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From page 233... ... M Best Company, 93-94, 95, 114-115 Academic medical centers access to care in, 85-87 computer networking of diagnostic data, 84 costs of malpractice insurance for faculty, 8, 85, 86 faculty in-house availability, 83, 84 low-income-patient caseload, 86 maternity care providers in, 19 practice of obstetrics in, 7-8, 82-87 teaching changes, 7-8, 84, 85, 125, 152 see also Residents, obstetrical Access to obstetrical services in Community and Migrant Health Centers, 68-69 ethical issues, 4 infant mortality and, 27 for low-income women, 7, 12, 25, 68-69, 147, 198-205 in rural areas, 29-30, 47-49, 86-87, 147, 150 threat of liability and, 2, 10, 68-69, 84, 125, 126, 150-151, 153 see also Obstetrical care Aid to Families with Dependent Children, 56 Alabama changes in obstetrical practice in, 189, 198, 207, 212 malpractice insurance costs in, 42-43, 61 Alphafetoprotein testing, 84 Alternative Medical Liability Act, 142 American Academy of Family Physicians 233 survey on changes in obstetrical care, 17-18, 46, 188, 194-195, 203-204, 211, 215 survey of insurance premium costs of members, 42 American College of Nurse-Midwives, 18, 104, 217 American College of Obstetricians and Gynecologists (ACOG) Read the entire page →
From page 234... ... 234 INDEX Arkansas malpractice claims frequency in, 2 malpractice insurance premiums in, 61, 95-96 Asphyxia, 77, 80, 81-82, 157, 158, 159 Aspiration, 80 Association of American Medical Colleges, 36, 86 Association of Professors of Gynecology and Obstetrics, 82 Attorneys' fees, 64, 127, 158, 159 Birthrates, 25, 31 Brain damage, claims for, 76-77, 81, 151; see also Cerebral palsy Bureau of Health Professions, 31 California changes in obstetrical practice in, 47, 189, 198, 207, 212 malpractice insurance premiums in, 61, 97, 98, 101, 110 physician fee increases in, 110 California Hospital Association, 135 California Medical Association, 135 Careers.in obstetrics, changes in, 36-37, 84-86 Centre for Socio-Legal Studies, 134 Cerebral palsy, 77, 79-82, 151-162, 158 Cesarean deliveries in academic medical centers, 82-83 charges for, 24 defensive, 76, 84 description of, 158 electronic fetal monitoring and, 75, 82, 151 by family practitioners, 18, 45 growth in, 8, 32, 75-76, 82-83, 151 and malpractice claims, 76 and malpractice insurance premiums, 101 maternal morbidity and mortality, 76 reasons for, 75-76, 83, 84 repeat procedures, 75 Charity care, decline in, 27 Children's Defense Fund, 20-21, 27 Chorionic villi sampling, 32, 158 Claims, see Malpractice claims and awards Clinics, 20, see also Community and Migrant Health Centers; freestanding birth centers CNA Insurance Company, 50, 216, 219 Colorado Physician Insurance Company, 118, 216, 224 Colorado Physician Mutual Company, 101 Community and Migrant Health Centers availability of obstetrical care in, 7, 65-71, 143 budgets, 22-23 caseloads, 5, 20, 22, 23, 67 characteristics of, 22, 23, 159 claims experience of, 66-67 deliveries in, 23 Federal Ibrt Claims Act coverage for, 12, 143-144, 155 liability concerns of, 65-66, 69-70, 150 malpractice insurance premium costs, 66, 67, 68, 70-71, 142 quality of care in, 69-70 reduction and elimination of services, 68-69, 150-151 referral arrangements of, 22, 68-69, 70-71, 144 staffing, 22, 67-68, 70, 143 Consigner Price Index, medical care component of, 97-98, 100, 105 Costs of obstetrical care in birth clinics, 51 dilation and curettage, 113 electronic fetal monitoring and, 82, 151 follow-up hospital visits, 110, 112 geographic differences in, 24 in hospitals, 24, 51 hysterectomy, 113 malpractice insurance premiums and, 109-112, 149 office visits, 110-112 by type of provider, 111-113 and willingness of patients to sue, 1 Council on Medical Specialty Societies, 117 Deliveries (births) access to services for, 48, 69, 70, 117 breech, 75, 83, 84, 118, 158 discontinuance of care at time of, 70 forceps, 75, 83, 84, 117-118, 160 in hospitals, by ownership status of hospital, 23 malpractice insurance costs per, 43-44 and,,maternal mortality, 76 Medicaid, 23 no-payment, 23, 44 oxytocin protocols, 118, 163 premature labor, 118, 163 vacuum extraction, 117-118, 164 see also Cesarean deliveries Doctors' Company of California, 101, 221 Dumping of women in labor, 29, 159 Education, see Academic medical centers; Residents, obstetrical Electronic fetal monitoring and cerebral palsy, 77, 79-80, 81-82 and cesarean deliveries, 75, 82, 151 computer networks for evaluation of tracings, 83, 84 costs of, 82, 151 description of, 159 effectiveness of, 8, 12, 76, 77, 79, 81-82 evaluation of technology, 78-79, 117, 151, 155 history of, 77-78, 159 and malpractice claims, 76-77, 81 Read the entire page →
From page 235... ... INDEX 235 and neonatal seizures, 79 prevalence of, 32, 52, 77 84, 151 randomized clinical trials of, 78, 79, 81, 163 recordkeeping for, 117 reimbursement rates for, 78 Employment Retirement Income Security Act, 159-160 Ethical issues dumping of women in labor, 29, 159 obligations of medical professions, 4-5 obligations of society, 4 private contracts approach to claims resolution, 140-141 termination of care at time of delivery, 70 Family and general practitioners changes in obstetrical practice, 5-7, 17-18, 29, 35, 38, 42, 44-48, 59, 69, 70, 74, 86-87, 149-150, 198-205, 207-212 charges for services, 44 claims experience of, 45, 101, 104 in Community and Migrant Health Centers, 22 deliveries per year, 43 education/training of, 15, 18, 160 expenses of, 108 fee increases, 110-113 income, 105-109 liability concerns of, 44-45, 207-211 malpractice insurance premiums for, 9, 42-44, 95, 98, 101, 105, 107-109, 148 no-pay caseloads, 44 number in U.S., 15-17, 37, 45 patient characteristics, 15, 45 population ratios for, 16-17 services performed by, 45, 160 Federal Ibrt Claims Act, 12, 143-144, 155, 160 Fetal bradycardia, 80, 158 Florida Academic Task Force for Review of the Insurance and Tort Systems, 114, 115, 120 malpractice insurance premiums in, 61, 97, 110 no-fault compensation system, 11, 122, 128, 133, 136, 137 obstetrical practice changes in, 41 Patient Compensation Fund, 121 physician fee increases in, 110 Tort Reform and Insurance Act of 1986, 122 Food and Drug Administration, licensing ~ of medical technologies, 76 Food, Drug, and Cosmetic Act, 78 Freestanding birth centers, 19, 49-51, 160 General practitioners, see Funnily and general practitioners Geographic differences in claims frequency for physicians, 2, 36 in costs of maternity care, 24 in financing of obstetrical care, 55 in malpractice insurance premiums, 42-43, 60-62, 95-97, 99, 101 malpractice problems of Community and Migrant Health Centers, 66 in Medicaid participation by physicians, 58-59 in obstetrical practice patterns, 41, 198-205, 207-215 in physician charges for services, 44, 149 in physician numbers and population ratios, 16-17 in providers of maternity care, 5, 6, 15-19, 29-30, 42, 44, 47-48, 198-205, 207-211 Georgia changes in obstetrical practice in, 41-42, 47, 190, 199, 208, 212-213 physician numbers and population ratios, 16, 47 Graduate Medical Education Advisory Committee, 31 Harvard Medical Institutions, 116-118 Harvard Medical Practice Study Group, 135 Harvard Risk Management Foundation, 77, 116, 117 Hawaii, liability coverage for Medicaid providers in, 12, 155 Health Care Financing Administration, Effectiveness Initiative, 12, 154-155 Health care providers, see Family and general practitioners; Nurse-midwives; Obstetrician-gynecologists; Physicians Health Care Quality Improvement Act of 1986, 11, 154 Health departments, see Public health agencies/programs Health insurance catastrophic, 56 and cesarean deliveries, 76 extent of coverage for maternity care, 24-25, 26 waiting periods, 25 see also Uninsured women Health maintenance organizations, 4, 19, 76, 93, 140, 160, 226 High-risk women birthrates among, 31-32 characteristics of, 31, 74-75, 160 data bases for identification of, 116 Medicaid reimbursement for care of, 62 reduction of care to, 38-42, 58-60, 84, 147, 150, 152, 198-205 referral sources for, 45 see also Low-income women; uninsured women In Read the entire page →
