in 2002. 21
• Rhode Island’s ratio of doctors-to-residents has increased. According to the
American Medical Association, Rhode Island had 277 doctors per 100,000 residents in 1990.
By 2001, that ratio had increased to 365 doctors per 100,000 residents. This is the seventh
highest ratio in the nation. 22
Figure 7
Licensed Physicians and Osteopaths
with Rhode Island Addresses
Year Number of Licensed Doctors
1999 2,623
2000 2,723
2001 2,867
2002 2,915
Source: Rhode Island Board of Medical Licensure and Discipline
Public Citizen’s Congress Watch 14 Medical Malpractice in Rhode Island
18. Repeat-Offender Doctors Are Responsible
for Half of Medical Malpractice Payouts
The insurance and medical communities have argued that medical liability litigation constitutes a
giant “lottery,” in which lawsuits are random events bearing no relationship to the care given by
a physician. 23 If the tort system is a lottery, it is clearly a rigged one, because some numbers
come up more often than others. A small percentage of doctors have paid multiple claims, and it
is these doctors who are responsible for much of the malpractice in Rhode Island. During the 12
years the National Practitioner Data Bank has been operating, 84 percent of Rhode Island doctors
have made no medical malpractice payouts.
• According to the federal government’s National Practitioner Data Bank, which covers
malpractice judgments and settlements since September 1990, 4.8 percent of Rhode Island’s
doctors are responsible for 52.7 percent of all payouts. These 155 repeat-offender doctors
have made two or more malpractice payouts to patients and have paid out $104.7 million in
damages. 24 Even more disturbing, just 1.6 percent of Rhode Island’s doctors (52), each of whom
has paid three or more malpractice claims, are responsible for nearly 26 percent of all payouts.
[See Figure 8]
Figure 8
Number of Medical Malpractice Payouts and
Amounts Paid by Rhode Island Doctors
1990 – 2002
Number
Number of of Doctors Percent/Total Percent of
Total Number Total Amount
Payout Doctors Total Number
that Made of Payouts of Payouts
Reports (3,231) of Payouts
Payouts
All 518 16.0% 768 $191,271,650 100.0%
1 363 11.2% 363 $86,605,350 47.3%
2 or More 155 4.8% 405 $104,666,300 52.7%
3 or More 52 1.6% 199 $49,636,800 25.9%
4 or More 19 0.6% 100 $26,853,250 13.0%
5 or More 9 0.3% 60 $14,646,000 7.8%
Source: National Practitioner Data Bank Annual Reports, Sept. 1, 1990-Sept. 30, 2002. (For these
calculations Public Citizen employs American Medical Association statistics from 1995, midway through the
25
time period, for the total of non-federal, licensed doctors in Rhode Island.)
Public Citizen’s Congress Watch 15 Medical Malpractice in Rhode Island
19. Two-Thirds of Doctors with Four or More
Malpractice Payouts Have not Been Disciplined
The Rhode Island state government and the state’s health-care providers have taken action to
discipline only a fraction of the state’s repeat-offender doctors. According to the National
Practitioner Data Bank and Public Citizen’s analysis of NPDB data:
• Of the 155 physicians in Rhode Island who have made two or more malpractice payouts to
patients since 1990, only 22, or 14.2 percent, have been disciplined by the Rhode Island State
Board of Medical Licensure and Discipline.
• Of the 19 physicians in Rhode Island who have who made four or more malpractice payouts,
only 6, or 31.6 percent, have been disciplined by the board. 26
The extent to which doctors can pay malpractice claims in Rhode Island and not be disciplined is
illustrated by the following NPDB descriptions of the 10 worst offenders who practice in Rhode
Island, none of whom has been disciplined by the state:
• Physician Number 34812 made 14 malpractice payouts between 1992 and 1998 involving
eight obstetrics related incidents, two incidents of failure to manage pregnancy, two
treatment related problems, and two surgery related problems. The damages add up to
$8,995,000.
• Physician Number 62116 made four malpractice payouts between 1994 and 2000 involving
a treatment related problem, failure to treat fetal distress, and two obstetrics related incidents.
The damages add up to $2,510,000.
• Physician Number 55230 made four malpractice payouts between 1994 and 2002 involving
two surgery related problems, failure to obtain consent to perform surgery, two treatment
related incidents, and improper performance of treatment. The damages add up to
$2,405,000.
• Physician Number 34620 made five malpractice payouts between 1991 and 2001 involving
delay in delivery, two obstetrics related problems, failure to diagnose, and a surgical
problem. The damages add up to $1,905,000.
• Physician Number 34699 made four malpractice payouts between 1992 and 2002 involving
improper choice of delivery method, two obstetrics related problems, and a treatment
problem. The damages add up to $1,632,500.
• Physician Number 34676 made four malpractice payouts between 1991 and 1996 involving
improper performance of surgery, a surgical problem, failure to treat, and a treatment related
problem. The damages add up to $960,000.
Public Citizen’s Congress Watch 16 Medical Malpractice in Rhode Island
20. • Physician Number 92505 made five malpractice payouts between 1996 and 1999 involving
two incidents of improper performance of treatment, and three treatment related incidents.
The damages add up to $531,000.
• Physician Number 34610 made five malpractice payouts between 1992 and 2000 involving
a surgical problem, three incidents of treatment problems, two incidents of failure to perform
surgery, and two incidents of wrong treatment performed. The damages add up to $422,500.
