摘要：Twenty-eight states have laws that limit payments in malpractice cases, and several studies indicate that these laws reduce the frequency and severity of malpractice claims and lower premiums. Moreover, proponents believe that such laws reduce health care expenditures by reducing the practice of defensive medicine. However, there is a dearth of empirical evidence about the impact of these laws on the cost of health care. We used multivariate models and relatively recent data to estimate the impact of state tort reform laws that directly limit malpractice damage payments on health care expenditures. Estimates from these models suggest that laws limiting malpractice payments lower state health care expenditures by between 3% and 4%. THE 2 KEY FUNCTIONS OF our medical malpractice system are to compensate victims of negligent care and to provide appropriate incentives for health care professionals to supply safe and efficient care. 1 , 2 Yet our medical malpractice system rarely compensates individuals who suffer injuries through medical negligence, and it often compensates those who suffer injuries unrelated to medical negligence. A landmark Harvard University study of malpractice claims in New York State found that only 2% of negligent injuries resulted in a claim and that only 17% of claims involved a negligent injury. 3 , 4 Moreover, there is concern that the most damaging attribute of our medical malpractice system is not that it fails to compensate victims or to deter poor performance but that it promotes the practice of “defensive medicine.” In its 1994 report on medical malpractice and the practice of defensive medicine, the Office of Technology Assessment wrote, “For more than two decades many physicians, researchers, and government officials have claimed that the most damaging and costly result of the medical malpractice system as it has evolved in the United States is the practice of defensive medicine: the ordering of tests, procedures, and visits, or avoidance of certain procedures for patients because of concern about malpractice liability risk.” 5 In order to reduce the cost of defensive medicine and to make malpractice insurance more affordable, many physicians, legislators, and others support laws that limit damage payments in medical malpractice cases. 6 , 7 Supporters maintain that escalating, multimillion-dollar awards are driving premium increases and that restricting malpractice payments will lower health care expenditures by reducing the practice of defensive medicine. 8 Opponents maintain that rapidly increasing malpractice premiums are in large part a consequence of insurance companies trying to offset the costs of ill-advised business decisions and declining investment income. Opponents also note that in most geographic areas there are only a few malpractice insurers, and they argue that insurers are able to maintain artificially high prices as a result of the limited competition. They also maintain that underwriting cycles for malpractice insurance have been too severe especially because claims payments have significantly exceeded claims costs for most recent time periods. 9 Others offer different reasons for rapidly escalating malpractice premiums and for the volatility in the market for malpractice insurance. 10 , 11 Some maintain that high premiums results from the risk distribution of malpractice claims (i.e., they argue that there is more uncertainty about the number and size of malpractice claims than there is in other lines of business) and the long average time period for claims settlement periods (i.e., the long time period between when a claim is filed until it is settled). 12 Thus, it is reasoned that insurers must continually increase premiums to maintain large reserves in an effort to support future claim payments. At present, there are 28 states with laws that limit damage payments in malpractice cases (Table 1 ▶ ) (Alaska, California, Colorado, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nevada, New Mexico, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Utah, Virginia, and West Virginia). 13 – 16 In addition, there have been determined efforts to pass legislation limiting damage payments in malpractice cases in Pennsylvania, New Jersey, and Connecticut. 17 – 19 TABLE 1— States With Caps on Malpractice Awards for Noneconomic Damages: United States, 1975–2005 Years With Any Cap Alabama 1987–1991 Alaska 1986– California 1975– Colorado 1986– Florida 1988–1991, 2003– Georgia 2005– Hawaii 1986– Idaho 1990– Illinois 1995–1997, 2005– Indianaa 1975– Kansas 1988– Louisianaa 1975– Maryland 1986– Massachusetts 1986– Michigan 1986– Mississippi 2002– Missouri 1986– Montana 1995– Nevada 2002– New Hampshire 1977–1980 New Mexicoa 1976– North Dakota 1995– Ohio 1975–1994, 1997–1999, 2003– Oklahoma 2004– Oregon 1987–1999 South Carolina 2005– South Dakota 1986– Texas 1977–1988, 2003– Utah 1986– Virginiaa 1976– Washington 1986–1988 West Virginia 1986– Wisconsin 1985–2005 Open in a separate window Note . Open ranges indicate the continued presence of caps. a Cap on total damages; current as of October, 2005. We estimated the impact of state tort reform laws that directly limit malpractice damage payments on all health care expenditures in a state. This is the first empirical study of the impact of such laws on state health care expenditures. Our study combined 1984, 1988, 1994, and 1998 data on state health care expenditures with data on a variety of other state characteristics including information about state tort reform law. Multivariate regression analysis was used to estimate equations explaining health care expenditures per capita where the state was the unit of observation. Several studies have shown that state tort reform laws directly limiting payments in medical malpractice cases reduce the frequency and severity of malpractice claims and lower premiums. 8 Moreover, proponents believe that the passage of such laws reduces health care expenditures because the laws reduce the practice of defensive medicine.