From page 236... ... 236 INDEX Hospitals closures of obstetrical units, 48 costs of maternity care in, 24 dumping of women in labor, 29, 159 Hill-Burton uncompensated service obligations, 161 investor-owned, 23-24, 160 limits of malpractice coverage, 96, 121 malpractice insurance sources, 93, 97 maternity care providers in, 19, 51-52 maternity services of, 5, 23 not-for-profit, 23-24, 162 obstetrical beds in, 23-24 preadmission cash deposits, 29 prenatal care caseloads, 20 public, 5, 23-24 reduction of emergency deliveries, 59 university, see Academic medical centers Hypoxia, 79-80 Hysterectomy, 110, 113 Idaho, changes in obstetrical practice in, 47, 190, 199, 208, 213 Illinois changes in obstetrical practice in, 47, 190, 199, 213 malpractice insurance premiums in, 60-61, 97 Medicaid reimbursements for normal deliveries in, 60-61 Infant mortality, 27, 59, 79, 160, 161 Informed consent, 8, 74, 118, 152, 161 Institute of Medicine, Council on Health Care Technology, 155 Insurance, see Health insurance; Malpractice insurance Insurance industry property-casualty, profitability of, 114-115, 149 regulation of, 3, 93, 95, 96, 101, 123 reinsurance companies, 96, 114 risk management activities of, 9, 149, 164 role in liability crisis, 1, 3, 149 see also Malpractice insurance Insurance Information Institute, 115 Intensive care, neonatal, 79, 80 Joint underwriting associations, 9, 51, 92, 94, 120, 161 Kansas changes in obstetrical practice in, 191, 200, 213 market share of joint underwriting associations in, 94 Kentucky changes in obstetrical practice in, 191, 200, 208, 213 physician participation in Medicaid in, 58 King's Fund Institute, 134 Liability Risk Retention Act, 94 Low birthweight, 26, 59, 80, 160 Low-income women access problems of, 6-7, 12, 25, 31, 54, 59-65, 74-75, 147, 150 characteristics of, 25, 27 claims settlements for, 64 continuity of care for, 63 effects of liability crisis on, 54-71, 147, 150 infant mortality among, 59 litigation propensity of, 64-65, 87-88, 150 low-birthweight infants, 59 sources of obstetrical care, 5, 14-15, 20-23, 65, 86, 150 survey of access problems of, 47-48 see also High-risk women; Medicaid; Uninsured women Madden v. Kaiser Foundation Hospitals, 141 Malpractice claims and awards for brain damage, 76-77, 81 cesarean deliveries and, 76 against Community and Migrant Health Centers, 66-67 consumer expectations of medicine and, 3, 88 data bases on, 11-12, 116-117 defined, 2 nil, 158-159 effects on insurance premium costs, 2 electronic fetal monitoring and, 76-77, 81 financial reasons for 88 frequency and severity of, 2, 10, 65, 88, 96, 113, 127, 130, 148, 149, 153, 158-159 growth of, 2, 125 limits on, 95, 122, 127; see also No fault compensation for lost earnings, 64 by low-income women, 64-65, 87-88 against nurses and nurse-midwives 20, 50 against obstetrician-gynecologists, 2, 51, 63 physician costs associated with, 110 against public health agency physi cians, 67 public perceptions of physicians and, 3, 88 tort reforms and, 10, 127, 130 Malpractice insurance availability of, 8-9, 96-104, 125, 148 claims-made policies, 9, 96, 97, 104, 148, 162 coverage limits, 95-96 economic burden of, 50, 149 for federally subsidized providers, 142-143 hospital association-owned companies, 94, 97 from joint underwriting associations 9, 51, 94, 97, 120, 121-122, 148, 160, 164 market size, 95, 114 Read the entire page →
From page 237... ... INDEX 237 market structure, 93-104 occurrence-based policies, 84, 96 from physician-owned and medical society-created companies, 9, 93-94, 97, 116, 148, 149, 158, 162, 163 profitability of, 112-119, 149 public expenditures on, 67 reserves, 113, 114, 163-164 responsibilities of insurance company, 93 risk retention groups/purchasing groups, 94-95, 163,164 self-insurance, 93, 97 sources of, 93-94 by specialty, 107 tail coverage, 84, 86, 96,162 see also Risk management activities Malpractice insurance premiums and accumulated exposure theory, 70 affordability of, 9, 97, 104-112, 148-149 and availability of obstetrical care, 59, 67-68, 69-70 bases for, 95-96, 102-103, 104, 113-114, 122-123 164 and careers in obstetrics 36 costs per delivery, 43-4i cross-subsidization of specialties, 120 defined, 161-162 discounts as risk management incen tives, 119, 164 experience rating of physicians and, 122-123, 160, 219-225 factors affecting, 2, 109-113, 125 for family/general practitioners, 9, 42 44, 95, 98, 100-101, 105-109, 148 federal subsidization of, 12, 144, 145, 155 and fee increases, 109-112, 149; see also Costs of obstetric care geographic differences in, 42-43, 60-62, 95-96, 97, 99, 101 increases in, 2, 93, 97-98, 100, 107, 109-112, 114, 125 insurer expenses covered by, 113 and Medicaid reimbursement rates, 60 for nurse-midwives, 9, 50-52, 95-96, 104, 105-106, 112, 148 for obstetrician-gynecologists, 2, 8, 35, 52, 97-101, 105-109, 148 as a percentage of expenses, 106-108 as a percentage of income, 105-109 and quality of care, 69-70 risk classifications, 95, 98, 101, 102-103, 120, 164 for self-employed physicians, by spe cialty, 100, 108-109 strategies for reducing, 119-122 surcharges, 52, 104, 120-123, 219-225 taxes, 93 tort reforms and, 130 Maryland changes in obstetrical practice in, 46, 191, 200, 208, 213 claims by Medicaid recipients in, 64 liability coverage for Medicaid providers in, 12, 128, 144, 145, 155 physician participation in Medicaid in, 58 Massachusetts changes in obstetrical practice in, 41, 191, 200, 213 malpractice claims in, 76 Medicaid eligibility in, 56 Maternal and Child Health agencies, 47-48, 57, 59 Maternity care, see Obstetrical care; Prenatal care Maternity Center Association, 51 Medicaid application processing, 57 benefits, 56 births paid for by, 55, 56 claims payment systems, 57 delays in reimbursements, 57 description of, 162 differential between private reimbur sement and, 58 eligibility, 54, 56-57,162,163 expenditures per birth, 55 liability coverage for providers, 12-13. 144-145, 155-156 physician participation in, 7, 54-55, 57-59, 69, 150 reforms in, 56-57, 62-63 reimbursement of nurse-midwives, 48-49 reimbursement policy, 56, 57-58, 60-62, 79, 121 role in delivery of obstetrical care, 55-65 state variation in programs, 56, 60-61 Medicaid patients, see Low-income women Medical Devices Act of 1976, 78 Medical Liability Mutual Insurance Company, 93-94, 98, 102-103, 216, 219 Medical Malpractice Insurance Association, 51 Medical technology assessment of, 12, 78-79, 154-155 consuTner acceptance of, 32 Michigan changes in obstetrical practice in, 47, 191, 201, 209, 213 malpractice insurance premiums in, 61, 97 Medicaid births in, 55 Missouri liability coverage for Medicaid providers in, 12, 144-145, 155 malpractice insurance premiums in, 60-61 Medicaid reimbursements for normal deliveries in, 60-61 State Legal Expense Fund, 144-145 Myers-Briggs personality test, 119, 162 National Association of Childbearing Centers, 51 Read the entire page →