• Physician Number 34811 made five malpractice payouts between 1991 and 2001 involving
two incidents of improper performance of surgery, failure to obtain consent for surgery, and
two incidents of surgery related problems. The damages add up to $585,000.
• Physician Number 34706 made four malpractice payouts between 1991 and 2000 involving
improper performance of surgery, a surgery related problem, failure to obtain consent for
surgery, and a miscellaneous incident. The damages add up to $182,250.
Public Citizen’s Congress Watch 17 Medical Malpractice in Rhode Island
21. Where’s the Doctor Watchdog?
Chances that Rhode Island could reduce its rate of malpractice claims by cutting the frequency of
medical errors are weakened by the state’s failure to provide consumers with information about
doctors’ records and by its failure to diligently discipline doctors who commit repeated
malpractice.
• The medical board is among the nation’s less stringent when it comes to
disciplining doctors. In 2002, Rhode Island ranked 35th among all states and the District
of Columbia for the frequency at which it takes disciplinary actions against doctors for
incompetence, misprescribing drugs, sexual misconduct, criminal convictions, ethical lapses
or other offenses. In 2002, the state Board of Medical Licensure and Discipline levied serious
sanctions against only 10 doctors, according to an ongoing Public Citizen project that tracks
“Questionable Doctors” nationwide. 27
Nationally in 2002, there were 3.6 serious actions taken for every 1,000 physicians. The rate
of serious actions by the Rhode Island Board of Medical Licensure and Discipline – 2.6 per
1,000 physicians – was roughly one-fifth of the rate in Wyoming, which is the top-ranked
state with 11.9 serious actions per 1,000 physicians. 28 [See Appendix]
• Five years after a disclosure law was adopted, consumers still can’t get vital
data. Rhode Island has yet to fully implement a 1997 law that called for public disclosure
of profiles containing information about individual physicians. Although some profiles are
available online, 29 they omit two crucial categories: malpractice information and criminal
convictions. According to a lawyer for the Board of Medical Licensure and Discipline, the
disclosure project has been undermined by clerical and computer programming problems and
by the board’s inability to effectively gather information from doctors. Even when the system
is updated this summer, the lawyer said, the profiles will not contain data on doctors’
malpractice payouts. 30
Public Citizen’s Congress Watch 18 Medical Malpractice in Rhode Island
22. Medical Liability Premium Spike Is Caused
by the Insurance Cycle and Mismanagement,
Not the Legal System
For much of the 1990s, doctors benefited from artificially lower insurance premiums. According
to the International Risk Management Institute (IRMI), one of the leading analysts of
commercial insurance issues, “What is happening to the market for medical malpractice
insurance in 2001 is a direct result of trends and events present since the mid to late 1990s.
Throughout the 1990s, and reaching a peak around 1997 and 1998, insurers were on a quest for
market share, that is, they were driven more by the amount of premium they could book rather
than the adequacy of premiums to pay losses. In large part this emphasis on market share was
driven by a desire to accumulate large amounts of capital with which to turn into investment
income.” IRMI also noted: “Clearly a business cannot continue operating in that fashion
indefinitely.”31
• The American Medical Association (AMA) acknowledges that spikes in
malpractice premiums are caused by insurance cycles. In a report by the AMA’s
Board of Trustees to its House of Delegates, the following statements acknowledged that
increasing malpractice insurance premiums were linked to the insurance underwriting cycle:
• “While the number of final settlements have decreased 16%, the expense of settling a
medical liability case has also increased significantly. The insurance underwriting cycle
is now at a point where insurers have both pricing power and a need to increase revenues
through premiums as returns on investments are no longer able to subsidize underwriting
loses [sic] and as insurers have suffered large claims losses in other areas.”32
• “For several years, insurers kept prices artificially low while competing for market share
and new revenue to invest in a booming stock market. As the bull market surged,
investments by these historically conservative insurers rose to 10.6% in 1999, up from a
more typical 3% in 1992. With the market now in a slump, the insurers can no longer use
investment gains to subsidize low rates. The industry reported realized capital gains of
$381 million last year, down 30% from the high point in 1998, according to the A. M.
