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OCR for page 229
Index
Abortions
based on fetal screening, 46, 47
jury verdicts on malpractice, 175, 176,
183-186, 189
septic, 34
Academic medical centers
access to care in, 69
cesarean sections in 29-30
electronic fetal monitoring in, 11, 17, 20
patient characteristics, 131
practice of obstetrics in, 11, 17, 20, 29-30
Access to obstetrical services
in Community and Migrant Health
Centers, 2, 65-66, 68, 69
ethical issues, 70, 71, 74
health insurance and, 60
for low-income women, 59-76, 78,
83-85, 87, 90-91, 92-93, 121-124
malpractice insurance costs and, 61, 63,
66-70, 73, 81-82, 84, 85, 102, 110,
123, 136-137
Medicaid reimbursement and, 37, 61,
62, 85, 87, 93
through private contracts, 121-124
in rural areas, 78, 85-87, 92-93
threat of liability and, 4, 61, 90-92, 93,
101-103
see also Obstetrical care
AFL-CIO, 137
Alabama, changes in obstetrical practice
in, 2, 82, 136
Alpha-fetoprotein testing, see Maternal
serum alpha-fetoprotein screening
American Academy of Family Physicians,
survey on changes in obstetrical care,
1, 80, 85
229
American Academy of Pediatrics, 47-48
American Bar Association, 137, 195-196,
197
American Bar Foundation, 45
American College of Nurse-Midwives, 104,
105-108
American College of Obstetricians and
Gynecologists (ACOG)
guidelines on cesarean deliveries, 33
hospital survey of malpractice claims,
92
position on electronic fetal monitoring,
24, 33
position on screening tests for new-
borns, 47-48
survey on effects of medical liability, 2,
23, 36, 80-81, 85
American Hospital Association, 167,
213-214, 225
American Medical Association (AMA)
Obstetrics-Gynecology Council on Long-
Range Planning and Development,
162
trial-of-labor guidelines, 33
American Medical Association-Specialty
Society's Medical Liability Project
advantages of, 138, 139
appeals, 143, 145
board review stage, 144-145
claims resolution process, 138, 140,
142-145, 150-151
damages, 146, 150, 151-152, 225
effects on liability and access problems,
149-154
evaluation of effectiveness of, 154
hearing stage, 143-144
OCR for page 230
230 INDEX
incorporation into existing state
systems, 153-154
informed consent considerations
146-147, 225
medical practices review board, 138
141-142, 145-146, 147-149, 150-151
152-153, 225
members, 138, 139
modification for specific types of claims
153-154
negligence and causation evaluation
145-146, 150, 151-152
number of claims anticipated under
150-151
preheating stage, 143
Amniocentesis, 47, 49
Amniotic fluid, meconium staining of, 9
Anencephaly, 46
Apgar scores, 11-14, 16, 30
Arizona
changes in obstetrical practice in, 2, 86
jury verdicts on malpractice in, 168,
171
Asphyxia, 17, 20, 36-37
Attorneys' fees, 91, 98, 157 200, 202, 215
217, 218, 219-220 22i
Auscultation, 9, 13, lo, 19, 22, 24
Bowen, Otis R., 162
Brain damage
claims for, 23, 36-37; see also Cerebral
palsy
costs of long-term care for, 159
defining cause of, 128, 160
California
alpha-fetoprotein testing in, 42, 48, 53
changes in obstetrical practice in, 86
injuries and claims in, 156, 165
jury verdicts on malpractice, 168, 171
172, 174
newborn screening in, 48, 53
California Hospital Association, 165
California Medical Association, 165
Cancer, malpractice verdicts for, 175, 176
184-185, 187, 188
Centers for Disease Control, 44, 45
Cerebral palsy, 36
Cesarean deliveries
in academic medical centers, 29-30
ACOG guidelines on, 33
comparison of national rates, 30-31
costs of, 35-36, 38
defensive, 27-38, 102
demographic factors in, 28-30
electronic fetal monitoring and, 12-14,
16, 22, 31
epidemiology of, 28-31
with fetal distress, 14
growth in, 27-29, 34, 37
historical perspective on, 27-28
and malpractice claims, 36-38
maternal age and, 28-29
maternal morbidity and mortality and
27, 28, 33, 34
and perinatal mortality, 30, 32-33
34-35
prenatal care and, 29
procedures, 28, 32, 33
reasons for, 28-33, 37-38
repeat procedures, 29, 30, 32-33, 38
risks of, 13, 27, 32, 33-34
timeliness of, 27-28
Charity care
decline in, 83, 84
and exemption from liability, 122-123,
133
tied to participation in no-fault compen-
sation plan, 93, 127, 130
Children's Defense Fund, 37
Chorionic villi sampling, 49