From page 238... ... 238 INDEX National Center for Health Services Research, Health Care Technology Assessment Program on Outcomes Research, 12, 155 National Collaborative Perinatal Project, 80 National Coordinating Committee on Medical Malpractice JUAs, 94 National Governors' Association, 47, 59, 196, 205, 211 National Health Service Corps, 13, 22, 143, 144, 156, 162 National Institute of Neurological and Communicative Disorders and Stroke, 80 National Medical Care Utilization and Expenditures Study, 15, 44 National Resident Matching Program, 36 National Survey of Family Growth, 44 Nevada, changes in obstetrical practice in, 47, 192, 201, 209, 214 New Jersey malpractice insurance premiums in, 60-61, 98 Medicaid reimbursements for normal deliveries in, 60-61 New York State changes in obstetrical practice in, 192, 201, 214 claims experience of obstetricians in, 51 Department of Insurance, 114-116, 120-123 electronic fetal monitoring in, 77 Excess Liability Insurance Pool, 121 joint underwriting associations in, 51, 94 malpractice claims frequency in, 2 malpractice insurance premiums in, 61, 95-96, 97, 98, 101, 121 merit rating plan for malpractice insurance premiums, 123 No-fault compensation cause-based, 134 Childhood Vaccine Injury Compensation Act, 133 collateral sources of compensation and, 133, 137 cost of claims under, 134, 135 defined, 162 designated compensable events plans, 11, 122, 131-137, 154, 159 eligibility under, 136 Florida plan for, 11, 122, 131, 133, 136, 137, 154 funding for, 137, 227 goals of, 136 indigent care provisions, 137 for loss of bodily function, 134 for loss of wages, 133, 134 number of claims compensated under, 134-135 in other countries, 134-135 for pain and suffering, 133, 134 pay-as-you-go system, 136-137 punitive damages under, 134, 137 research on, 135 Virginia plan for, 11, 122, 131, 133, 136-137, 154, 226-227 Nonstress testing, 52 North Carolina, changes in obstetrical practice in, 59, 192, 201, 209, 214 Nurse-midwives, certified births attended by, 48-49 changes in obstetrical practice, 7, 19, 35, 50-52, 150 claims experience of, 20, 50, 104 employers of, 19, 50, 51, 104 fees, 50, 112 income, 19, 50, 105 insurance availability for, 9, 50, 51, 97, 104, 148 job opportunities for, 51, 52, 104, 150 malpractice insurance premiums for, 9, 50-52, 95-96, 104, 112, 148 Medicaid reimbursement of, 48-49 number in U.S., 5, 19 patient characteristics, 5, 15, 19 services provided by, 18, 19, 162-163 training of, 18 Nurse-midwives, lay, 5, 14 Nurses, 19-20 Obstetrical care consumer acceptance of high technol ogy in, 32 costs of, 24, 109-113, 125, 147 elimination of, 6, 27, 35, 38-39, 46, 52, 59, 74, 150, 198-205, 212 financing of, 24-25, 26, 27, 44, 54, 143; see also Health insurance; Medicaid inability to pay for, 27, 29, 44 projected increase in need for, 30-32 quality of, 69-70 reductions in services, 6 -- 7, 27, 46, 74, 150, 198-205 shortages in U.S., 5-6, 25-32, 47-48, 150 sources of, 14-20 state programs for financing, 25 see also Access to obstetrical services; Practice of obstetrics Obstetrician-gynecologists changes in obstetrical practice, 6-7, 27, 35, 38-42, 47, 59, 74, 87, 150, 198-205, 213 claims experience of, 2, 35-36, 51, 63, 87 in Community and Migrant Health Centers, 22 deliveries per year, 43, 44 education and training of, 163 expenses of, 106, 107-108 fee increases, 110-113 geographic distribution of, 5, 15-17, 18, 198-205 high-risk-patient caseloads, 39-40. 41-42, 59, 71, 74, 150 income trends, 9, 105-109, 149 Read the entire page →
From page 239... ... INDEX 239 job changes by, 85-86 malpractice insurance premiums for, 2, 9, 35, 43, 44, 52, 86, 97-101, 104-109, 148 Medicaid participation rates, 57, 58 no-pay caseloads, 44 number in U.S., 15, 16-17 projected supply of, 31 self-employed, 97-98, 107-108 solo practice by, 75, 84, 85 trends in career choices of graduating seniors as, 37 Omnibus Budget Reconciliation Act, 54, 56, 62 Oregon, changes in obstetrical practice In, 47, 192, 202, 209, 214 Oregon Medical Society, 44 Pennsylvania, malpractice insurance premiums in, 98 Pennsylvania Hospital Insurance Company, 94, 216, 219 Pennsylvania Medical Society Liability Insurance Company, 117-119, 216 Perinatal care, public programs, provider participation in, 59, 67-68 Physician Insurers' Association of America, 116-117, 217 Physician-patient relationship effects of liability concerns on, 8, 74, 87-89, 125, 147, 151-153 importance of, 11, 87-88, 152-154 Myers-Briggs personality test and, 119, 162 as a producer-consumer relationship, 3-5, 89, 152-153 and risk management activities, 225 Physicians availability of malpractice insurance for, 96-104 disciplinary measures against, 117, 134 educational strategies for risk manage ment, 118-119 effects of lawsuits on, 44-45, 87, 152 ethical obligations of, 4-5 fear of suits, 63-65, 150 federally subsidized, 142-143 income trends, 105-109 limits of malpractice coverage, 95 Medicaid participation by, 7, 54-55, 57-59, 69, 150 negative attitudes toward patients, 88-89 number of, and population ratios, by state, 16-17 nurse-midwives as employees of, 19, 50 perceptions of blame for liability crisis, 1, 126 in public health centers, 67, 143-145 public perceptions of, 3 self-employed, 97-98, 107 shortages in rural areas, 29-30 see also Family and general practi tioners, Nurse-midwives; Obstetri cian-gynecologists Physicians Insurance Association of America, 81 Practice of obstetrics in academic medical centers, 7-8, 82-87 age of physician and, 38-39 anesthesia in, 84 auscultation, 78, 79 beneficial changes in, 8, 83, 151 consultations with other physicians, 74, 83, 84, 118 diagnostic testing, 8, 32, 52, 73, 83, 84, 110, 117, 118, 152 discussions with patients, 8, 74, 83, 152 by individual physicians, 73-82 informed consent documentation, 8, 74, 118, 152, 161, 225 malpractice issues as a factor in, 39, 41-42, 44-46, 73-89, 125, 147, 149, 151-152 overuse of medically inadvisable pro cedures, 10, 126 quality assurance, 84 recordkeeping, 8, 83, 84, 110, 11.7, 118, 151 standardization of protocols, 84, 117-118 trends in, 40-42, 52 see also Cesarean deliveries; Deliveries (births) ; Electronic fetal monitor ing; Physician-patient relationship Premiums, see Malpractice insurance prem~ums Prenatal care access to, 26, 48 and cesarean deliveries, 75-76 charges for, 44 effectiveness in improving pregnancy outcomes, 27 insufficient, 26-28, 32, 84 number of visits, 31 sources of, 5, 20-23 standard of, 32, 163 see also Obstetrical care Public health agencies/programs clinics, 5, 20-21 liability coverage for obstetrical providers in, 144-145 maternity care providers in, 5, 19 physician withdrawal from, 59, 60 reimbursement rates, 60 see also Community and Migrant Health Centers Recommendations data base on claims, 154 federal research support for tort reforms, 11, 132, 154 federal tort claims act coverage for obstetrical providers, 12, 143-144, 155 goal of, 11, 153 liability coverage for Medicaid providers, 12-13, 143-144, 155 Read the entire page →
From page 240... ... , 141-142 effectiveness of, 9-10, 127, 130-132, 149, 153 federal research support for, 11 goals of, 164 limits on awards, 2, 127-130, 140, 145 and malpractice insurance premiums, 130 patient compensation funds, 95, 120-121, 128-129 periodic payment of future damages, 127-130 physician disciplining/credentialing, 134, 137, 138 pretrial screening panels, 127-130, 138, 163 private contracts, 11, 131, 139-141, 154 recommended, 11, 131-132 res ipsa loquitur, 127-129, 164 restrictions on informed consent, 127 state efforts on, 11, 127-129 see also No-fault compensation Tort system alternatives to, 132-143, 149, 153, 154; see also Tort reforms goals of, 126 role in medical liability crisis, 9-10, 126, 147, 153 social insurance alternative to, 142-143 Read the entire page →
From page 241... ... General Accounting Office, 2, 114-115, 130 U.S. Surgeon General, objectives for infant health, 26 Utah Medical Insurance Association, 117, 118, 216, 225 Virginia changes in obstetrical practice in, 193, 203, 214 no-fault compensation system, 11, 122, 129, 133, 226-227 Washington changes in obstetrical practice in, 193-194, 203, 210, 214 claims by Medicaid recipients in, 65 malpractice insurance costs in, 42-43, 62, 101 physician participation in Medicaid 58 West Virginia, changes in obstetrical practice in, 47, 194, 203, 210, 215 Read the entire page →

