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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

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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

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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

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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

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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

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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

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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

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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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