Research by Author & Topic

Publications by Randall R. Bovbjerg on Hospitals and Physicians

This study, funded by the Maine Health Access Foundation, presented alternative estimates of the costs of health care that uninsured Maine residents receive and determined how much public revenue was available to offset those costs. Using data from health care providers, the study estimated that the costs of caring for the uninsured in Maine were $138 million in 2005, with hospitals and Veterans' Affairs facilities identified as the largest providers. Estimates based on household survey data from the Medical Expenditure Panel Survey showed that uncompensated care costs for the uninsured were only $81 million in 2005. The report discusses possible reasons for the large discrepancy between these two sources. Our review of federal and state funding sources in 2005 suggests there were roughly $110 million available to offset these costs of caring for the uninsured.

Malpractice problems are threefold: (1) Physicians and other medical providers periodically face great difficulty in finding and financing liability insurance protection. (2) Preventable patient injuries continue to occur much too frequently, few of them addressed by lawsuits. (3) Tort litigation fails to prevent these preventable injuries and creates liability risk that is hard to insure. Malpractice reforms have always been single-minded: help doctors get liability insurance by cutting back on legal remedies. Affected physicians and attorneys dominate debate and either attack or defend traditional legal process. Policy should instead combine liability reform with thoroughgoing promotion of patient safety. (Indiana Health Law Review 3(1): 3-26, 2006)

In this ARRP Bulletin "FaceOff" commentary, Randall R. Bovbjerg argued that conventional tort reform like caps on awards successfully limit the scope of the current system and reduce physicians' premiums--but do not compensate more people, improve deterrence or equitably spread the impact of their cutbacks. True improvement calls for more even-handed tort reforms, and for experiments with non-courtroom-based injury resolution by medical institutions, health plans or states, perhaps even by Medicare. (AARP Web Exclusive, April 2006)

Enterprise liability means holding hospitals or health plans responsible for patient injuries from physician care. This reform seeks better prevention of injury and more efficient insurance. Systems can do more than individuals to improve patient safety, but first practitioners and institutions must combine into functioning systems, which is not happening in today's medical markets, contrary to mid-1990s expectations. Liability change needs to follow rather than lead market changes. For now, public policy should promote injury prevention in other ways--as a demanding purchaser, a promulgator of performance standards, a funder of research and development, and a communicator of information to patients and health plan enrollees. (Medical Malpractice and the U.S. Health Care System, edited by William M. Sage and Rogan Kersh, Cambridge University Press, pp219-244 (2006).)

The uninsurance rate in the District is lower than the national average, but an unacceptably high number of residents remain uncovered. To help assess ways to improve coverage, the DC Department of Health convened the Health Care Coverage Advisory Panel under the District's State Planning Grant (SPG). This final report of the Panel, staffed by the authors, makes eight recommendations, including better outreach and enrollment in Medicaid and other existing public programs, allowing uninsured residents to buy in to such programs, better information on private options, and ongoing monitoring of coverage accomplishments and prevailing insurance market conditions.

Higher price and lower availability for malpractice coverage, along with constrained medical fees have lead medical practitioners to declare a crisis and demand tort reform. Doctors and other reformers blame the legal system, while trial lawyers blame insurers. Neither side sufficiently addresses the core problems of too many preventable medical injuries and an underperforming legal system. Physicians should do more to boost patient safety, even within the current legal system, and should also support experimentation with broader alternatives described here that deliver compensation more efficiently and mesh better with emerging paradigms of patient safety. (Clinics in Perinatology 32(1):203-233, March 2005.)

Tort-lawsuits-plus-liability-coverage cost only about $25 billion in 2002, and extra defensive medicine probably added a bit more. These small fractions of a $1.5-trillion medical economy would be a bargain if they actually bought the compensation, injury deterrence, and justice that advocates claim. They do not. Few sue and fewer collect, slowly and with high overhead; high rates of preventable error and injury persist; and justice is ill served by omitting most injuries, resolving them slowly, and paying out hugely variable amounts. Better systems would make practitioners more willing to disclose problems, feed back improvements in real time, and compensate consistently. (Health Affairs 23(5):277, September/October 2004.)

Today's tort liability falls short of its laudable goals of deterring substandard care, compensating those injured and operating a fair injury resolution process. Medical and safety reformers call for cutting back liability, but reforms ought to improve both compensation and patient safety. Scenarios toward improvement are presented, but a key improvement is listing avoidable classes of events (ACEs) in advance, so that compensability is clearer, than paying those promptly through an insurance process rather than adjudication. Journal of Law, Medicine & Ethics 33(3): 478-500 (Fall 2005)

On November 2nd, 2005, The Urban Institute and Health Affairs convened a roundtable of experts to discuss health care economizing and financing. The discussion centered on four topics: (1) consumers; (2) the role of state and federal government; (3) providers and other intermediaries; and (4) other efficiency efforts. This document provides a brief summary of the participants' comments in each of these four areas.

American health care features little patient safety and too much physician silence about injuries. Preventable medical injuries are numerous, and research presents a convincing case that advancing capabilities in patient safety could greatly reduce harm to patients. Safety and silence are not unrelated, as safety analysis starts with disclosure of problems. Two main sets of factors resist patient safety and promote physician silence: internal medical culture and the external sociolegal environment of health care. Recognition of the importance of external accountability, external oversight of medical discipline, and tort compensation should be modified to make it easier for practitioners to do the right thing. Tort liability alternatives are warranted. (Journal of Legal Medicine 25:505–16.)