From page 233...

... M Best Company, 93-94, 95, 114-115 Academic medical centers access to care in, 85-87 computer networking of diagnostic data, 84 costs of malpractice insurance for faculty, 8, 85, 86 faculty in-house availability, 83, 84 low-income-patient caseload, 86 maternity care providers in, 19 practice of obstetrics in, 7-8, 82-87 teaching changes, 7-8, 84, 85, 125, 152 see also Residents, obstetrical Access to obstetrical services in Community and Migrant Health Centers, 68-69 ethical issues, 4 infant mortality and, 27 for low-income women, 7, 12, 25, 68-69, 147, 198-205 in rural areas, 29-30, 47-49, 86-87, 147, 150 threat of liability and, 2, 10, 68-69, 84, 125, 126, 150-151, 153 see also Obstetrical care Aid to Families with Dependent Children, 56 Alabama changes in obstetrical practice in, 189, 198, 207, 212 malpractice insurance costs in, 42-43, 61 Alphafetoprotein testing, 84 Alternative Medical Liability Act, 142 American Academy of Family Physicians 233 survey on changes in obstetrical care, 17-18, 46, 188, 194-195, 203-204, 211, 215 survey of insurance premium costs of members, 42 American College of Nurse-Midwives, 18, 104, 217 American College of Obstetricians and Gynecologists (ACOG)

