Scott Ransom DO, MBA, MPH

1
The Impact of Medical Malpractice on Provider
Satisfaction and Supply

• Scott Ransom DO, MBA, MPH
• President
• Professor in Obstetrics, Gynecology,
• Health Management and Policy

2
Acknowledgments

• The studies presented were supported by Grant
  1060.II from the Blue Cross Blue Shield of
  Michigan Foundation and by the NIH Roadmap
  Initiative Grant 1 P20 RR020682-01.
• Key collaborators from the University of
  Michigan, Ann Arbor
• Xiao Xu, PhD
• Kristine Siefert, PhD, MPH
• Peter Jacobson, JD, MPH
• Jodi Lori, MS, CNM
• The Wayne County Medical Society of Southeast
  Michigan and the Southeastern Michigan ACNM
  Chapter helped advertise the study through their
  website and/or monthly newsletter.

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Related Publications

• Xu X, Siefert KA, Jacobson PD, Lori JR, Ransom
  SB. The effects of medical liability on obstetric
  care supply in Michigan. American Journal of
  Obstetrics Gynecology 2008198(2)205.e1-9.
  (2008 BCBSM Foundation McDevitt Excellence in
  Research Award in the area of policy research)
• Xu X, Lori JR, Siefert KA, Jacobson PD, Ransom
  SB. Malpractice liability burden in midwifery A
  survey of Michigan certified nurse-midwives.
  Journal of Midwifery Womens Health
  200853(1)19-27.
• Xu X, Siefert KA, Jacobson PD, Lori JR, Ransom
  SB. The impact of malpractice burden on Michigan
  obstetrician-gynecologists career satisfaction.
  Womens Health Issues 200818(4)229-237.

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Related Publications (continued)

• Xu X, Siefert KA, Jacobson PD, Lori JR,
  Gueorguieva I, Ransom SB. Malpractice Burden,
  rural location, and discontinuation of obstetric
  care a study of obstetric providers in Michigan.
  Journal of Rural Health 2009 25(1)33-42.
• Ransom SB, Dombrowski MP, Shephard R, Leonardi M.
  The Economic cost of the medical-legal tort
  system. American Journal of Obstetrics
  Gynecology 1996 174(6)1903-7.
• Ransom SB, Studdert DM, Dombrowski MP, Mello MM,
  Brennan TA. Reduced Medicolegal risk by
  compliance with obstetric clinical pathways a
  case-control study. Obstetrics Gynecology
  2003101(4)751-5.
• Xu X, Siefert KA, Jacobson PD, Lori JR,
  Gueorguieva I, Ransom SB. Medical Liability
  Burden Differences between Michigan
  obstetricians in metropolitan and
  non-metropolitian areas. In Press

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Medical Malpractice LiabilityBackground
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What is Medical Malpractice?

• Medical malpractice is professional negligence by
  act or omission by a health care provider in
  which care provided deviates from accepted
  standards of practice in the medical community
  and causes injury to the patient.
• Medical malpractice litigation system seeks to
• compensate negligently injured consumers and
  achieve corrective justice
• give health care providers incentive to undertake
  precautionary care and assure good quality of
  care.

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Why Is It a Concern for Physicians?

• Medical malpractice claims in 2007
• 11,482 paid claims on behalf of non-federal
  physicians nationwide
• Averaged 11.8 paid claims / 1,000 non-federal
  physicians
• Medical malpractice litigation
• 50 of liability claims against physicians were
  dropped, withdrawn or dismissed without payment.
  BUT each costs an average of 19,000 to defend.
• Physicians are found not negligent in 91 of
  trial cases.
• STILL, each of these cases costs an average of
  over 100,000 to defend.

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Why Is It a Concern for Physicians?

• Payments of medical malpractice claims in 2007
• 3,717,105,850 nationwide
• Averaged 323,733 / paid claim
• Non-financial costs
• Emotional distress
• Considerable time commitment involved

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Number of Paid Medical Malpractice Claims, 2007
Source Kaiser Family Foundation analysis of data
from the National Practitioner Data Bank.
Available at http//www.statehealthfacts.org/comp
aremapdetail.jsp?ind436cat8sub102yr18typ1
cha1093oa
10
Average Payments on Medical Malpractice Claims,
2007
Source Kaiser Family Foundation analysis of data
from the National Practitioner Data Bank.
Available at http//www.statehealthfacts.org/comp
aremapdetail.jsp?ind437cat8sub102yr18typ4
cha698oa
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Why Is It A Concern for Physicians
Data source Medical Liability Monitor annual
survey 2004-2007
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Why Is It A Concern for the Health Care System?

• Defensive medicine
• Cost 84-151 billion each year
• Patient safety unnecessary procedures and false
  positives
• Reduced access to care
• Retire early
• Discontinuation of high-risk procedures
• Leaving/closing practices in high risk or high
  premium states/areas
• Unwillingness to provide on-call emergency
  department coverage
• Estimated medical malpractice costs in 2006 was
  30.3 billion nationwide

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Obstetrics/Gynecology One of the Most Affected
Specialties

• Professional liability claim filed against
  ob-gyns
• 89 of ob-gyns had 1 claim during their career
• Averaging 2.62 claims / ob-gyn
• Malpractice awards for cases involving ob-gyns
  are extremely high
• Most frequently reported payment amount
  1,000,000
• Average for all paid claims 504,925
• Average payment for claims involving a
  neurologically-impaired infant 1,150,687