Best Company, one of the most comprehensive sources of insurance industry data.” 33
Other authoritative insurance analysts and studies indicate that this is a temporary “crisis”
spurred by insurers’ pricing and cash-flow policies, not patient litigation:
• West Virginia regulators emphasize the impact that the economic downturn
has had on the malpractice insurance market. In West Virginia, a state that the
AMA has declared to be in a medical malpractice “crisis,” the Insurance Commission
reported, “[T]he insurance industry is cyclical and necessarily competitive. We have
witnessed these cycles in the Medical Malpractice line in the mid-’70s, the mid-80s and the
present situation. This particular cycle is, perhaps, worse than previous cycles as it was
delayed by a booming economy in the ’90s and is now experiencing not just a shortfall in
Public Citizen’s Congress Watch 19 Medical Malpractice in Rhode Island
23. rates due to competition, but a subdued economy, lower interest rates and investment yields,
the withdrawal of a major medical malpractice writer and a strong hardening of the
reinsurance market. Rates will, at some point, reach an acceptable level to insurers and
capital will once again flow into the Medical Malpractice market.”34
• Medical liability premiums track investment results. J. Robert Hunter, one of the
country’s most knowledgeable insurance actuaries and director of insurance for the
Consumer Federation of America, recently analyzed the growth in medical liability
premiums. He found that premiums charged do not track losses paid, but instead rise and fall
in concert with the state of the economy. When the economy booms and investment returns
are high, companies maintain premiums at modest levels; however, when the economy falters
and interest rates fall, companies increase premiums in response. 35
• The same trends are present in other lines of insurance. Property/casualty refers to
a large group of liability lines of insurance (a total of 30) including medical malpractice,
homeowners, commercial, and automobile. The property/casualty insurance industry has
exhibited cyclical behavior for many years, as far back as the 1920s. These cycles are
characterized by periods of rising rates leading to increased profitability. Following a period
of solid but not spectacular rates of return, the industry enters a down phase where prices
soften, supply of the insurance product becomes plentiful, and, eventually, profitability
diminishes or vanishes completely. In the down phase of the cycle, as results deteriorate, the
basic ability of insurance companies to underwrite new business or, for some companies,
even to renew some existing policies can be impaired. This is because the capital needed to
support the underwriting of risk has been depleted through losses. The current market began
to harden in 2001, following an unusually prolonged period of soft market conditions in the
property-casualty section in the 1990s. The current hard market is unusual in that many lines
of insurance are affected at the same time, including medical malpractice. As a result,
premiums are rising for most types of insurance. The increases have taken policyholders by
surprise given that they came after several years of relatively flat to decreasing prices. 36
• Rhode Island doctors have endured insurance “crises” for 28 years. As recently
as February, the Rhode Island Medical Society’s board of directors acknowledged that the
state had witnessed up-and-down cycles in the medical liability insurance industry since the
mid-1970s. In an advisory to members, the board recounted major problems that occurred
with medical liability insurers in 1975, when coverage became largely unavailable; for a
number of years beginning in 1987, when nine different “risk retention groups” began going
bankrupt; and again in 1993, when a large, unrated carrier, Premier Alliance, became
insolvent. The primary cause for these problems, the board concluded, has been “under-
reserving” of funds by the insurance companies. 37
Public Citizen’s Congress Watch 20 Medical Malpractice in Rhode Island
24. Caps on Damages Are a False “Solution”
Caps on “non-economic damages” are not part of the proposal currently in the state Legislature,
but they are included in a federal bill that Rhode Island’s U.S. senators are considering and has
already passed the U.S. House of Representatives. There is convincing evidence that limits on
awards for pain and suffering penalize severely injured patients the most, without cutting the
frequency of medical errors or reducing the rates doctors pay for liability insurance.
• “Non-economic” damages are not as easy to quantify as lost wages or
medical bills, but they compensate real injuries. So-called “non-economic” damages
are awarded for the pain and suffering that accompany any loss of normal functions (e.g.
blindness, paralysis, sexual dysfunction, lost bowel and bladder control, loss of limb) and
inability to engage in daily activities or to pursue hobbies, such as hunting and fishing. This
category also encompasses damages for disfigurement and loss of fertility. According to
Physician Insurers Association of America (PIAA), the average total payment between 1985
and 2001 for a “grave injury,” which encompasses paralysis, was only $454,454.
• No evidence supports the claim that jury verdicts are random “jackpots.”
Studies conducted in California, Florida, North Carolina, New York, and Ohio have found
that jury verdicts bear a reasonable relationship to the severity of the harm suffered. 38 In
total, the studies examined more than 3,500 medical malpractice jury verdicts and found a
consistent relationship between the severity of the injury and the size of the verdict.
Uniformly the authors concluded that their findings did not support the criticism that jury
verdicts are frequently unpredictable and irrational.
• The insurance industry’s own statistics demonstrate that awards are
proportionate to injuries. The PIAA Data Sharing Report also demonstrates the
relationship between the severity of an injury and the size of the settlement or verdict. 39
PIAA, as do most researchers, measures severity of injury according to the National
Association of Insurance Commissioners’ classifications. 40 The average indemnity paid per
file was $49,947 for the least severe category of injury and increased with severity, to
$454,454 for grave injuries. All researchers found that the amount of jury verdicts fell off in
cases of death, for which the average indemnity was $195,723. This is not surprising, as the
costs of medical treatment for a grave injury are likely to be greater, and pain and suffering
would be experienced over a longer time period than in the case of death. 41
• Capping awards hurts women in particular. Limiting medical malpractice awards for
non-economic injury has a disproportionate impact on women – especially as it relates to a
woman’s ability to have children, according to a study by the director of the Insurance Law
Center at the University of Connecticut School of Law. “This is so for two main reasons,”
reported Tom Baker, Connecticut Mutual Professor of Law. “First, the largest part of the
economic damages in many tort claims is lost wages, and women earn on average less money
than men. Second, the most significant effect of many medical and other injuries inflicted on
women is harm to reproductive capacity. Although this may be hard to believe, harm to
reproductive capacity does not entitle women to receive significant economic damages …
[and] lowering the price of making a women infertile cannot be sound policy.”42
Public Citizen’s Congress Watch 21 Medical Malpractice in Rhode Island
25. Insurance Companies and Their Lobbyists Admit
Caps on Damages Won’t Lower Insurance Premiums
Caps on damages for pain and suffering will significantly lower the awards paid to
catastrophically injured patients. But because such truly severe cases comprise a small
percentage of medical malpractice claims, and because the portion of the medical liability
premium dollar that pays for compensation is dwarfed by the portion that pays for defense
lawyer fees, caps do not lead to lower premiums. Insurance companies and their lobbyists
understand this – so don’t take our word for it, take theirs.