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From page 234...

... 234 INDEX Arkansas malpractice claims frequency in, 2 malpractice insurance premiums in, 61, 95-96 Asphyxia, 77, 80, 81-82, 157, 158, 159 Aspiration, 80 Association of American Medical Colleges, 36, 86 Association of Professors of Gynecology and Obstetrics, 82 Attorneys' fees, 64, 127, 158, 159 Birthrates, 25, 31 Brain damage, claims for, 76-77, 81, 151; see also Cerebral palsy Bureau of Health Professions, 31 California changes in obstetrical practice in, 47, 189, 198, 207, 212 malpractice insurance premiums in, 61, 97, 98, 101, 110 physician fee increases in, 110 California Hospital Association, 135 California Medical Association, 135 Careers.in obstetrics, changes in, 36-37, 84-86 Centre for Socio-Legal Studies, 134 Cerebral palsy, 77, 79-82, 151-162, 158 Cesarean deliveries in academic medical centers, 82-83 charges for, 24 defensive, 76, 84 description of, 158 electronic fetal monitoring and, 75, 82, 151 by family practitioners, 18, 45 growth in, 8, 32, 75-76, 82-83, 151 and malpractice claims, 76 and malpractice insurance premiums, 101 maternal morbidity and mortality, 76 reasons for, 75-76, 83, 84 repeat procedures, 75 Charity care, decline in, 27 Children's Defense Fund, 20-21, 27 Chorionic villi sampling, 32, 158 Claims, see Malpractice claims and awards Clinics, 20, see also Community and Migrant Health Centers; freestanding birth centers CNA Insurance Company, 50, 216, 219 Colorado Physician Insurance Company, 118, 216, 224 Colorado Physician Mutual Company, 101 Community and Migrant Health Centers availability of obstetrical care in, 7, 65-71, 143 budgets, 22-23 caseloads, 5, 20, 22, 23, 67 characteristics of, 22, 23, 159 claims experience of, 66-67 deliveries in, 23 Federal Ibrt Claims Act coverage for, 12, 143-144, 155 liability concerns of, 65-66, 69-70, 150 malpractice insurance premium costs, 66, 67, 68, 70-71, 142 quality of care in, 69-70 reduction and elimination of services, 68-69, 150-151 referral arrangements of, 22, 68-69, 70-71, 144 staffing, 22, 67-68, 70, 143 Consigner Price Index, medical care component of, 97-98, 100, 105 Costs of obstetrical care in birth clinics, 51 dilation and curettage, 113 electronic fetal monitoring and, 82, 151 follow-up hospital visits, 110, 112 geographic differences in, 24 in hospitals, 24, 51 hysterectomy, 113 malpractice insurance premiums and, 109-112, 149 office visits, 110-112 by type of provider, 111-113 and willingness of patients to sue, 1 Council on Medical Specialty Societies, 117 Deliveries (births) access to services for, 48, 69, 70, 117 breech, 75, 83, 84, 118, 158 discontinuance of care at time of, 70 forceps, 75, 83, 84, 117-118, 160 in hospitals, by ownership status of hospital, 23 malpractice insurance costs per, 43-44 and,,maternal mortality, 76 Medicaid, 23 no-payment, 23, 44 oxytocin protocols, 118, 163 premature labor, 118, 163 vacuum extraction, 117-118, 164 see also Cesarean deliveries Doctors' Company of California, 101, 221 Dumping of women in labor, 29, 159 Education, see Academic medical centers; Residents, obstetrical Electronic fetal monitoring and cerebral palsy, 77, 79-80, 81-82 and cesarean deliveries, 75, 82, 151 computer networks for evaluation of tracings, 83, 84 costs of, 82, 151 description of, 159 effectiveness of, 8, 12, 76, 77, 79, 81-82 evaluation of technology, 78-79, 117, 151, 155 history of, 77-78, 159 and malpractice claims, 76-77, 81

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From page 235...

