Using Sovereign Immunity to Examine the Effects of Tort Liability on Defensive Medicine and Health

利用主权豁免来检验侵权责任对防御性医学和健康的影响

• 批准号: 10266836
• 负责人: Kandice Ann Kapinos
• 金额: $ 9.72万
• 依托单位: RAND CORPORATION
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-09-30 至 2023-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10266836
• 关键词: Accident and Emergency department; Accounting; Address; Adult; Affect; Age; Award; Caring; Characteristics; Charge; Clinical; Complex; Data; Defensive Medicine; Diagnosis; Elderly; Emergency Department patient; Emergency department visit; Ensure; Expenditure; Experimental Designs; Fees; Financial compensation; Florida; Frequencies; Fright; Grant; Health; Health Care Costs; Healthcare; Healthcare Fees; Hospital Departments; Hospitalization; Hospitals; Image; Immunity; Incidence; Individual; Industry; Inpatients; Insurance; Laws; Lawyers; Legal; Liability Insurance; Litigation; Malpractice; Mediating; Medical; Medical Errors; Medicare; Natural experiment; Negligence; Outcome; Pain; Pathway interactions; Patient Care; Patients; Pattern; Personal Liabilities; Physicians; Policies; Population; Probability; Provider; Quality of Care; Recovery; Reporting; Research; Research Project Summaries; Services; State Hospitals; System; Teaching Hospitals; Testing; Time; Tort; Universities; Unnecessary Procedures; Work; base; cost; health care settings; improved; inpatient service; medical malpractice; military health system; multiple chronic conditions; novel; patient safety; payment; prevent; unnecessary treatment; wasting

Project Summary Research suggests that the U.S. wastes billions each year on defensive medicine – unnecessary procedures and treatment that add no clinical value—with recent estimates suggesting that defensive medicine might account for 8-20% of Medicare spending and over 1/3 of overall hospital spending. Much of the “waste” occurs in hospital settings (e.g. low-value imaging and testing, unnecessary hospitalizations) where 85% of inpatient stays and 53% of emergency department (ED) visits are among adults age 45 and older. Although the fear of medical malpractice lawsuits may help prevent medical errors and improve patient safety, it may also result in over-utilization and higher healthcare costs. In an effort to curb the number of non-meritorious lawsuits and reduce defensive medicine costs, a number of states have enacted tort reforms. Noneconomic damage caps (limits to the amount awarded for “pain and suffering”), have shown the most promising effects, but evidence is mixed on whether these caps have changed the probability of being sued or the supply of physicians. For patients, there appears to be little evidence that caps resulted in changes in quality and mostly evidence of no effects on utilization and costs, except for certain healthcare settings or patients. We know little about the effects of a more substantial reform except from a recent study on the military health system. The authors found a significant effect of liability immunity, but it is unclear the extent to which this effect might hold for the broader US population, and in particular for older adults who are more likely than younger patients to be medically complex, have multiple chronic conditions, and need inpatient care, a setting where 85% of U.S. defensive medicine costs occur. The overall objective of this R03 is to use a natural experimental design to determine the causal effect of liability immunity on inpatient care and expenditures in the civilian health industry. In 2011, the Florida legislature extended the state's sovereign immunity to cover non-profit university teaching hospitals, eliminating personal liability for physicians practicing in six large hospitals accounting for roughly 10% of the state's hospital caseload. Sovereign immunity, in contrast to damage caps or other reforms that modify payment amounts, serves as a legal bar to lawsuits. Using individual-level hospital inpatient discharge and emergency department data covering all patients in Florida over a 10-year period, we will use a regression-adjusted difference-in-differences strategy to compare changes in defensive practice, quality, and charges in hospitals granted immunity to other large hospitals in Florida following the law change. We can also test for mediating factors, including the type of service (e.g. emergency department) and patient characteristics (e.g. age, diagnosis). Based on preliminary findings in the military health system, we hypothesize that liability immunity will reduce the incidence of defensive medicine and quality of care. Our findings have significant potential to inform malpractice reform efforts to address defensive practice to ensure efficiency in healthcare.

项目摘要 研究表明，美国每年在防御性医疗上浪费数十亿美元--不必要的程序， 没有增加临床价值的治疗--最近的估计表明，防御性药物可能是 占医疗保险支出的8-20%，占医院总支出的1/3以上。大部分“浪费”发生在 医院环境（例如，低价值成像和测试，不必要的住院），其中85%的住院患者 住院和53%的急诊（艾德）就诊是45岁及以上的成年人。虽然害怕 医疗事故诉讼可能有助于防止医疗错误和提高病人的安全，它也可能导致 过度使用和更高的医疗费用。为了遏制无价值诉讼的数量， 为了减少防御性医疗费用，一些州已经颁布了侵权法改革。非经济损失上限 （对“痛苦和折磨”赔偿额的限制）显示出最有希望的效果，但证据表明， 关于这些上限是否改变了被起诉的概率或医生的供应，人们的看法不一。为 患者，似乎没有证据表明，上限导致质量的变化，大多数证据表明，没有 对利用率和成本的影响，但某些医疗机构或患者除外。我们对这一点知之甚少。 除了最近对军事卫生系统的研究之外，更实质性的改革的影响。作者 发现责任豁免的重大影响，但不清楚这种影响可能在多大程度上适用于 更广泛的美国人群，尤其是老年人，他们比年轻患者更有可能 医学上复杂，有多种慢性病，需要住院治疗，85%的美国人 防御性医疗费用。本R 03的总体目标是使用自然实验设计， 确定责任豁免对住院治疗和平民健康支出的因果影响 行业2011年，佛罗里达州立法机构将该州的主权豁免权扩大到非营利性大学。 教学医院，消除了在六家大医院执业的医生的个人责任， 大约占全州医院病例的10%主权豁免，与损害上限或其他改革相比 修改付款金额，作为诉讼的法律的障碍。使用个人级住院病人 出院和急诊科数据涵盖了佛罗里达10年期间的所有患者，我们将使用 回归调整差异中的差异策略，以比较防守实践，质量和 法律修改后，医院的指控赋予了佛罗里达其他大医院豁免权。我们也可以 测试中介因素，包括服务类型（如急诊科）和患者特征 (e.g.年龄，诊断）。根据军队卫生系统的初步调查结果，我们假设， 免疫将减少防御性医疗的发生率和护理质量。我们的发现具有重大意义 潜在的通知医疗事故改革努力，以解决防御性做法，以确保医疗保健的效率。