• Premium on the Truth:
“Insurers never promised that tort reform would achieve specific savings.” – American
Insurance Association43
“We wouldn’t tell you or anyone that the reason to pass tort reform would be to reduce
insurance rates.” – Sherman Joyce, president of the American Tort Reform Association44
“Many tort reform advocates do not contend that restricting litigation will lower insurance
rates, and I’ve never said that in 30 years.” – Victor Schwartz, general counsel to the
American Tort Reform Association45
• Florida:
“No responsible insurer can cut its rates after a bill (that caps damages at $250,000) passes.”
– Bob White, president of First Professionals Insurance Co.46
• Mississippi:
“Regardless of what may result from the ongoing tort reform debate, please remember that
such proposed public policy changes are critical for the long-term, but do not provide a
magical ‘silver-bullet’ that will immediately affect medical malpractice insurance rates …
The 2003 rate change [a 45 percent increase] would happen regardless of the special session
outcome.” – Medical Assurance Company of Mississippi47
• Nevada:
“The primary insurer for Las Vegas obstetricians, American Physicians Assurance, has no
plans to lower premiums for several years, if ever, said broker Dennis Coffin.” – The Las
Vegas Review-Journal 48
“[John Cotton of the Nevada Physicians’ Task Force] noted that even if the bill reflected a
cap of $5, there would not be an immediate impact on premiums.” – Minutes of the Nevada
Assembly Committee on Medical Malpractice Issues 49
Public Citizen’s Congress Watch 22 Medical Malpractice in Rhode Island
26. • New Jersey:
During a hearing on medical malpractice issues, New Jersey Assemblyman Paul D’Amato
asked Patricia Costante, Chairwoman and CEO of MIIX Group of Companies, “[A]re you
telling the insured physicians in New Jersey that if this State Legislature passes caps that
you’ll guarantee that you won’t raise your premiums, in fact, you’ll reduce them?” Costante
replied: “No, I’m not telling you [or them] that.”50
The New Jersey Medical Society commissioned Tillinghast-Towers Perrin, a leading
actuarial firm, to analyze the effects of a $250,000 cap on pain and suffering damages. The
findings: “We would expect that a $250,000 cap on non-economic damages will produce
some savings, perhaps in the 5 percent to 7 percent range for physicians.” – Letter from
Tillinghast-Towers analysts James Hurley and Gail Tverberg51
• Ohio:
“In the short run, we may even see prices go up another 20 percent, and people will say,
‘Gee, what happened, I thought we addressed this?”’ – Ray Mazzotta, president of
Columbus-based Ohio Hospital Insurance Co. 52
“The stroke of the governor’s pen [enacting caps on damages] will not result in immediate
lowering of rates by responsible companies.” – Frank O’Neil, spokesman for Birmingham,
Ala.-based Medical Assurance 53
• Wyoming:
During a hearing on medical malpractice insurance issues, Bruce Crile of the Doctors’
Company and Melissa Dennison of OHIC Insurance Company testified that insurance rates
would not drop if caps on damages were imposed. “Both the Doctors’ Company and OHIC’s
actuaries say a cap of $500,000 is meaningless for purposes of ratemaking. Even with caps
enacted premiums will still increase, but with predictability of the risk there will be a
moderating of rate increases.” – Minutes of the Wyoming Legislature’s Joint Labor, Health
and Social Services Interim Committee 54
Public Citizen’s Congress Watch 23 Medical Malpractice in Rhode Island
27. Rather than Facing “Runaway Litigation,”
Doctors Benefit from a Claims Gap
Although no comparable studies have been cited in Rhode Island, there is convincing evidence
from around the nation that the majority of patients who suffer injuries from medical malpractice
never file lawsuits.
• A landmark Harvard Medical Practice Study found that only a small percentage
of medical errors result in lawsuits. Twelve years ago, Harvard researchers using a
sample of hospitalizations in New York State compared medical records to claims files. They
found that only one in 7.6 instances of medical negligence committed in hospitals results in a
malpractice claim. 55 Researchers replicating this study made similar findings in Colorado and
Utah. 56 [See Figure 9]
• Actual numbers collected by government agencies show a similar claims gap.
A Florida statute requires hospitals to report “adverse incidents,” defined as “an event over
which health care personnel could exercise control” that results in death or injury. Tables
prepared by Florida’s Agency for Health Care Administration have compared reports of
adverse incidents to filing of new malpractice claims. From 1996 through 1999, Florida
hospitals reported 19,885 incidents but only 3,177 medical malpractice claims. 57 In other
words, for every six preventable medical errors only one claim is filed. [See Figure 10]
• Malpractice insurance costs amount to only 3.2 percent of the average
physician’s revenues. According to experts at the federal government’s Medicare
Payment Advisory Commission (MedPAC), who have no axe to grind about medical
liability, liability insurance premiums make up just a tiny part of a physician’s expenses and
have increased by only 4.4 percent over the last year. 58 The increase in this expense is
noticeable primarily because of the decreases in reimbursements that doctors are receiving
from HMOs and government health programs.