Claims, see Malpractice claims and
awards
Clinical Laboratory Improvement Act of
1967, 52-53
Clinics, see Community and Migrant
Health Centers; Freestanding birth
centers
CNA Insurance Company, 107
Cocaine, fetal damage from, 128, 135, 160
College of American Pathologists, 53
Colorado
jury verdicts on malpractice, 168, 171
174
physician participation in Medicaid in
84
physician shortages in, 136
Community and Migrant Health Centers
affiliation with hospitals 63, 65
availability of obstetrical care in, 2
65-66, 68, 69
characteristics of, 62-63, 67
claims experience of, 73
contractual arrangements with other
providers, 68-69
deliveries in, 71
discontinuance of care at time of deliv-
ery, 1, 70, 71, 74
federal appropriations for, 73
Federal Tort Claims Act coverage for
65, 74-75
financial burdens of, 2, 63, 67
future role of, 62
liability concerns of, 63-65
malpractice insurance availability for
72, 73
malpractice insurance premium costs, 2
63, 66, 67, 73
patient characteristics, 2, 62
reduction and elimination of services
63, 66, 73
referral arrangements of, 63, 69, 71
73
staffing, 62-63, 65-71, 74-75, 87
Consumer Price Index, medical care
component of, 216
Costs of obstetrical care
cesarean deliveries, 35-36, 38
in Community and Migrant Health
Centers, 68
OCR for page 231
electronic fetal monitoring and, 16,
19-20, 22
malpractice insurance premiums and, 2,
61, 68, 88-89, 137
neonatal intensive care, 3
prenatal care and delivery by nurse-
midwives, 108, 110
Cragin, E. B., 32
Cystic fibrosis, 49
Dalkon shield, 22
Defensive medicine
cesarean sections as, 27-38
fear of litigation and, 24, 102
research needs on, 5
see also Electronic fetal monitoring
Deliveries (births), see Labor and delivery
Designated compensable events plans
appeals 204
avoidability concept, 211
claims handling, 204
costs of, 139
criteria for specifying coverage, 142,
198-199, 208
disadvantages of, 139-140, 207-208
funding for, 201-202
goals and objectives of, 207-208
implementation by contract, 196, 197
interface with other compensation
systems, 205-206
proof standards, 211
and quality of health care, 207
schedule of awards, 202-203
Developmental disabilities and delays, 11,
44
Diabetes mellitus, 50
Diethylstilbestrol, 22
DNA-based testing, 49-52, 53
Down's syndrome, 48, 121
Dumping of women in labor, 1, 70, 71,
74
Dystocia, 29-33, 38
Ectopic pregnancies, 34
Education, of physicians on use of new
technologies, 47, 48-49, 53, 97, 149
Electronic fetal monitoring (EFM)
ACOG position on, 24, 33
benefits of, 13, 17, 149
and cesarean deliveries, 12-14, 16, 22,
31, 37
costs of, 16, 19, 22
development of, 18
diffusion of, 17-20, 21, 24
and dystocia, 31, 32
effectiveness of, 11-16, 31, 37
evaluation of technology, 11, 12, 18-19,
20, 23-24
with fetal scalp-blood sampling, 10,
12-14, 16, 31
history of, 9-11, 18
interpretation of tracings, 37
and malpractice claims, 20, 21-24, 37,
38
methods, 10
INDEX 231
and neonatal intensive care, 12-13, 15,
16
and neonatal seizures, 12, 13, 15-16
and operative vaginal deliveries, 12-14,
16
policies on, 18-19
prevalence of, 1~11, 20, 31, 36, 102, 110
promised benefits of, 11 31
randomized clinical trials of, 11, 12-16,
18, 20-21
reimbursement rates for, 19-20
risks from, 22, 149
standard of customary practice, 22
validation of diagnosis made by, 10
Ethical issues
in DNA-based testing, 51, 53-54
on health insurance, 51
physician disclosure of participation in
no-fault compensation scheme, 127,
131
termination of care at time of delivery,
1, 70, 71, 74
Familial hypercholesterolemia, 49, 50
Family and general practitioners
changes in obstetrical practice, 1, 2, 59,
80-81, 82, 85-86, 167
claims experience of, 90
in Community and Migrant Health
Centers, 68, 70-71
deliveries per year, 88-89
malpractice insurance premiums for, 2,
72, 78, 88-89
Medicaid participation by, 84, 85
Federal Health Care Quality Improve-
ment Act of 1986, 158
Federal Tort Claims Act, 65, 74-75, 107
Fetal bradycardia, 9, 10
Fetal distress
and cesarean deliveries, 29, 30
indicators of, 9
malpractice claims for, 36, 190, 214
Fetal scalp-blood sampling, 10, 12-14, 16,
31
Florida
caps on attorneys' fees in, 219
malpractice claims in, 136, 156