... INDEX 235 and neonatal seizures, 79 prevalence of, 32, 52, 77 84, 151 randomized clinical trials of, 78, 79, 81, 163 recordkeeping for, 117 reimbursement rates for, 78 Employment Retirement Income Security Act, 159-160 Ethical issues dumping of women in labor, 29, 159 obligations of medical professions, 4-5 obligations of society, 4 private contracts approach to claims resolution, 140-141 termination of care at time of delivery, 70 Family and general practitioners changes in obstetrical practice, 5-7, 17-18, 29, 35, 38, 42, 44-48, 59, 69, 70, 74, 86-87, 149-150, 198-205, 207-212 charges for services, 44 claims experience of, 45, 101, 104 in Community and Migrant Health Centers, 22 deliveries per year, 43 education/training of, 15, 18, 160 expenses of, 108 fee increases, 110-113 income, 105-109 liability concerns of, 44-45, 207-211 malpractice insurance premiums for, 9, 42-44, 95, 98, 101, 105, 107-109, 148 no-pay caseloads, 44 number in U.S., 15-17, 37, 45 patient characteristics, 15, 45 population ratios for, 16-17 services performed by, 45, 160 Federal Ibrt Claims Act, 12, 143-144, 155, 160 Fetal bradycardia, 80, 158 Florida Academic Task Force for Review of the Insurance and Tort Systems, 114, 115, 120 malpractice insurance premiums in, 61, 97, 110 no-fault compensation system, 11, 122, 128, 133, 136, 137 obstetrical practice changes in, 41 Patient Compensation Fund, 121 physician fee increases in, 110 Tort Reform and Insurance Act of 1986, 122 Food and Drug Administration, licensing ~ of medical technologies, 76 Food, Drug, and Cosmetic Act, 78 Freestanding birth centers, 19, 49-51, 160 General practitioners, see Funnily and general practitioners Geographic differences in claims frequency for physicians, 2, 36 in costs of maternity care, 24 in financing of obstetrical care, 55 in malpractice insurance premiums, 42-43, 60-62, 95-97, 99, 101 malpractice problems of Community and Migrant Health Centers, 66 in Medicaid participation by physicians, 58-59 in obstetrical practice patterns, 41, 198-205, 207-215 in physician charges for services, 44, 149 in physician numbers and population ratios, 16-17 in providers of maternity care, 5, 6, 15-19, 29-30, 42, 44, 47-48, 198-205, 207-211 Georgia changes in obstetrical practice in, 41-42, 47, 190, 199, 208, 212-213 physician numbers and population ratios, 16, 47 Graduate Medical Education Advisory Committee, 31 Harvard Medical Institutions, 116-118 Harvard Medical Practice Study Group, 135 Harvard Risk Management Foundation, 77, 116, 117 Hawaii, liability coverage for Medicaid providers in, 12, 155 Health Care Financing Administration, Effectiveness Initiative, 12, 154-155 Health care providers, see Family and general practitioners; Nurse-midwives; Obstetrician-gynecologists; Physicians Health Care Quality Improvement Act of 1986, 11, 154 Health departments, see Public health agencies/programs Health insurance catastrophic, 56 and cesarean deliveries, 76 extent of coverage for maternity care, 24-25, 26 waiting periods, 25 see also Uninsured women Health maintenance organizations, 4, 19, 76, 93, 140, 160, 226 High-risk women birthrates among, 31-32 characteristics of, 31, 74-75, 160 data bases for identification of, 116 Medicaid reimbursement for care of, 62 reduction of care to, 38-42, 58-60, 84, 147, 150, 152, 198-205 referral sources for, 45 see also Low-income women; uninsured women In

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From page 236...

... 236 INDEX Hospitals closures of obstetrical units, 48 costs of maternity care in, 24 dumping of women in labor, 29, 159 Hill-Burton uncompensated service obligations, 161 investor-owned, 23-24, 160 limits of malpractice coverage, 96, 121 malpractice insurance sources, 93, 97 maternity care providers in, 19, 51-52 maternity services of, 5, 23 not-for-profit, 23-24, 162 obstetrical beds in, 23-24 preadmission cash deposits, 29 prenatal care caseloads, 20 public, 5, 23-24 reduction of emergency deliveries, 59 university, see Academic medical centers Hypoxia, 79-80 Hysterectomy, 110, 113 Idaho, changes in obstetrical practice in, 47, 190, 199, 208, 213 Illinois changes in obstetrical practice in, 47, 190, 199, 213 malpractice insurance premiums in, 60-61, 97 Medicaid reimbursements for normal deliveries in, 60-61 Infant mortality, 27, 59, 79, 160, 161 Informed consent, 8, 74, 118, 152, 161 Institute of Medicine, Council on Health Care Technology, 155 Insurance, see Health insurance; Malpractice insurance Insurance industry property-casualty, profitability of, 114-115, 149 regulation of, 3, 93, 95, 96, 101, 123 reinsurance companies, 96, 114 risk management activities of, 9, 149, 164 role in liability crisis, 1, 3, 149 see also Malpractice insurance Insurance Information Institute, 115 Intensive care, neonatal, 79, 80 Joint underwriting associations, 9, 51, 92, 94, 120, 161 Kansas changes in obstetrical practice in, 191, 200, 213 market share of joint underwriting associations in, 94 Kentucky changes in obstetrical practice in, 191, 200, 208, 213 physician participation in Medicaid in, 58 King's Fund Institute, 134 Liability Risk Retention Act, 94 Low birthweight, 26, 59, 80, 160 Low-income women access problems of, 6-7, 12, 25, 31, 54, 59-65, 74-75, 147, 150 characteristics of, 25, 27 claims settlements for, 64 continuity of care for, 63 effects of liability crisis on, 54-71, 147, 150 infant mortality among, 59 litigation propensity of, 64-65, 87-88, 150 low-birthweight infants, 59 sources of obstetrical care, 5, 14-15, 20-23, 65, 86, 150 survey of access problems of, 47-48 see also High-risk women; Medicaid; Uninsured women Madden v. Kaiser Foundation Hospitals, 141 Malpractice claims and awards for brain damage, 76-77, 81 cesarean deliveries and, 76 against Community and Migrant Health Centers, 66-67 consumer expectations of medicine and, 3, 88 data bases on, 11-12, 116-117 defined, 2 nil, 158-159 effects on insurance premium costs, 2 electronic fetal monitoring and, 76-77, 81 financial reasons for 88 frequency and severity of, 2, 10, 65, 88, 96, 113, 127, 130, 148, 149, 153, 158-159 growth of, 2, 125 limits on, 95, 122, 127; see also No fault compensation for lost earnings, 64 by low-income women, 64-65, 87-88 against nurses and nurse-midwives 20, 50 against obstetrician-gynecologists, 2, 51, 63 physician costs associated with, 110 against public health agency physi cians, 67 public perceptions of physicians and, 3, 88 tort reforms and, 10, 127, 130 Malpractice insurance availability of, 8-9, 96-104, 125, 148 claims-made policies, 9, 96, 97, 104, 148, 162 coverage limits, 95-96 economic burden of, 50, 149 for federally subsidized providers, 142-143 hospital association-owned companies, 94, 97 from joint underwriting associations 9, 51, 94, 97, 120, 121-122, 148, 160, 164 market size, 95, 114

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From page 237...