• The compensation gap helps explain why, although medical injuries are
costly, expenditures on medical liability comprise less than 1 percent of
overall health care costs. As the Congressional Budget Office reported, “Malpractice
costs account for a very small fraction of total health care spending; even a very large
reduction in malpractice costs would have a relatively small effect on total health plan
premiums. In addition, some of the savings leading to lower medical malpractice
premiums—those savings arising from changes in the treatment of collateral-source benefits—
would represent a shift in costs from medical malpractice insurance to health insurance.”59
Public Citizen’s Congress Watch 24 Medical Malpractice in Rhode Island
28. Figure 9
Malpractice Claims Gap:
Ratio of Medical Errors to Claims Filed
10
7.6
8 6.7
6 5.1
4
2 1 1 1
0
New York Colorado Utah
Medical Errors Malpractice Claims
Source: Harvard Medical Practice Study Group, Patients, Doctors and Lawyers: Medical Injury,
Malpractice Litigation, and Patient Compensation in New York (1990); Studdert et al, “Beyond Dead
Reckoning: Measures of Medical Injury Burden, Malpractice Litigation, and Alternative Compensation
Models from Utah and Colorado,quot; 33 Ind. L. Rev. 1643 (2000).
Figure 10
Florida Malpractice Claims Gap: 1996-1999
Ratio of Medical Errors to Claims Filed
25,000
19,885
20,000
15,000
10,000
5,000 3,177
0
Adverse Malpractice
Incidents Claims
Source: The Agency for Health Care Administration, Division of Health Quality Assurance. Reported
malpractice claims by district compared to reported adverse incidents 1996, 1997, 1998, 1999
Public Citizen’s Congress Watch 25 Medical Malpractice in Rhode Island
29. Few Malpractice Lawsuits Are “Frivolous”
Legislation introduced in the Rhode Island General Assembly contains provisions designed to
make it harder for injured patients to seek compensation. Shortened statutes of limitations, tight
deadlines for preparing cases and mandatory “certificates of merit” are needed, the bill’s
sponsors claim, to combat “the many meritless claims” that patients have filed. 60
Additionally, the President and some members of the U.S. Senate and House have made similar
comments about “frivolous lawsuits” in their efforts to promote a federal medical malpractice
bill that would place caps on pain-and-suffering awards to injured patients. 61
In reality, medical malpractice cases are brought on a contingency fee basis, meaning the
attorney receives payment only in the event there is a settlement or verdict. If the claim is closed
without payment, the attorney does not receive a fee. Since attorneys must earn money to stay in
business, it follows that they would not intentionally take on a non-meritorious case.
• The high cost of preparing a medical malpractice case discourages frivolous
claims – and meritorious claims as well. Medical malpractice cases are very
expensive for plaintiffs’ attorneys to bring, with out-of-pocket costs for cases settled at or
near the time of trial (when most cases are settled) ranging from $15,000 to $25,000. 62 If the
case goes to trial, the costs can easily be doubled. 63 These costs do not include the plaintiff’s
attorney’s time, and an attorney pursuing a frivolous case incurs opportunity costs in not
pursuing other cases. An attorney incurs expenses beginning with the determination of
whether a case has merit. First, the attorney is required to obtain copies of the patient’s
medical records from all the providers for analysis by a competent medically trained person.
If that initial consultation reveals a likelihood of medical negligence, the records must then
be submitted to medical specialists, qualified to testify in court, for final review. Typically,
the records must be sent to experts outside of the plaintiff’s state, as physicians within the
state will refuse to testify against local colleagues. As a result, the experts who agree to
review records and testify can and do charge substantial fees. Fees from $1,000 per hour to
several thousand dollars are not uncommon. 64 Discovery involves taking the sworn testimony
of witnesses and experts. Such depositions cost $300 and up, depending upon their length
and complexity. If an expert witness is deposed, the plaintiff’s attorney is charged for the
witness’ preparation time and time attending the deposition.
• The small numbers of claims pursued to a defense verdict are not frivolous.
Researchers at the American Society of Anesthesiologists arranged for pairs of doctors to
review 103 randomly selected medical negligence claims files. 65 The doctors were asked to
judge whether the anesthesiologist in question had acted reasonably and prudently. The
doctors only agreed on the appropriateness of care in 62 percent of the cases; they disagreed
in 38 percent of cases. The researchers concluded, “These observations indicate that neutral
experts (the reviews were conducted in a situation that did not involve advocacy or financial
compensation) commonly disagree in their assessments when using the accepted standard of
reasonable and prudent care.” The percentage of all medical malpractice claims that go to
trial is only 6.6 percent, according to PIAA, meaning that the parties and their attorneys
Public Citizen’s Congress Watch 26 Medical Malpractice in Rhode Island
30. ultimately reach agreement about liability five times more often than neutral doctors do. If
truly frivolous lawsuits were being pursued, the proportion of claims going to trial would
exceed the 38 percent of claims on which even doctors will disagree.
• The costs of defending claims that are ultimately dropped are not
unreasonable. Medical liability insurers have complained about the costs of defending
cases that are ultimately dropped. But the professional obligation of lawyers to exercise due
diligence is essentially identical to the duty of physicians. The lawyer must rule out the
possibility of proving medical negligence before terminating a claim, just as doctors must
rule out the possibility of illnesses suggested by their patients’ symptoms. The doctor
performs his duty by administering tests; the lawyer performs hers by using discovery
procedures. Both processes can lead to dead ends. But plaintiffs’ lawyers have no financial
incentive to abuse the litigation process: they are using their own time and money to pursue
discovery activities, and are only paid for work on behalf of clients whose cases are
successful.