malpractice insurance premiums in, 216
no-fault compensation in, 138, 153
Food and Drug Administration, regulation
of medical technologies, 17, 19, 47-48,
50, 52
Food, Drug, and Cosmetic Act, 19, 45-46
Freestanding birth centers, 105, 109
General practitioners, see Family and
general practitioners
Genetic defects
counseling on, 51, 53
identification of affected allele, 49-50
see also Screening for birth defects/
genetic disorders; and specific defects
Geographic differences
in access to obstetrical care, 2, 85-87,
136-137, 157
OCR for page 232
232 INDEX
in cesarean section risks, 34
in jury verdicts on malpractice,
168-169, 170-175
in malpractice insurance premiums, 89
in Medicaid reimbursement rates, 2,
88-94
in nurse-midwifery practice, 105
in obstetrical practice patterns, 81, 105,
157
Georgia
changes in obstetrical practice in, 82, 85
jury verdicts on malpractice, 168, 171,
174
Harvard Risk Management Foundation,
36
Hawaii, liability coverage for Medicaid
providers in, 5
Health Care Financing Administration,
53
Health Care Protection Act of 1987, 224
Health care providers, see Family and
general practitioners; Nurse-mid-
wives; Obstetrician-gynecologists;
Physicians
Health departments, see Public health
agencies/programs
Health insurance
and access to care, 60
Blue Cross, 20, 30
and cesarean deliveries, 30
EFM reimbursement policy, 20
ethical issues, 51
premium increases, 110, 138
reimbursement policies for new technol-
ogies, 49, 53
see also Uninsured women
Health maintenance organizations, 48,
118, 196, 197, 205
Hemophilia, 50
High-risk women
characteristics of, 61, 87, 90
EFM use on, 13, 18-19, 20
reduction of care to, 59, 80-83, 87, 90,
137
see also Low-income women; Uninsured
women
Hospitals
closures of obstetrical units, 86
effects of joint and several liability on,
152
emergency room deliveries, 70
exemption from liability for charity
care, 122-123, 133
investor-owned, 30
limits of malpractice coverage, 109
malpractice claims against, by Medicaid
patients, 92
malpractice insurance expenditures by,
154-155
Medicaid deliveries in, 92
not-for-profit, 30
privileges for family practitioners and
nurse-midwives, 69, 109
public, 30, 70
risk management programs, 5
university, see Academic medical cen-
ters
Hysterectomy, 175, 176-177, 184-186,
188, 189
Idaho, changes in obstetrical practice in
86, 105
Blinois
changes in obstetrical practice in, 82, 83
jury verdicts on malpractice, 168, 171,
172, 174
malpractice plaintiffs in, 91
Infant mortality
from asphyxia, 17
cesarean deliveries and, 30, 32-33,
34-35
EFM and, 11-13, 15-17
HHS initiative on, 2-3
neonatal intensive care and, 34-35
perinatal causes of, 37
prematurity and, 35
prenatal care and, 3
socioeconomic status and, 35, 87
U.S. rates of, 35, 78
Informed consent, 23, 101-103, 116,
146-147
Institute of Medicine, Council on Health
Care Technology, 12, 21
Insurance, see Health insurance; Malprac-
tice insurance
Insurance industry
ethical issues involving, 51
regulation of, 215
taxes on, to fund no-fault compensation,
126, 129-130, 196
underwriting practices, 5
see also Malpractice insurance
Intensive care, neonatal, 3, 12-13, 15, 16,
34-35
Ireland
EFM clinical trials, 12-15
PKU screening in, 45
Johns Hopkins University, 44, 47, 165
Johnson, Kirk, 162, 163
Joint underwriting associations, 109
Jury verdicts
ability of juries to evaluate medical
testimony, 138, 190
on abortion cases, 175, 176, 183-186,
189
by cause of injury, 179-184, 186-189,
191
by class of injury, 180-181, 184-185
collateral source rule and, 218
consistency of, 138, 156-157, 187
emotional basis for, 4, 23, 98, 150
filed cases resulting in, 167, 195
geographic distribution of, 168-169,
170-175
on hysterectomy cases, 175, 176-177,
184-186, 188, 189
influence on out-of-court settlements,
163-164, 167-169, 176, 207
OCR for page 233
on labor and delivery cases, 166,
175-176, 183-185, 187, 188-191
methodology for studying, 169-170
need to articulate reasons for, 159
plaintiff success rates, 98, 166,
173-178, 180-183, 186-190
on pregnancy cases, 175-177, 182-185
severity of injury and, 177-178,
182-183, 185-189, 191, 215
sources of information on, 169
studies of, 163
time consumed for, 159, 195
