100,000 deaths and 15,000 permanent disabilities are associeated with physician negligence each year
20 fold difference in morality rates for coronary artery bypass surgery amoung hospitals
blacks have a higher rate of malpractice
The Components of High-Quality Care
Adequate Access to Care
Adequate Scientific Knowledge
Competent Health Care Providers
slow to accept new technologies/methods
Money and Quality of Care
more surgery is harmful
conflict of interest with investments
Health Care Institutions & Quality of Care
great variance in mortality rates--attributed to organization
high volume institutions are better at services
continuous quality improvment (CQI) better for morale than assigning blame
Proposals for Improving Quality
Is it a system or personel error?
Maximizing Excellence
Medical Practice Guidelines
physicians may not be aware of advances due to gaps in training, limited expereince, or insufficient time or motivation
practice guidelines--may not have enough data for them or the cases may be too different--have to take into account the patient’s wishes
Peer Review based on CQI
JCAHO imposed by medicare requiered peer review
peer review is not an effective tool
uses negative incentives, fails to act quickly
very different assesments by different peers
liability for criticizing the physician
Financially Neutral Clinical Decision Making
sallaried physicians
payment per capita with an incentive for preventative treatment (Great Britian)
Improving Institutions
don’t try CQI on low-volume facilities which should be closed
Where does Malpractice Reofrm Fit In?
Goals: to financially compensate people who have suffered medical injuries and to preent physicians from negligently causing harm to their patients
HOWEVER: 99% of patients who are harmed due to negligence recive no compensation and 83% of physicians sued for malpractice have not acted negligently.
leads doctors to added stress and to want to avoid responsibilitiy--particularly with CQI issues
enormous waste--less than half of the malpractice premiums go to physicians
defensive medicine costs 2% of health care costs
based on trial by jury as the best method for assigning blame
low-income people get less because their wages are worth less so lawyers are less likely to take their cases so they get less
takes a long time to compensate injured patients
Tort Reform
Alternative Dispute Resolution
mediation and arbitration
possibly more scientific
The Use of Practice Guidelines to Resolve Claims
would not apply to 80% of claims which are complex
No-fault Malpractice Reform
reduce fees from 50-20% by removing lawyers, but provide no incentive for reforming physicians
Enterprise Liability
incentive to reduce incidents
Conclusion
get the people who know what is going on to have an incentive to work towards improvement