Public Citizen’s Congress Watch 27 Medical Malpractice in Rhode Island
31. Empirical Evidence Does not Confirm the Existence
of “Defensive Medicine” – Patient Injuries Refute It
In many states, when questions about malpractice “reform” arise, doctors and their lobbyist’s
claim that a fear of litigation has prompted physicians to perform additional medical tests –
resulting, they say, in higher costs and risks to patients. A search of studies and scholarly
literature, however, finds no empirical evidence that doctors are actually practicing this sort of
“defensive” medicine:
• A search of the scholarly literature on medicine will turn up dozens of studies
documenting the incidence of medical errors, but not one peer-reviewed study
documenting purely defensive medicine. One might laugh at the spectacle of a
lobbying campaign constructed around a flimsy theory unsupported by any empirical
evidence. Unfortunately, the evidence disproving the theory is so overwhelming and
compelling as to be truly frightening. Several recent studies demonstrate that current
disincentives to unsafe and sloppy practices are inadequate, and show how much more
dangerous medical care would be if deterrents were further weakened.
• The Congressional Budget Office has rejected the defensive medicine theory.
The Congressional Budget Office (CBO) was asked to quantify the savings from reduced
“defensive medicine” if Congress passed H.R. 4600. This bill, which contained very stringent
restrictions on patients’ ability to recover damages, passed the U.S. House in 2002. CBO
declined, saying:
Estimating the amount of health care spending attributable to defensive medicine is
difficult. Most estimates are speculative in nature, relying, for the most part, on surveys
of physicians’ responses to hypothetical clinical situations, and clinical studies of the
effectiveness of certain intensive treatments. Compounding the uncertainty about the
magnitude of spending for defensive medicine, there is little empirical evidence on the
effect of medical malpractice tort controls on spending for defensive medicine and, more
generally, on overall health care spending.
A small number of studies have observed reductions in health care spending correlated
with changes in tort law, but that research was based largely on a narrow part of the
population and considered only hospital spending for a small number of ailments that are
disproportionately likely to experience malpractice claims. Using broader measures of
spending, CBO’s initial analysis could find no statistically significant connection
between malpractice tort limits and overall health care spending. Although the provisions
of H.R. 4600 could result in the initiation of fewer lawsuits, the economic incentives for
individual physicians or hospitals to practice defensive medicine would appear to be little
changed. 66
Public Citizen’s Congress Watch 28 Medical Malpractice in Rhode Island
32. • Defensive medicine hasn’t prevented wrong-patient surgery. New York hospitals
reported 27 instances of invasive procedures performed on the wrong patient between April
1998 and December 2001. 67 There were nine such instances in Florida in 2001. 68 In trying to
determine how such shocking errors could occur, researchers analyzed one case in detail. The
case study determined that medical personnel had ignored “many seemingly clear signals that
they were subjecting the wrong patient to an invasive procedure.” In this case, “defensive
medicine” measures would have included follow-up questioning or record-checking when the
patient told personnel she had not been admitted for cardiac treatment. Surely if the medical
providers were frightened of lawsuits they would have made such minimal inquiries.
• Defensive medicine hasn’t prevented medication errors. An Auburn University
study of 36 hospitals and nursing homes in Colorado and Georgia found that on average, 19
percent of medication doses were given in error, with 7 percent judged to be potentially
harmful. 69 The authors said this amounts to about 40 potential adverse drug events per day in a
typical 300-patient facility. The errors were made in spite of the presence of observers from the
research team – who could easily have been called as witnesses in a medical liability lawsuit.
An earlier study by Boston researchers estimated that there are some 500 preventable adverse
drug events in the average hospital each year, in spite of the fact that “drug injuries frequently
result in malpractice claims, and in a large study of closed claims… accounted for the highest
total expenditure of any type of procedure-related injury.”70
• Defensive medicine hasn’t prevented mammography errors. The New York Times
reported in June 2002 some very disturbing facts about errors committed by radiologists in
reading mammograms. 71 Studies indicate that some doctors and clinics miss as many as one
in three cancers. Despite the possibility of lawsuits, doctors with no aptitude for
mammography continue to read mammograms. Clinics continue to employ doctors who read
too few mammograms to keep their skills sharp. It appears that only reviews by regulators
spur doctors and clinics to meet minimum standards.
• Defensive medicine hasn’t prevented hospital infections. The Chicago Tribune
reported on July 21, 2002 that some 75,000 Americans die each year because of infections
acquired in hospitals that “were preventable, the result of unsanitary facilities, germ-laden
instruments, unwashed hands and other lapses.”72 If medical providers fear being sued over
the slightest lapse, why would doctors and nurses neglect to take the most elementary
precautions of washing their hands and changing scrub uniforms? Why would American
hospitals “have collectively pared cleaning staffs by 25 percent since 1995”? 73 Previously,
consultants retained by medical provider groups have argued that medical providers
overspend on precautionary measures by five to nine percent. 74
• Defensive medicine hasn’t caused hospitals to keep nursing staffs up-to-
strength. Two reports published in the past six months concluded that patients in hospitals
where nurses had heavier workloads had a higher risk of dying. 75 One report found
specifically that each additional patient per nurse corresponded to a 7 percent increase in both
patient mortality and deaths following complications. 76 Nevertheless, nursing shortages
persist, even though the defensive medicine theory predicts over-staffing.