on tubal ligation cases, 175-177,
184-189
see also Lawsuits/litigation; Malpractice
claims and awards
Kansas, 168, 171, 174
Kentucky
changes in obstetrical practice in, 82, 83
physician participation in Medicaid in,
83
Labor and delivery
access to services for, 81
breech, 29, 30, 32, 37, 190
costs of, 35-36, 38, 110
discontinuance of care at time of, 1, 70,
71, 74
forceps, 12-14, 16, 32, 37, 183
in hospitals, by ownership status of hos-
pital, 30
malpractice claims and awards for, 166,
175-176, 183-185, 187, 188-191
malpractice insurance costs per, 2, 61,
88
and maternal mortality, 27, 28, 33, 34
Medicaid, 84, 85, 92
by nurse-midwives, 105, 106
oxytocin protocols, 13, 15, 189-191
premature labor, 35
risks in, 34
see also Cesarean deliveries
Lawsuits/litigation
costs of, 91, 98, 119, 138, 157, 204
expert testimony, 151, 204, 212, 219
information needs for defense against, 4
by low-income women, 37, 61, 90-91, 93
psychological effects on physicians, 90
social attitudes and, 98-99
see also Jury verdicts; Malpractice
claims and awards
Low birthweight, 3, 36, 78, 87, 158
Low-income women
access problems of, 56-76, 78, 83-85,
87, 90-91, 92-93, 121-124
bargaining power in private contracts,
121-124
cesarean deliveries, 30
characteristics of, 60, 61, 78, 87, 90
continuity of care for, 90
effects of liability crisis on, 37, 56-76,
78, 83-85, 87, 90-91, 92-93
infant mortality among, 35, 87
litigation propensity of, 37, 61, 90-93
INDEX 233
low-birthweight infants, 87
prenatal care for, 90
sources of obstetrical care, 2, 61
see also High-risk women; Medicaid;
Uninsured women
Madden v. Kaiser Foundation Hospitals,
133
Malpractice claims and awards
for abortion cases, 183, 185-186
for brain damage, 23, 36-37
for cancer cases, 185, 187
cesarean deliveries and, 36-38
clearinghouses and data bases on, 4,
144-145, 148, 152, 158
and collateral source payments, 137,
147, 152, 218
against Community and Migrant
Health Centers, 73
consumer expectations of medicine and,
149
costs of processing, 200, 214
court filings for, 167
effects on insurance premium costs, 138,
157, 198
electronic fetal monitoring and, 20,
21-24, 37, 38
against family practitioners, 90
under Federal Tort Claims Act, 107
for fetal distress, 36, 190, 214
frequency of, 1, 36, 45, 59, 108, 134,
136, 141, 166, 195, 213, 216
for hysterectomy cases, 185, 186
for labor and delivery cases, 166, 183,
185, 214-215
limits on, 147, 151-152; see also No-
fault compensation
litigation expenses as a portion of, 157
for lost earnings, 64, 147
by low-income women, 37, 61, 90-93
malpractice insurance dollars paid for
38, 138
measu~nt of economic dams - , 91, 147
for neural tube defects, 41
number of medical maloccurrences
resulting in, 164-166, 191
against nurse-midwives, 107, 108
against obstetrician-gynecologists, 1, 73,
90, 108, 137, 215
payments for, 214-215
for phenylketonuria, 41, 43, 45, 48,
51-52
physician costs associated with, 137
and physician fees, 125-126
for pregnancy cases, 182, 185
protection against, 23; see also
Defensive medicine
against public health agency physi-
cians, 73
settled out of court, 23, 125, 143-144,
150, 163-164, 166, 215, 218, 219
settled without payment, 166
severity of, 1, 36, 45, 91, 108, 125,
133-134, 136, 138, 150, 160, 166,
180-182, 191, 195, 213, 216
OCR for page 234
234 INDEX
statute of limitations on, 206
time for resolution of, 137, 150, 215
tort reforms and, 5, 215-216
for tubal ligation cases, 185, 186
see also Jury verdicts; Lawsuits/litiga-
tion; Medical liability
Malpractice insurance
availability of, 72, 107-110
claims-made policies, 107-108
coverage limits, 107, 133
economic burden of, 136, 154-155
for federally subsidized providers, 2, 63
66, 67, 73, 93
from joint underwriting associations,
109
occurrence-based policies, 107
from physician-owned and medical
society-created companies, 108-110
public expenditures for, 73
reporting endorsement, 108
requirement for, 109
sources of, 108-109
Malpractice insurance premiums
and accumulated exposure theory, 70,
71-72, 74
and availability of obstetrical care, 61,
63, 66-70, 73, 81-82, 84, 85, 102,
110, 123, 136-137
bases for, 70-73, 108, 147, 157
costs per delivery, 2, 61, 88-89