... INDEX 237 market structure, 93-104 occurrence-based policies, 84, 96 from physician-owned and medical society-created companies, 9, 93-94, 97, 116, 148, 149, 158, 162, 163 profitability of, 112-119, 149 public expenditures on, 67 reserves, 113, 114, 163-164 responsibilities of insurance company, 93 risk retention groups/purchasing groups, 94-95, 163,164 self-insurance, 93, 97 sources of, 93-94 by specialty, 107 tail coverage, 84, 86, 96,162 see also Risk management activities Malpractice insurance premiums and accumulated exposure theory, 70 affordability of, 9, 97, 104-112, 148-149 and availability of obstetrical care, 59, 67-68, 69-70 bases for, 95-96, 102-103, 104, 113-114, 122-123 164 and careers in obstetrics 36 costs per delivery, 43-4i cross-subsidization of specialties, 120 defined, 161-162 discounts as risk management incen tives, 119, 164 experience rating of physicians and, 122-123, 160, 219-225 factors affecting, 2, 109-113, 125 for family/general practitioners, 9, 42 44, 95, 98, 100-101, 105-109, 148 federal subsidization of, 12, 144, 145, 155 and fee increases, 109-112, 149; see also Costs of obstetric care geographic differences in, 42-43, 60-62, 95-96, 97, 99, 101 increases in, 2, 93, 97-98, 100, 107, 109-112, 114, 125 insurer expenses covered by, 113 and Medicaid reimbursement rates, 60 for nurse-midwives, 9, 50-52, 95-96, 104, 105-106, 112, 148 for obstetrician-gynecologists, 2, 8, 35, 52, 97-101, 105-109, 148 as a percentage of expenses, 106-108 as a percentage of income, 105-109 and quality of care, 69-70 risk classifications, 95, 98, 101, 102-103, 120, 164 for self-employed physicians, by spe cialty, 100, 108-109 strategies for reducing, 119-122 surcharges, 52, 104, 120-123, 219-225 taxes, 93 tort reforms and, 130 Maryland changes in obstetrical practice in, 46, 191, 200, 208, 213 claims by Medicaid recipients in, 64 liability coverage for Medicaid providers in, 12, 128, 144, 145, 155 physician participation in Medicaid in, 58 Massachusetts changes in obstetrical practice in, 41, 191, 200, 213 malpractice claims in, 76 Medicaid eligibility in, 56 Maternal and Child Health agencies, 47-48, 57, 59 Maternity care, see Obstetrical care; Prenatal care Maternity Center Association, 51 Medicaid application processing, 57 benefits, 56 births paid for by, 55, 56 claims payment systems, 57 delays in reimbursements, 57 description of, 162 differential between private reimbur sement and, 58 eligibility, 54, 56-57,162,163 expenditures per birth, 55 liability coverage for providers, 12-13. 144-145, 155-156 physician participation in, 7, 54-55, 57-59, 69, 150 reforms in, 56-57, 62-63 reimbursement of nurse-midwives, 48-49 reimbursement policy, 56, 57-58, 60-62, 79, 121 role in delivery of obstetrical care, 55-65 state variation in programs, 56, 60-61 Medicaid patients, see Low-income women Medical Devices Act of 1976, 78 Medical Liability Mutual Insurance Company, 93-94, 98, 102-103, 216, 219 Medical Malpractice Insurance Association, 51 Medical technology assessment of, 12, 78-79, 154-155 consuTner acceptance of, 32 Michigan changes in obstetrical practice in, 47, 191, 201, 209, 213 malpractice insurance premiums in, 61, 97 Medicaid births in, 55 Missouri liability coverage for Medicaid providers in, 12, 144-145, 155 malpractice insurance premiums in, 60-61 Medicaid reimbursements for normal deliveries in, 60-61 State Legal Expense Fund, 144-145 Myers-Briggs personality test, 119, 162 National Association of Childbearing Centers, 51

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From page 238...

... 238 INDEX National Center for Health Services Research, Health Care Technology Assessment Program on Outcomes Research, 12, 155 National Collaborative Perinatal Project, 80 National Coordinating Committee on Medical Malpractice JUAs, 94 National Governors' Association, 47, 59, 196, 205, 211 National Health Service Corps, 13, 22, 143, 144, 156, 162 National Institute of Neurological and Communicative Disorders and Stroke, 80 National Medical Care Utilization and Expenditures Study, 15, 44 National Resident Matching Program, 36 National Survey of Family Growth, 44 Nevada, changes in obstetrical practice in, 47, 192, 201, 209, 214 New Jersey malpractice insurance premiums in, 60-61, 98 Medicaid reimbursements for normal deliveries in, 60-61 New York State changes in obstetrical practice in, 192, 201, 214 claims experience of obstetricians in, 51 Department of Insurance, 114-116, 120-123 electronic fetal monitoring in, 77 Excess Liability Insurance Pool, 121 joint underwriting associations in, 51, 94 malpractice claims frequency in, 2 malpractice insurance premiums in, 61, 95-96, 97, 98, 101, 121 merit rating plan for malpractice insurance premiums, 123 No-fault compensation cause-based, 134 Childhood Vaccine Injury Compensation Act, 133 collateral sources of compensation and, 133, 137 cost of claims under, 134, 135 defined, 162 designated compensable events plans, 11, 122, 131-137, 154, 159 eligibility under, 136 Florida plan for, 11, 122, 131, 133, 136, 137, 154 funding for, 137, 227 goals of, 136 indigent care provisions, 137 for loss of bodily function, 134 for loss of wages, 133, 134 number of claims compensated under, 134-135 in other countries, 134-135 for pain and suffering, 133, 134 pay-as-you-go system, 136-137 punitive damages under, 134, 137 research on, 135 Virginia plan for, 11, 122, 131, 133, 136-137, 154, 226-227 Nonstress testing, 52 North Carolina, changes in obstetrical practice in, 59, 192, 201, 209, 214 Nurse-midwives, certified births attended by, 48-49 changes in obstetrical practice, 7, 19, 35, 50-52, 150 claims experience of, 20, 50, 104 employers of, 19, 50, 51, 104 fees, 50, 112 income, 19, 50, 105 insurance availability for, 9, 50, 51, 97, 104, 148 job opportunities for, 51, 52, 104, 150 malpractice insurance premiums for, 9, 50-52, 95-96, 104, 112, 148 Medicaid reimbursement of, 48-49 number in U.S., 5, 19 patient characteristics, 5, 15, 19 services provided by, 18, 19, 162-163 training of, 18 Nurse-midwives, lay, 5, 14 Nurses, 19-20 Obstetrical care consumer acceptance of high technol ogy in, 32 costs of, 24, 109-113, 125, 147 elimination of, 6, 27, 35, 38-39, 46, 52, 59, 74, 150, 198-205, 212 financing of, 24-25, 26, 27, 44, 54, 143; see also Health insurance; Medicaid inability to pay for, 27, 29, 44 projected increase in need for, 30-32 quality of, 69-70 reductions in services, 6 -- 7, 27, 46, 74, 150, 198-205 shortages in U.S., 5-6, 25-32, 47-48, 150 sources of, 14-20 state programs for financing, 25 see also Access to obstetrical services; Practice of obstetrics Obstetrician-gynecologists changes in obstetrical practice, 6-7, 27, 35, 38-42, 47, 59, 74, 87, 150, 198-205, 213 claims experience of, 2, 35-36, 51, 63, 87 in Community and Migrant Health Centers, 22 deliveries per year, 43, 44 education and training of, 163 expenses of, 106, 107-108 fee increases, 110-113 geographic distribution of, 5, 15-17, 18, 198-205 high-risk-patient caseloads, 39-40. 41-42, 59, 71, 74, 150 income trends, 9, 105-109, 149