Public Citizen’s Congress Watch 29 Medical Malpractice in Rhode Island
33. Solutions to Reduce Medical Errors
Reducing compensation to victims of medical malpractice does not, as doctors contend, “reduce
costs;” it merely shifts the costs of injuries away from dangerous doctors and unsafe hospitals
and onto the injured patients, their families, and taxpayers. This, in turn, reduces the incentive to
practice medicine with due regard to patient safety. The only way to reduce the cost of medical
injuries is to reduce negligence; the best way to accomplish this is by reforming the regulatory
oversight of the medical profession. Public Citizen’s recommendations for addressing the real
medical malpractice problems are:
Open the National Practitioner Data Bank to Empower Consumers with
Information About Their Doctors
Information about doctor discipline, including state sanctions, hospital disciplinary actions and
medical malpractice awards is now contained in the National Practitioner Data Bank. HMOs,
hospitals and medical boards can look at the National Practitioner Data Bank. Unfortunately,
consumers cannot because the names of physicians in the database are kept secret from the
public. Congress should lift the veil of secrecy and allow the people who have the most to lose
from questionable doctors to get the information they need to protect themselves and their
families.
Implement Patient Safety Measures Proposed by the Institute of Medicine
Public Citizen believes in personal responsibility and accountability for negligence as one of the
principal methods for deterring medical errors. Nevertheless, we acknowledge that the “systems
approach” to patient safety advocated by the Institute of Medicine shows considerable promise.
We are disappointed that some three years after the release of its report, almost nothing has been
done to establish mandatory nationwide error reporting systems, identify unsafe practices, or
raise performance standards.
• Medication errors are among the most common preventable mistakes, but
safety systems have been put in place in very few hospitals. Although experts
using the systems approach have identified a number of promising strategies to reduce
malpractice, few have been implemented. Experts have estimated that more than 950,000
serious drug errors occur annually in hospitals alone. 77 Recent studies show that computer
physician order entry (CPOE) systems can reduce error rates by 55 percent, 78 CPOE is an
electronic prescribing system that intercepts errors where they most commonly occur – at the
time medications are ordered. Physicians enter orders into a computer, rather than on paper.
Orders are automatically checked for potential problems, such as drug interactions or
allergies. CPOE also resolves problems associated with deciphering doctors’ notoriously bad
handwriting. But in spite of these benefits, fewer than three percent of hospitals have fully
implemented CPOE. 79
Public Citizen’s Congress Watch 30 Medical Malpractice in Rhode Island
34. • Evidence-based hospital referral could save 4,000 lives every year, but has not
been implemented. Evidence-based hospital referral means directing patients with high-
risk conditions to hospitals with characteristics shown to be associated with better outcomes.
Dr. Adams Dudley, a researcher at the University of San Francisco at California, identified
10 surgical procedures for which outcomes were strongly related to hospital volume. Using
data from California hospitals, he estimated that using evidence-based hospital referral for
those 10 procedures would prevent over 4,000 deaths across the U.S. each year. 80
• Surgery performed on the wrong part of the body, to the wrong patient, and
performing the wrong procedure on a patient are all completely preventable,
yet continue to occur. Such mistakes should never happen, according to a special alert
reissued December 5, 2001 by the Joint Commission on Accreditation of Healthcare
Organizations. 81 To prevent these accidents, the JCAHO recommends the surgical site be
marked with a permanent marker. Sometimes referred to as “signing your site,” doctors
place their initials on the surgical site with a permanent marking pen in a way that cannot be
overlooked and then actually operate through or next to the initials. JCAHO also recommends
orally verifying the surgery in the operating room just before starting the operation. 82
Limit Physicians’ Workweek to Reduce Hazards Created by Fatigue
American medical residents work among the highest—if not the highest—number of hours in the
professional world. They work up to 120 hours a week, including 36-hour shifts for several
weeks at a time. 83 After 24 hours of wakefulness, cognitive function deteriorates to a level
equivalent to having a 0.10 percent blood alcohol level. 84 In other words, doctors who would be
considered too unsafe to drive may still treat patients for 12 more hours. 41 percent of resident-
physicians attribute their most serious mistake in the previous year to fatigue. 85 45 percent of
residents who sleep less than four hours per night report committing medical errors. 86 Working
these extreme hours for years at a time also has ill-effects on doctors’ own personal health and
safety. Multiple studies in the medical literature demonstrate that sleep-deprived and overworked
residents are at increased risk of being involved in motor vehicle collisions, suffering from
depressed mood and depression, and giving birth to growth-retarded and/or premature infants. 87
If the maximum workweek for residents was limited to 80 hours, it could considerably reduce
mistakes due to fatigue and lack of supervision.
Ensure Adequate Nurse Staffing
Two reports published in the past year concluded that patients in hospitals where nurses had
heavier workloads had a higher risk of dying. 88 One report found specifically that each additional
patient per nurse was associated with a 7 percent increase in both patient mortality and deaths
following complications. 89 Both houses of the Rhode Island General Assembly now are
considering two bills that address issues of nurse overwork and fatigue. One measure would
prevent mandatory overtime for hourly paid nurses, except in cases of emergencies. 90 The other
would require hospitals to ensure an adequate ratio of nurses-to-patients, depending on the types
or care and injuries. 91
Public Citizen’s Congress Watch 31 Medical Malpractice in Rhode Island
35. Improve Oversight of Physicians
Public Citizen has long sought greater consumer access to information about doctors, and there
have been recent improvements in making that information available. Most state medical boards
now provide some physician information on the Internet, but the information about disciplinary
actions varies greatly, is often inadequate and can be difficult for people to access. 92
For more than a decade, Public Citizen’s Health Research Group has been carefully scrutinizing
the performance of state medical boards. As reported in our Questionable Doctors publication93
and on the website www.questionabledoctors.org too little discipline is being done. Too many state
medical boards, despite their duty to protect the public, still believe their first responsibility is to
rehabilitate “impaired physicians” and shield them from the public’s prying eyes. Fewer than
one-half of 1 percent of the nation’s doctors face any serious state sanctions each year. The 2,708
total serious disciplinary actions a year, the number state medical boards took in 2001, are a
pittance given estimates that between 44,000 and 98,000 deaths of hospitalized patients are
caused by medical errors annually.