cross-subsidization of specialties, 126
131, 202
experience rating and, 201, 212
factors affecting, 2, 5, 70-72, 74, 138,
157
for family/general practitioners, 2, 72,
78, 88-89
federal subsidization of, 74, 93
and fee increases, 88; see also Costs of
obstetrical care
geographic differences in, 89, 216
for group practices, 101
increases in, 1-2, 59, 78, 102, 107, 108,
157, 216
and Medicaid reimbursement rates
88-89
for nurse-midwives, 72, 107, 108, 110
for obstetrician-gynecologists, 1-2,
71-72, 73, 78, 88-89, 109, 110-111,
216
as a percentage of claims paid out, 38,
138
as a percentage of expenses, 88
as a percentage of income, 88, 110
physician revolt against, 115, 132
and quality of care, 70-72, 74
for specialists, 100
state coverage of, 5, 93
surcharges, 109-110
tort reforms and, 126, 129-131, 150,
215-216
underwriting practices and, 5
Manic-depressive disorder, 49
Maryland
changes in obstetrical practice in, 80, 83
claims by Medicaid recipients in, 91
liability coverage for Medicaid providers
in, 93
physician participation in Medicaid in,
83
Massachusetts
caps on attorneys' fees in, 220
cesarean section rates in, 29
Committee on Maternal Welfare, 34
Maternal and Child Health Program, 18,
84
Maternal serum alpha-fetoprotein
(MSAFP) screening, 41, 42, 45-49
Maternity care, see Obstetrical care;
Prenatal care
Medicaid
births paid for by, 62
caseloads for providers, 84, 87
deliveries per provider, 84, 85, 92
enrollment process, 60
federal matching payments, 93
liability coverage for providers, 2, 63
66, 67, 73, 93
physician participation in, 37, 60, 61
69, 75, 83-85, 87, 88, 92-94, 127
and prenatal care, 60
reforms in, 60, 62, 89, 90, 93-94
Medicaid patients, see Low-income women
Medicaid reimbursement
and access to care, 37, 61, 62, 85, 87, 93
delays in, 62
increases in rates, 2, 60, 62, 89
and malpractice insurance premiums
88, 89
for medical technologies, 17
rates, 88, 93-94
state variation in, 2, 88-89 93
Medical Devices Act of 1976, is, 45-46
Medical liability
causes of problems, 97-99, 161-163
for charity care, 122-123, 133
and customary practice, 22, 145-146
joint and several, 152
locality rule, 146
maternal drug abuse and, 128-129
medical technology and, 22, 43, 51, 100
149, 162-163
negligence standards, 129, 145-146,
150, 151-152, 160, 163
for not using a procedure, 21
and physician behavior, 101-103
proof of injury, 21-22, 146, 150, 151,
154, 156
and quality of care, 70-72
reasonable care standards, 22, 145-146
in screening for birth defects and
genetic disorders, 41-54
for using a procedure, 22
see also Tort system
Medical maloccurrences, prevalence of
119, 164-165, 167
Medical technology
assessment of, 4, 11-12, 17-21, 23-24
43, 47, 52
biases in evaluation of, 18
OCR for page 235
INDEX 235
classification of, 19
consumer acceptance of, 17
costs of, 4
development stages, 17
diffusion of, 10, 12, 16-22, 24, 48
education of physicians in use of, 47-49,
53, 97, 149
and medical liability, 22, 43, 51, 100,
149, 162-163, 191
policies toward, 17-18
rationing of, 4
regulation of, 19, 45-46, 47
research needs on, 5
see also Electronic fetal monitoring;
Screening for birth defects/genetic
disorders
Mental retardation, 36, 43, 46, 189
Michigan, changes in obstetrical practice
in, 86
Mississippi, changes in obstetrical care in,
2
Missouri
jury verdicts on malpractice, 168, 171,
172, 174, 175
liability coverage for Medicaid providers
in, 5, 93
Mixson, William, 162
Muscular dystrophy, Duchenne-type, 49,
50
National Association of Insurance
Commissioners, 166
National Center for Health Services
Research, Health Care Technology
Assessment Program on Outcomes Re-
search, 4
National Center for Health Statistics, 165
National Commission on Infant Mortality
Prevention, 90
National Governors' Association, 84, 87
National Health Service Corps, 60-61, 63,
67, 68, 74, 75
National Institutes of Health
assessment of medical technology, 17,
18
consensus on EFM, 18-19
support of technology development, 18
National Natality Survey, 11
National Professional Liability Reform Act
of 1987, 224
Nevada, changes in obstetrical practice in,
85
New Jersey, medical licensing board effec-
tiveness in, 157
New York State
