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Glossary Ad damnum clause: The clause of a plaintiffs complaint that con- tains a statement of the plaintiffs money loss or the damages that are claimed. AMA-Specialty Society proposal: A fault-based administrative system for resolving medical malpractice claims. Proposed by the American Medical Association and 32 medical specialty societies, this system would replace the existing civil justice system with one whereby claims would be resolved by reviewers and examiners under the jurisdiction of strengthened state medical boards or new state agencies. Amniocentesis: A procedure during pregnancy by which the abdomi- nal wall and fetal membranes are punctured by a cannula (a small tube) to withdraw amniotic fluid for testing. Apgar score: A method for estimating the severity of birth asphyxia by rating certain physical signs, including color, heart rate, respira- tion, reflex response to nose catheter, and muscle tone. It is deter- mined at 1 minute and at 5 minutes after birth. The lower the score, the more severely asphyxiated the infant; infants with low Apgar scores are more likely to have residual brain damage. Arbitration: An alternative to a formal court hearing. The hearing and determination of a case between parties in controversy by a person or persons chosen by the parties or appointed under statu- tory authority instead of by a judicial tribunal provided by law. 157

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158 GLOSSARY Asphyxia: Suffocation owing to oxygen deprivation, resulting in an- oxia (failure of oxygen to reach or be utilized by body tissues) and carbon dioxide accumulation in the body. Perinatal asphyxia is due to placental or neonatal pulmonary dysfunction and may occur before or during labor or after delivery when elective spontaneous breathing is not initiated. Attorneys' fees: The charges made by attorneys for services in repre- senting a client. A contingent fee is an arrangement that depends on a successful outcome in the case and is usually a percentage of the plaintiffs monetary recovery. Caps on attorneys' fees are limits on the amount attorneys may charge for their services. Bradycartlia (fetal): Abnormally slow heart rate. Breech presentation, delivery: The position of a fetus whose but- tocks or feet (rather than head) present at the head of the birth canal during labor. Varieties include frank breech, in which the buttocks are presented and the legs are extended along the trunk; complete breech, in which the buttocks are presented and the legs are crossed indian-style; and footling breech, when one or both legs are extended and present first. Captive insurance company: One owned by providers, such as a hospital or a group of physicians. Cerebral palsy: One of the more common forms of brain damage in the infant, it comprises a group of diverse, nonprogressive disorders of the central nervous system. Quadriplegia (paralysis of both arms and legs) and hemiparesis (muscle weakness or partial paralysis on one side of the body) are characteristic manifestations, and mental retardation, seizures, and dystonia (muscle tone disorders) may be present. Cesarean section: Delivery by surgical incision in the body of the uterus within the abdomen. Two general types of incisions are used: classical, which is longitudinal and is made in the upper segment of the uterus; and tower segment, or cervical, which is transverse and is made in the lower portion of the uterus. Chorionic villi sampling: A procedure for diagnosing genetic disor- ders, it involves removing and examining a small piece of the membrane (chorion) surrounding the developing embryo. The sam- ple is removed through the cervix by means of a minor suction procedure. The procedure causes mild discomfort and carries a small risk of miscarriage. Claim: A petition asserting the right to money or property because of an injury. The severity of claims refers to the size of awards and

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GLOSSARY 159 settlements; the frequency of claims refers to the number of claims paid out per capita. CIaims-made policy: See Malpractice insurance contract. Collateral source rule: If the plaintiff receives compensation for injuries from a source wholly independent of the defendant, that compensations not be deducted from whatever damages the defen- dant must pay. Some states have enacted provisions to offset this rule, that is, to reduce the amount the defendant must pay by whatever the amount of the plaintiffs other awards, if any. Community Health Centers and Migrant Health Centers: Federally funded clinics providing primary health care services, including perinatal services, to medically underserved and disad- vantaged populations who would otherwise not have access to such care. Contingent fee: An arrangement between attorney and client whereby the attorney agrees to represent the client for a percentage of the amount recovered: for example, 25 percent if the case is settled, 30 percent if the case goes to trial. This fee arrangement is common in personal injury actions. Cream skimming: A practice by insurers of covering only the lower risk individuals who fall into any given category. In the case of medical malpractice insurance, an insurer would cover only physi- cians believed to be at low risk. Designated compensable events (DCE) system: A proposal for compensating medical malpractice claims based on a listing of medical injuries that are strongly associated with negligence and that would be compensated without regard to fault. This option allows liability claims to be moved out of the tort system into an insurance system that would compensate victims of certain spe- cif~ed maloccurrences. Dumping: Denial of services or hospital admission because of inabil- ity to pay. Electronic fetal monitoring: A procedure for monitoring the fetus during labor to determine its well-being. Initially thought to be a useful means of detecting asphyxia, EFM can be done externally (using ultrasound), internally (by attaching electrodes to the fetus to obtain an EKG), or sequentially (using both techniques). Testing the pH of a blood sample from the scalp of the fetus is an integral part of EFM. Employment Retirement Income Security Act: Law requiring em- ployers with pension plans to allow employees to join within a