State discipline rates ranged from 10.52 serious actions per 1,000 doctors (Arizona) to 0.73
actions per 1,000 physicians (District of Columbia), a 14.4-fold difference between the best and
worst states. If all the boards did as good a job as the lowest of the top five boards, Kentucky’s
rate of 6.32 serious disciplinary actions per 1,000 physicians, it would amount to a total of 5,089
serious actions a year. That would be 2,381 more serious actions than the 2,708 that actually
occurred in 2001. It is likely that patients are being injured or killed more often in states with
poor doctor disciplinary records than in states with consistent top performances.
Negligent doctors are rarely disciplined with loss or suspension of their license for inferior care.
Instead, state medical boards focus on more easily documentable offenses such as prescription
drug violations and fraud convictions or disciplinary action in another state as potential
indicators of substandard care. Congress could encourage better oversight through grants to state
medical boards, tied to the boards’ agreements to meet performance standards. The following
state reforms would help protect patients:
• Reform medical board governance. States should sever any remaining formal,
debilitating links between state licensing boards and state medical societies. Members of
medical boards (and separate disciplinary boards, where present) should be appointed by the
governor, and the governor’s choice of appointees should not be limited to a medical
society’s nominees. At least 50 percent of the members of each state medical board and
disciplinary board should be well-informed and well-trained public members who have no
ties to health care providers and who, preferably, have a history of advocacy on behalf of
patients. The governor should appoint members to the Medical Board whose top priority is
protecting the public’s health, not providing assistance to physicians who are trying to evade
disciplinary actions.
Public Citizen’s Congress Watch 32 Medical Malpractice in Rhode Island
36. • Beef up medical board funding and staffing. State legislatures should permit medical
boards to spend all the revenue from medical licensing fees, rather than being forced to give
part to the state treasury. The medical boards should raise their fees to $500 a year. All
boards could benefit from hiring new investigators and legal staff. Boards should employ
adequate staff to process and investigate all complaints within 30 days, to review all
malpractice claims filed with the board, to monitor and regularly visit doctors who have been
disciplined to ensure their compliance with the sanctions imposed, and to ensure compliance
with reporting requirements. They should hire investigators to seek out errant doctors,
through review of pharmacy records, consultation with medical examiners, and targeted
office audits of those doctors practicing alone and suspected of poor care.
• Require risk prevention. States should adopt a law, similar to one in Massachusetts, that
requires all hospitals and other health care providers to have a meaningful, functioning risk
prevention program designed to prevent injury to patients. Massachusetts also requires all
adverse incidents occurring in hospitals or in doctors’ offices to be reported to the medical
board.
• Require periodic recertification of doctors based on a written exam and audit
of their patients’ medical care records.
Public Citizen’s Congress Watch 33 Medical Malpractice in Rhode Island
37. Solutions to Make Insurance Rates More Predictable
The following recommendations for state insurance regulators to implement have been made by
J. Robert Hunter, Director of Insurance for the Consumer Federation of American, on behalf of
Americans for Insurance Reform: 94
Investigations and Audits
There must be a full and thorough investigation of the insurance companies’ data to determine if
there are errors and over-reserving in the data. An investigation should determine:
1) The extent to which the extraordinarily high profitability of the insurance industry during
much of the 1990s, and its lower profitability today, is related to the performance of
interest rates and the stock market during those periods;
2) The extent to which today’s rate increases are an attempt to recoup money that insurers
lost in the stock market or in other poorly-performing assets;
3) The extent to which insurers are adversely affected by today’s low interest rates;
4) Whether insurers’ estimates of their future claims payments, which are the basis for rate
increases, are unreasonably high today; and
5) Whether it is proper, or lawful, for insurers to seek substantial rate increases despite
having hugely increased their surplus – the money they have “in the bank,” with
policyholder-supplied funds, particularly if the insurer is overcapitalized.
In addition, state insurance commissioners are urged to institute, or seek statutory authority to
institute, annual, rather than the typical once-every-three-years, audits of insurance companies
operating in their state. These annual audits should ascertain whether the companies are engaging
in questionable accounting practices and whether their business and investment practices, by
failing to take into account cyclical economic downturns, present unacceptable financial risks for
insurance consumers and shareholders.
Specific Reforms
• Regulate excessive pricing. One cause of the cycle is the lack of regulatory action to
end excessive and inadequate rates during the different phases of the cycle. Insurance
Commissioners should start now by regulating the excessive prices being charged by
insurers. They should, at least, hold the necessary hearings to determine if the prices are not
excessive.
Public Citizen’s Congress Watch 34 Medical Malpractice in Rhode Island