court filings for malpractice in, 167
electronic fetal monitoring in, 11
Governor's Advisory Commission on
Liability Insurance, 137
jury verdicts on malpractice, 168,
171-175
malpractice insurance premiums in, 216
New Zealand
cesarean section rates in, 31
no-fault tort system, 140, 157
No-fault compensation
AMA position on, 138-141
benefits of, 139
costs of, 139
coverage, 116, 125-129, 138, 153, 196
definition of compensable events, 125
eligibility under, 116, 125-129
flaws in, 130, 131, 214
Florida plan for, 138, 153
funding for, 126, 129-131
goals of, 194
indigent care provisions, 93, 127, 130
limitations on claims, 116, 125, 126
for loss of wages, 126
for medical and support services, 126,
127
New Zealand system, 140, 157
for pain and suffering, 126
recommendations on, 75
social value of, 194-195
trial lawyers' position on, 127
Virginia plan for, see Virginia Birth-
Related Neurological Injury Compen-
sation Act
see also Designated compensable events -
plans
North Carolina
changes in obstetrical practice in, 84
malpractice insurance premiums in,
216
Nurse-midwives, certified
births attended by, 105-106
changes in obstetrical practice, 108-110
claims experience of, 107, 108
collaboration with physicians, 105, 109
education and training of, 104-105
employers of, 67, 68-69, 105, 110
fees, 108, 110
hospital privileges, 69, 109
income, 107, 110
job opportunities for, 108, 110, 111
licensing, certification, and regulation
of, 105
malpractice insurance for, 72, 107-110
number in U.S., 105
patient characteristics, 106
recommended employment of, 75
referral arrangements of, 105
services provided by, 104
studies and surveys of, 105-106
Nurse-midwives, lay, 104-105
Obstetrical care
consumer acceptance of high technology
in, 17
costs of, 2, 16, 19-20, 22, 35-36, 38, 61,
68, 88-89, 108, 110, 137
elimination of, 36, 59, 61, 78, 80-83,
85-87, 102, 110, 123, 136-137, 157
financing of, see Health insurance;
Medicaid
non-malpractice factors affecting avail-
ability of, 59, 82
quality of, 4, 5, 70-72, 75, 141,
152-153, 158
OCR for page 236
236 INDEX
reductions in services, 36, 37, 59,
66-69, 78, 81-83, 123, 137, 157
for self-paying patients, 30
shortages in U.S., 2, 37, 102, 136-137
sources of, 2, 61
see also Access to obstetrical services
Practice of obstetrics
Obstetrician-gynecologists
changes in obstetrical practice, 1, 36,
59, 80-81, 82, 84-86, 102, 137, 157
claims experience of, 1, 73, 90, 108, 137
215
in Community and Migrant Health
Centers, 67, 70
deliveries per year, 89
expenses of, 88-89, 161
geographic distribution of, 86
group practice, 101
high-risk-patient caseloads, 36, 137
income trends, 88
indigent caseloads, 84
malpractice insurance premiums for,
1-2, 71-72, 73, 78, 88-89, 109,
110-111, 216
Medicaid participation rates, 60, 75, 83,
85
solo practice by, 101
Office of Technology Assessment, 11-12,
63
Ohio, changes in obstetrical care in, 82
Omnibus Budget Reconciliation Act, 89,
94
Oregon
changes in obstetrical practice in, 83, 86
jury verdicts on malpractice in, 168,
171, 174
Peer review organizations, 4, 17, 20, 97,
143
Phenylketonuria (PKU) screening, 41, 42,
43-45, 46-47, 50
Physician-patient relationship
effects of liability concerns on, 37,
99-103
factors in the deterioration of, 100-101,
103
in group practices, 101
importance of, 99
informed consent and, 23, 101-103,
146-147
and management of high-risk pregnan-
cies, 90
as a producer-consumer relationship, 99,
103, 214; see also Private contracts
Physicians
disciplinary measures against, 141-142
education and training in new technolo-
gies, 47, 48-49, 53, 97, 149, 153
effects of lawsuits on, 90
ethical obligations of, 127, 131
fear of suits, 4, 61, 90-92, 93, 101-103,
141
federally subsidized, 60-61, 63, 67, 68,
74, 75
fees, 88
incompetent or impaired, 97-98, 148,
158
legal obligations of, 149
licensing, credentialing, and monitoring
of, 75-76, 127, 139, 141-142,
144-145, 147-149, 152-153, 158
Medicaid participation by, 37, 60, 61,
69, 75, 83-85, 87, 88, 92-94, 127
nurse-midwives as employees of, 109
office laboratories, 53
perceptions of blame for liability crisis,
90-91, 161-163, 215
public perceptions of, 99, 103
shortages in rural areas, 78, 85-87.