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160 GLOSSARY reasonable time after starting work. It ensures that money will be there to pay pension benefits when due; that employees are in- formed of their rights under the plan; and that, if an employee is denied a pension, the denial can be reviewed. Experience rating: The practice of basing professional liability in- surance premiums on a group's claims experience. Family physicians: General practitioners whose comprehensive spe- cialty takes into account social, physiological, economic, cultural, and biological dimensions of health care. Education and training include four years of graduate medical school and three years of residency. Federal Tort Claims Act: A limited waiver of sovereign immunity, the FTCA establishes the circumstances under which an injured party may sue the United States under circumstances in which the U.S. government, if it were a private person, would be liable. Fee-for-service: A method of paying physicians whereby the physi- cian charges a fee for each service performed. Forceps delivery: Extraction of an infant from the mother during labor by means of forceps, a double-bladed instrument, applied to the infant's head. Mi~forceps delivery refers to use of the instru- ment after the infant's head has entered the birth canal but before it has reached the lower part of the birth canal. Outtetforceps clelivery refers to use of the instrument when the infant's head is visible at the outlet of the birth canal. For-profit hospitals: Institutions and multihospital systems that are owned by individuals and corporations, to whom profits are distrib- uted. Freestanding birth centers: Facilities providing comprehensive ma- ternity care to women anticipating a normal childbirth, at a cost less than that of in-patient hospital delivery. . General practitioners: Physicians who have completed medical school and one year of internship and whose practice is not limited to a specialty. Health maintenance organization (HMO): An organization provid- ing comprehensive health care for a fixed monthly premium per member; premiums are paid to the plan and do not vary with utilization of services. In a staff model HMO, participating physi- cians are salaried employees of the HMO. High-risk women: Women who are statistically more likely to be at risk and to experience a bad outcome of pregnancy, particularly higher rates of infant mortality and low-birthweight infants.

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GROSSLY 161 Hill-Burton uncompensated service obligations: Obligations set forth in certain regulations issued pursuant to the Hill-Burton Act [42 U.S.C. 291, 300. et. seq. (1976~] that impose specified obliga- tions for community service and charity care on hospitals that receive funds under the Hill-Burton Act. Indemnification: Security against loss or damage that may occur in the future and the provision of compensation for loss or damage already suffered that is, insurance. Indemnity payments: Money paid in compensation for hurt, loss, or damage. Infant mortality rate: Number of deaths per 1,000 infants in the first year of life. Informed consent: The name for the general principle of law describ- ing the physician's duty to disclose to the patient the risks involved in a proposed course oftreatment, as well as the optional or alterna- tive courses of treatment available, so that the patient may intel- ligently exercise his or her judgment by balancing the probable risks of the procedure against the probable benefits. Joint and several liability: A situation in which one or more of the parties to an action may be sued separately or all together at the option of the plaintiff. Joint underwriting association (JUA): Nonprofit pooling arrange- ment created by a state legislature to provide professional liability insurance to health care providers in that state. Although intended to be self-supporting through premiums collected, some JUAs can assess policyholders for deficits. Deficits exceeding what can be recouped from policyholders are generally covered through assess- ments of any company authorized to write casualty insurance or specified lines of insurance in the state. Liability (in tort): The legal responsibility of a wrongdoer for a civil wrong that causes an injury. Malpractice: Professional misconduct or unreasonable lack of skill. This term is usually applied to conduct by doctors, lawyers, and accountants. Medical malpractice is commonly defined as any devi - ation from the accepted medical standard of care due a given patient that causes injury. Malpractice insurance contract: An agreement by an insurance company to accept, in return for a fee, orpremium, financial respon- sibility for payment of any claims up to a specific level of coverage during a fixed period. It is the insurer's responsibility to investigate

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162 GLOSSARY and defend any claims made against the insured under the terms of the contract. Under an occurrence-based policy, the insurance com- pany is liable for any incidents that occurred during the period the policy was in force, regardless of when the claim is filed. A ciaims- made policy provides coverage for malpractice incidents for which claims are made while the policy is in force. A tailpol~cy is a special policy to cover residual claims. Medicaid: A joint federal-state program under which the federal government sets basic standards and provides matching funds and the states establish eligibility, benefits, and reimbursement rates to provide health care to the poor. States that participate in the program must cover the categorically needy, that is, persons eligible for cash welfare benefits, and may also cover the mecizcally needy, that is, persons whose incomes are high enough to disqualify them from cash assistance but not high enough to pay their medical bills. The programs play a critical role in providing financial access to obstetrical services for low-income women. Metropolitan areas: Areas with a center city (or twin cities) of 50,000 or more, together with surrounding, economically related jurisdic- tions. Morbidity: A diseased state or symptom, the incidence of disease, or the rate of sickness. Mutual, reciprocal insurance company: One owned by providers, such as a medical society. Myers-Briggs personality test: A personality type indicator in which 166 items are scored for four Jungian polarities: extraver- sion-introversion, sensation-intuition, thinking-feeling, and judg- ment-perception. National Health Service Corps (NHSC): Professionals repaying medical education scholarships and loans by working in medically underserved areas. Physicians serve one year for every year of training they receive under NHSC funding. No-fault compensation: A method for compensating victims of medi- cal maloccurrence without determining fault. Not-for-profit hospitals: Hospitals and multihospital systems, tra- ditionally run by religious groups, whose capital and revenue have historically come from charitable donations and governmental grants but are increasingly being obtained from billing for services. They can and do make profits (usually termed a surplus). Nurse-midwifery: The independent management of the care of es- sentially normal newborns and women antepartally, intrapartally, postpartally, and gynecologically within a system that provides for