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From page 239...

... INDEX 239 job changes by, 85-86 malpractice insurance premiums for, 2, 9, 35, 43, 44, 52, 86, 97-101, 104-109, 148 Medicaid participation rates, 57, 58 no-pay caseloads, 44 number in U.S., 15, 16-17 projected supply of, 31 self-employed, 97-98, 107-108 solo practice by, 75, 84, 85 trends in career choices of graduating seniors as, 37 Omnibus Budget Reconciliation Act, 54, 56, 62 Oregon, changes in obstetrical practice In, 47, 192, 202, 209, 214 Oregon Medical Society, 44 Pennsylvania, malpractice insurance premiums in, 98 Pennsylvania Hospital Insurance Company, 94, 216, 219 Pennsylvania Medical Society Liability Insurance Company, 117-119, 216 Perinatal care, public programs, provider participation in, 59, 67-68 Physician Insurers' Association of America, 116-117, 217 Physician-patient relationship effects of liability concerns on, 8, 74, 87-89, 125, 147, 151-153 importance of, 11, 87-88, 152-154 Myers-Briggs personality test and, 119, 162 as a producer-consumer relationship, 3-5, 89, 152-153 and risk management activities, 225 Physicians availability of malpractice insurance for, 96-104 disciplinary measures against, 117, 134 educational strategies for risk manage ment, 118-119 effects of lawsuits on, 44-45, 87, 152 ethical obligations of, 4-5 fear of suits, 63-65, 150 federally subsidized, 142-143 income trends, 105-109 limits of malpractice coverage, 95 Medicaid participation by, 7, 54-55, 57-59, 69, 150 negative attitudes toward patients, 88-89 number of, and population ratios, by state, 16-17 nurse-midwives as employees of, 19, 50 perceptions of blame for liability crisis, 1, 126 in public health centers, 67, 143-145 public perceptions of, 3 self-employed, 97-98, 107 shortages in rural areas, 29-30 see also Family and general practi tioners, Nurse-midwives; Obstetri cian-gynecologists Physicians Insurance Association of America, 81 Practice of obstetrics in academic medical centers, 7-8, 82-87 age of physician and, 38-39 anesthesia in, 84 auscultation, 78, 79 beneficial changes in, 8, 83, 151 consultations with other physicians, 74, 83, 84, 118 diagnostic testing, 8, 32, 52, 73, 83, 84, 110, 117, 118, 152 discussions with patients, 8, 74, 83, 152 by individual physicians, 73-82 informed consent documentation, 8, 74, 118, 152, 161, 225 malpractice issues as a factor in, 39, 41-42, 44-46, 73-89, 125, 147, 149, 151-152 overuse of medically inadvisable pro cedures, 10, 126 quality assurance, 84 recordkeeping, 8, 83, 84, 110, 11.7, 118, 151 standardization of protocols, 84, 117-118 trends in, 40-42, 52 see also Cesarean deliveries; Deliveries (births) ; Electronic fetal monitor ing; Physician-patient relationship Premiums, see Malpractice insurance prem~ums Prenatal care access to, 26, 48 and cesarean deliveries, 75-76 charges for, 44 effectiveness in improving pregnancy outcomes, 27 insufficient, 26-28, 32, 84 number of visits, 31 sources of, 5, 20-23 standard of, 32, 163 see also Obstetrical care Public health agencies/programs clinics, 5, 20-21 liability coverage for obstetrical providers in, 144-145 maternity care providers in, 5, 19 physician withdrawal from, 59, 60 reimbursement rates, 60 see also Community and Migrant Health Centers Recommendations data base on claims, 154 federal research support for tort reforms, 11, 132, 154 federal tort claims act coverage for obstetrical providers, 12, 143-144, 155 goal of, 11, 153 liability coverage for Medicaid providers, 12-13, 143-144, 155

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From page 240...

... , 141-142 effectiveness of, 9-10, 127, 130-132, 149, 153 federal research support for, 11 goals of, 164 limits on awards, 2, 127-130, 140, 145 and malpractice insurance premiums, 130 patient compensation funds, 95, 120-121, 128-129 periodic payment of future damages, 127-130 physician disciplining/credentialing, 134, 137, 138 pretrial screening panels, 127-130, 138, 163 private contracts, 11, 131, 139-141, 154 recommended, 11, 131-132 res ipsa loquitur, 127-129, 164 restrictions on informed consent, 127 state efforts on, 11, 127-129 see also No-fault compensation Tort system alternatives to, 132-143, 149, 153, 154; see also Tort reforms goals of, 126 role in medical liability crisis, 9-10, 126, 147, 153 social insurance alternative to, 142-143

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From page 241...

... General Accounting Office, 2, 114-115, 130 U.S. Surgeon General, objectives for infant health, 26 Utah Medical Insurance Association, 117, 118, 216, 225 Virginia changes in obstetrical practice in, 193, 203, 214 no-fault compensation system, 11, 122, 129, 133, 226-227 Washington changes in obstetrical practice in, 193-194, 203, 210, 214 claims by Medicaid recipients in, 65 malpractice insurance costs in, 42-43, 62, 101 physician participation in Medicaid 58 West Virginia, changes in obstetrical practice in, 47, 194, 203, 210, 215

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Index Pages 233-241

Index
Pages 233-241