92-93, 136
see also Family and general practi-
tioners; Nurse-midwives; Obstetri-
cian-gynecologists
Polin, Frank E., 27
Polycystic disease, 49
Practice of obstetrics
in academic medical centers, 11, 17, 20,
29-30
auscultation, 9, 13, 17, 19, 22, 24
diagnostic testing, 110
fear of litigation and, 24
informed consent, 48, 102-103
malpractice issues as a factor in, 81-82
101-103
recordkeeping, 48, 102
standards for, 76
see also Cesarean deliveries, Electronic
fetal monitoring; Labor and delivery;
Physician-patient relationship;
Screening for birth defects/genetic
disorders
Pregnancy cases, malpractice verdicts on
175-177, 182-185
Premiums, see Malpractice insurance
premiums
Prenatal care
access to, 60
and cesarean deliveries 29
effectiveness in improving pregnancy
outcomes, 3, 90
insufficient, 3, 60, 78, 90
research on content of, 5
standard of, 102
see also Obstetrical care
Private contracts
access for the poor to, 121-124
advantages over no-fault schemes
133-132
AMA position on, 140-141
binding the child in, 120-121
claims processing, 140-141
coverage, 127, 196
difficulties in implementing, 116, 117
141, 197
enforcement of, 116
flaws in, 214
information needs for decision making
on, 117-119, 130
limitations on, 117-124
market logic in, 116-124, 129, 140
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INDEX
and physician-patient relationship, 214
research needs on, 138
statutory authority for, 197
Professional Medical Liability Reform Act
of 1987, 224
Prolapsed cord, 10
Public health agencies/programs
budget constraints, 124
clinics, 123
control over diffusion of technologies, 17
liability coverage for obstetrical pro-
viders in, 123-124
physician withdrawal from, 84, 87
see also Community and Migrant
Health Centers
Randomized clinical trials
barriers to implementation of, 12
of EFM, 11, 12-16, 18, 20-21
Recommendations
Federal Tort Claims Act coverage for
obstetrical providers, 74
liability coverage for Medicaid pro-
viders, 75
licensing, credentialing, and monitoring
of physicians, 75-76
National Health Service Corps, 75
standards of obstetrical practice
Research needs
defensive medicine, 5
hospital risk management programs, 5
insurance underwriting practices, 5
medical technology, 5
patient income and malpractice claims,
93
patient outcomes, 4
physician practice patterns and mal-
practice claims, 4
prevention of substandard practices of
physicians, 4
tort reforms, 5, 138
Retinoblastoma, 49, 50
Retrolental fibroplasia, 22
Richmond, John Lambert, 27
Risk management activities
by hospitals, 5
physician commitment to, 149
research needs on, 5
Risk Retention Act, 107
Rural areas
economic characteristics of medical
practice in, 2
health care providers in, 85
malpractice insurance premiums in, 89
number of deliveries in, 89
obstetrical care shortages in, 78, 85-87,
92-93, 136
Sammons, James, 162
Schulman, Harold, 162
Screening for birth defects/genetic disor-
ders
assessment of methods, 42, 43, 47, 50,
52-53
DNA-based testing, 49-52, 53
evolution of, 52
false negatives, 42, 44, 52
false positives, 42, 46, 47, 52
follow-ups, 45, 47, 48, 50, 53
laboratory quality assurance, 43, 44-45,
48, 52-53
legally mandated, 42, 43
and malpractice claims, 43, 45, 48,
51-52
Maternal serum alpha-fetoprotein
screening, 41, 42, 45-49
for mutations, 42-43
parental consent for, 45
Phenylketonuria screening, 41, 42,
43-45, 46-47, 50
physician education on, 47, 48-49, 53
97, 149, 153
predictive value of, 42, 46-47, 50-51
regulation of, 45-46, 47-48, 50, 52-53
reliability of, 42
sensitivity of, 42-46, 50, 52
specificity of, 42, 43, 46-47, 52
Seizures, in newborns, 12, 13, 15-16
Sickle-cell anemia, 50
Social Security disability system, 144
Spina bifida, 46
St. Paul Companies, 155, 215, 216
State licensure boards, 4
Stillbirths, 11, 12 15
Surveys and studies
biases in, 64, 79, 83, 91
on changes in obstetrical practice pat-
terns, 2, 23, 36, 80-81, 137
on electronic fetal monitoring, 11
of liability concerns of public health
centers, 63-65
limitations of, 64, 79, 83, 92
on malpractice claims, 91-92, 214
on Medicaid providers, 84
methodologies, 63-65, 79-80, 82, 83, 92,
169-170
national 79, 80-81
National Natality Survey, 11
of nurse-midwifery practice, 105-106
of patient outcomes need for, 4
on PKU screening, 45