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GLOSSARY 163 physician consultation. Certified nurse-midwives are individuals educated in the two disciplines of nursing and midwifery who are certified by the American College of Nurse-Midwives. Obstetrician-gynecolog~sts: Physicians whose practice covers preg- nancy and childbirth and diseases of women, particularly those affecting the sex organs. Educational requirements include four years of graduate medical school, three of which are in obstetrics- gynecology, and at least three years of residency. Occurrence-based medical malpractice policy: See Malpractice insurance contract. Oxytoc~n: A hormone that stimulates contractions of the uterine muscle; used to induce or speed labor. Premature labor: Onset of labor with effacement and dilation of the cervix before 37 weeks of gestation. Prenatal care: Physical examinations and laboratory tests at regular intervals during pregnancy. Premium: See Malpractice insurance contract. Presumptive eligibility: An option that allows providers to assume a patient is eligible for Medicaid, based on his or her statement of income, and to render services for a specified period of time while the Medicaid application is being processed. Pretrial screening: Evaluation of medical malpractice claims before they enter the court system. Screening is generally mandatory but not binding, and the findings are generally admissible in a subse- quent trial, although they are not conclusive. States differ in the number, composition, and method of selection of members of screen- ing panels, in the type of evidence that will be reviewed, and in the rules regarding subsequent admissibility of the panel's findings. Provider mutuals, residuals: Insurance companies established by medical societies. The policyholders are the residual claimants to profit and the residual bearers of loss. Purchasing groups: Groups that may provide or obtain liability insurance under an exemption from many state laws. They are permitted to obtain group policies from any insurer, including those not licensed in the state. Randomized clinical trial: A controlled experiment requiring that individuals be randomly assigned to one of two or more treatments or program variations. The random assignment ensures that the estimated differences between the groups so constituted are statis

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164 GLOSSARY tically unbiased, that is, that any differences in effects can be ascribed to treatment. Reserve: Money set aside by insurers for unknown contingencies. Residual policy market: A situation in which premiums for insur- ance through a joint underwriting association are set, and lia- bilities in excess of premiums and interest income can be funded through assessments on other property and casualty insurance companies in the state. Res ipsa loquitur: Literally, "the thing speaks for itself." A legal doctrine of presuming tort liability in certain circumstances. Respiratory distress syndrome: A disorder, primarily of premature infants, occurring during the first days of life. It is characterized by difficulty in breathing and cyanosis. Risk classification: A method used by insurance companies for rank- ing medical specialties by relative risk and setting premiums on that basis. Risk management: Efforts by insurers to identify high-risk areas of medical care and to encourage more effective or appropriate methods of managing the risks of medical care. Risk management activities include data gathering and analysis, clinical standard setting and the development of protocols, education, and discounted premiums as incentives to involve physicians in risk management activities. Risk retention groups: Groups that may provide or obtain liability insurance under an exemption from many state laws. They need only be licensed in one state to sell insurance in all 50. Rural areas: Used in a general sense to describe nonmetropolitan areas. Sliding fee scale: Fees based on family income. Statute of limitations: A law prescribing the time period within which a particular legal action may be brought. Structured payments: Awards for future Tosses made in install- ments throughout the plaintiffs period of disability instead of in a lump sum. This method of payment may reduce the total amount paid out. Tail insurance: See Malpractice insurance contract. Tort law: Branch of law, based largely on common law, permitting recovery through the judicial system for private or civic wrong or injury other than breach of contract. Tort reforms: Legislation modifying common-law tort doctrine that is intended to relieve the medical liability crisis. Reforms enacted

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GLOSSARY 165 thus far are designed to moderate the frequency and severity of medical malpractice claims in order to control the cost and ensure the availability of professional liability insurance. Toxemia: A condition, also known as preeciampsia, occurring in the latter half of pregnancy and characterized by an acute elevation of blood pressure and usually by swelling and protein in the urine. Ultrasonography: A noninvasive, pulse-echo diagnostic technique that allows real-time uterine scanning and prenatal diagnosis. Pulses from an oscillating transducer produce bursts of ultrasonic energy that are directed into tissue. Dots produced on a display for each echo reflection coalesce and form an echo outline of the ana- tomic structures being examined. It is particularly useful for eval- uating the viability and development of the fetus and for locating the placenta. Underwriting: Ensuring the satisfaction of an obligation for loss or damage on consideration of a premium. Vacuum extractor: An obstetrical instrument using suction rather than forceps in the second stage of labor.