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Obstetrics/Gynecology One of the Most Affected
Specialties

• Medical liability insurance premium for ob-gyns
• In 1979, most ob-gyns paid lt 8,000/year
• Nowadays, among the highest of all medical
  specialties
• Family physicians practicing obstetrics are also
  affected
• Even certified nurse-midwives (CNMs), who used to
  be less concerned about the issue, are starting
  to see increases in their liability insurance
  premiums

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Obstetrics/Gynecology One of the Most Affected
Specialties
Source Mello MM. Understanding medical
malpractice insurance A primer. Available at
http//www.rwjf.org/pr/synthesis/reports_and_brief
s/pdf/no8_primer.pdf
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Medical Liability Climate in Michigan

• Michigan is classified by the AMA as a state
  showing signs of looming medical liability crisis
• In 2007, 414 paid malpractice claims totaling
  55.3 million in paid claims
• 133,490 / paid claim
• 12.3 paid claims / 1,000 non-federal physicians
• Liability insurance premium for ob-gyns in
  Michigan has been among the highest in the country

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Medical Liability Insurance Premium in Michigan

• Data source Medical Liability Monitor annual
  survey 2004-2007

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Research Question

• Media reports and increasing objective data
  obstetricians discontinue obstetrics or stop
  delivering babies because of
• fear of malpractice lawsuits
• difficulty in the availability and affordability
  of malpractice insurance.
• No data on obstetric providers experience
• laws and regulations that govern malpractice
  insurance and litigation are generally made at
  the state level
• prior research has shown strong evidence of
  variation in claim severity across states.

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Design of Our Study
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Specific Aims

• To assess obstetric providers medical
  malpractice liability burden
• To examine the influence of medical malpractice
  burden on obstetric providers clinical practice

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Data Source - Survey

• A statewide survey of 2,282 obstetrical providers
  in 2006 included
• 800 ob-gyns
• 1,200 family medicine / general practice
  physicians
• 282 nurse-midwives
• Sampling frame
• AMA Physician Masterfile
• American College of Nurse-Midwives member mailing
  list
• U of M Nurse-Midwifery program senior students
  mailing list

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Data Source - Survey

• A self-administered questionnaire with repeated
  follow-ups
• Over-sampled
• Ob-gyns
• CNMs
• Non-office-based physicians (e.g., hospital
  employed, residents, fellows)
• Physicians in rural counties
• No financial incentives for completing the survey
• Overall response rate 48.1

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Study Population
2,282 surveys
2,175 surveys
107 undeliverable surveys
1,046 respondents (48.1)
1,129 Non-Respondents
899 respondents currently engaged in clinical
practice in MI or in a residency/fellowship/nurse-
midwifery program in MI
101 not currently active in clinical care
29 not currently practicing in MI
17 insufficient data
Ob-gyns (n330 48.2)
Family physicians (n416 41.3)
Nurse-midwives (n153 76.9)
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Study Population Statistical Analysis

• Weights were created and routinely used in data
  analysis to adjust for unequal probability of
  sampling (stratified random sampling) and
  non-response bias
• Bivariate and multivariate analyses with
  corrections for the survey sample design

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Sample Characteristics
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Respondent Characteristics
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Medical Malpractice Burden
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Medical Malpractice Claim Experience
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Medical Liability Insurance Coverage
Note Data reported in this table do not include
residents/fellows/nurse-midwifery students.
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Impact of Medical Malpractice Pressure on
Obstetric Practice
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Overall Impact of Malpractice Pressure on
Clinical Practice
Note Data reported in this table do not include
residents/fellows/nurse-midwifery students.
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Practice of Defensive Medicine Ob/Gyn
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Practice of Defensive Medicine FP/GP
34
Practice of Defensive Medicine CNM
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Planned changes in obstetric care provision among
Michigan providers who were currently practicing
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Plans for future practice among residents and
fellows
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Frequently Cited Reasons to Include Obstetrics in
Practice

• Compatibility with lifestyle/family life
• 48.8 ob-gyns
• 58.2 family physicians
• 53.6 of nurse-midwives
• Interest in obstetrics
• 45.7 of ob-gyns
• 36.3 of family physicians
• 53.6 of nurses-midwives
• Risk of malpractice litigation
• 45.5 of ob-gyns
• 47.7 of family physicians
• 29.3 of nurse-midwives

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Factors Affecting Provider Choice of Practice
Location
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Summary of Key Findings

• 18.3, 18.7, and 11.9 of ob-gyns, family
  physicians, and nurse-midwives, respectively,
  planned to discontinue delivering babies in the
  next 5 years
• 35.5, 24.5, and 12.6 of ob-gyns, family
  physicians, and nurse-midwives, respectively,
  planned to reduce their provision of high-risk
  obstetric care
• Risk of malpractice litigation was 1 of the
  most cited factors affecting providers decision
  to include obstetrics in their practice

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Does Compliance with Standards Reduce Medical
Malpractice Risk?

• Noncompliance with clinical pathways was
  significantly more common among claims than
  controls (43.2 versus 11.7, Plt0.001 odds ratio
  5.76, 95 confidence interval (3.59,9.2)
• Adherence to clinical pathways might protect
  clinicians and institutions against medical
  malpractice litigation
• Ransom SB, Studdert DM, Dombrowski MP, Mello MM,
  Brennan TA. Reduced medicolegal risk by
  compliance with obstetric clinical pathways a
  case-control study

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Questions?
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