of prenatal care by Medicaid recipients,
60
state, 45, 79, 80-81
Swine Influenza Immunization Program, 21
Technology, see Medical technology
Texas
changes in obstetrical practice in, 2, 84
claims rates in, 166
jury verdicts on malpractice in, 168,
171, 172, 174, 175
medical maloccurrences in, 165
Thalassemia, 50
Tort Policy Working Group, 137, 156
Tort reforms
alternatives to, 221-225
AMA-Specialty Society's fault-based
administrative system, 138-153
arbitration, 223, 224
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238 INDEX
caps on attorneys' fees, 217, 218,
219-221, 224, 225
collateral source payments, 137, 147,
152, 203, 217, 218, 224, 225
deleterious side effects of, 130, 131
economic damage guarantee (Moore-
Gephardt proposal), 221-224
effectiveness of, 5, 137, 213-216, 217-218
federal proposals, 224
joint and several liability, 152, 217,
218-219, 225
limits on awards, 147, 151-152,
215-216, 217, 218, 220-221, 224, 225
and malpractice insurance premiums,
126, 129-131, 150
market approaches, 115-124; see also
Private contracts
periodic payment of future damages,
147, 152, 160, 202, 203, 222, 224
physician disciplining/credentialing,
138, 141-142, 144-145, 147-149, 223
pretrial screening panels, 137, 204, 216,
217, 224
private contracts 115-124
recommended, 7i-76
res ipsa loquitur, 210
research needs on, 5
restrictions on informed consent, 146-147
state efforts on, 5 215-218
statute of limitations on claims, 217,
224, 225
structured payments, 217, 222, 224, 225
see also Designated compensable events
plans; No-fault compensation
Tort system
claims handling, 203-204
collateral source rule, 202, 205, 212
flaws in, 38, 137-138, 206-207
funding of, 201
general description of, 195
goals and objectives of, 206-207
implementation and legal authority, 197
interface with other compensation
systems, 205
measurement of benefits, 202
negligence standard in, 195, 198, 207, 211
payer and payee in, 200-201
and quality of health care, 207
role in medical liability crisis, 98, 162
standard setting in, 115-116
Tubal ligation, 175-177, 184-189
Tunkl v. Regents of the University of Cali-
forn~a, 133
Twentieth Century Fund, 137
Ultrasonography, 10, 47, 110
Uninsured women
diminished care of, 60, 61
number in U.S., 3, 59-60, 63
prenatal care for, 60
sources of care for, 62, 69
see also Low-income women
United Kingdom
cesarean section rate in, 31
MSAFP testing in, 46
PKU screening in, 44, 45
University of Southern California, 18
University of Texas Health Science
Center, 135
U.S. Department of Health and Human
Services
expenditures on liability insurance cov-
erage for staff, 73
infant mortality initiative, 2-3
research on alternative medical prac-
tices, 5
Task Force on Medical Liability and
Malpractice, 1, 4, 224
U.S. Department of Health, Education,
and Welfare, Commission on Medical
Malpractice, 91
U.S. General Accounting Office, 60, 91,
137, 155, 163, 214, 215
Vander Kolk, Kenneth J., 161-162
Virginia Birth-Related Neurological
Injury Compensation Act
advantages of, 216-217
benefits distribution, 126-127, 196, 203,
216-217
claims processing, 196, 204, 216
constitutionality of, 210
coverage, 116, 125-129, 138, 153, 196,
199-200, 209-210, 216
definition of birth-related neurological
injury, 199
disclosure of participation to patients,
127, 131, 197-198, 206, 210
funding for compensation, 126, 129-131,
196, 201, 202, 209
goals and objectives of, 206-207, 216
indigent care requirement, 93, 127, 130
interface with other compensation
systems, 206
participation in, 127, 131, 134, 196,
197-198, 216
physician monitoring under, 127
political setting for enactment, 124-126
and quality of care, 217
rebuttable presumptions in, 128-129
recoveries under 200
social value of, ;94-195
statutory design, 126-127
Washington
births to Medicaid-covered mothers, 62
changes in obstetrical practice in, 82,
83, 85, 157
claims by Medicaid recipients in, 91-92
jury verdicts on malpractice in,
168-169, 172-175
malpractice insurance costs in, 88
physician participation in Medicaid in,
83-85
West Virginia, changes in obstetrical
practice in, 83, 86
White House Conference of Child Health
and Protection, 28
Young, Frank, 47
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Representative terms from entire chapter:
obstetrical practice
