Dear Editor,

In a letter you recently published about online medical ratings, your headline cried: "There Has Got to Be a Better Way” for patients to share information on health care providers.

With a plethora of anonymous ratings sites available – in which anyone, including physicians themselves or a person with an axe to grind – can post a review, it’s important for consumers to have a trusted resource in which the information is verifiable and where both sides of the story can be shared.

Angie's List goes to great lengths to hold members accountable and to provide the fairest, most reliable information possible. We alert physicians when they are first added to the List, and we offer them an opportunity to respond to each report, either directly to the patient or on our site.

We've been offering local consumer ratings for 14 years, and that experience gave us an advantage as we launched health care ratings last year. We sought advice from physicians, did a ton of research and applied our tried and true accountability structure to our health care ratings. In short, we don't allow anonymous reviews; we hold both members and doctors accountable for truthfulness; we encourage physicians to contact patients who've reported about them; and we rigorously monitor for attempts to game our system.

After learning of efforts to have patients sign waivers that limit their free speech, we surveyed physicians rated on our List and found that more than 60 percent think public commentary waivers is a bad idea. Yet, nearly 20 percent said they would consider offering waivers.

In a simultaneous survey of our members, we found that 97 percent would walk away from doctors who wanted them to sign waivers.

Most physicians who oppose the ratings say patients can't accurately judge or report on the level of care they receive. Others are concerned about anonymous reviews that lack accountability. To the first, we say, patients can and are giving great insights into the care they receive. To the second, we say, we've got that covered. 

Consumer ratings are only increasing, and most physicians are cautiously welcoming them. Done right, consumer ratings offer physicians great insight into how their patients feel about customer care. The ratings provide consumers with great insight into how their local doctors deliver service.

Physicians who strive to provide high quality care should embrace consumer ratings and work with ratings providers rather than try to shield themselves. When reliable information flows freely, everybody wins.

Angie Hicks Founder of Angie’s List ]]> http://www.physiciansnews.com/2009/05/07/letter-to-the-editor-angies-list-view-on-online-ratings/feed/ 0 http://www.physiciansnews.com/2003/07/01/pew-reports-raise-more-questions-than-answers/ http://www.physiciansnews.com/2003/07/01/pew-reports-raise-more-questions-than-answers/#comments Tue, 01 Jul 2003 06:58:24 +0000 Physicians News http://clients.ikodum.com/phynews/?p=29

By Jeffrey Barg

A recent report of the Project on Medical Liability in Pennsylvania, funded by The Pew Charitable Trusts, provides independent confirmation of many of the things physicians have been saying about the malpractice crisis.Understanding Pennsylvania’s Medical Malpractice Crisis: Facts About Liability Insurance, the Legal System and Health Care in Pennsylvania, released in June, documents the crisis in the availability and affordability of malpractice insurance. (The report is available online at http://medliabilitypa.org/research/report0603/) The report cites the CAT Fund as a contributing factor and identifies the largest driver of the increased cost of malpractice coverage as the unusually large cost of investigating, defending and paying legal claims in Pennsylvania.

The report, authored by leading malpractice researcher Randall R. Bovbjerg, J.D., and Anna Bartow, M.D., cites numerous problems with the CAT Fund. "In recent years, its pay-as-you-go financing necessitated large annual assessments to cover accumulating claims from prior periods," states the report. "In addition, legislative cutbacks in the extent of the Fund’s future obligations have induced rate increases for private insurers." Other problems with the CAT Fund cited in the report include:

• "Unlike other states with public compensation funds, such as Indiana, Pennsylvania has committed substantial resources to paying malpractice claims but has not instituted limits on those claims by adopting caps on damages, shorter statutes of limitations, or similar measures."

• "Pennsylvania . . . is disadvantaged in attracting physicians because new doctors pay a high assessment to cover losses generated by their predecessors, a problem that continues under MCARE."

• "Plaintiff’s lawyers . . . complain that the Fund often resists paying meritorious cases, while many providers and primary carriers opine that it is harder to mount a joint defense with the Fund than with another private insurer. These tendencies may help explain why malpractice cases in Pennsylvania are resolved so slowly."

The report concludes that while problems in the insurance industry have contributed to the crisis, the primary causes of the crisis are the costs of investigating, defending and paying legal claims in Pennsylvania. Data show that Pennsylvania ranks high in terms of (1) malpractice filings and trial rates in urban counties; (2) the rate of claims paid; (3) average settlement amounts; (4) malpractice payouts adjusted for population; (5) the rate of growth in malpractice payouts per population; and (6) average time elapsed from incident to payment of the claim. Philadelphia plaintiffs were more than twice as likely to win jury trials as the national average and the number of awards plus settlements of million or more in Philadelphia were only slightly less than for the entire state of California.

The report does not explain why, other than the influence of CAT Fund, Pennsylvania’s malpractice system is more costly than most other states’ or what the impact of the malpractice crisis is. This information gap is a significant impediment to the report’s usefulness to policy-makers. It does note that there is no data to suggest that Pennsylvania’s malpractice system is more costly than other states’ because of lower quality health care in the state. There is no evidence of the cost of health care rising because of the crisis, or of a shortage of physicians or hospital beds, according to the report.

The report does warn, however, that access problems may occur, in part because of the great financial strains physicians and hospitals are undergoing. These access problems may already be occurring in certain areas of the state such as rural areas and inner cities, for certain patient subgroups such as Medicaid patients and the uninsured, or in certain medical subspecialties such as obstetrics, orthopedics and neurosurgery — all of which may have been undetectable in the report’s aggregate and somewhat dated data, the report’s authors admit.

The issue of the malpractice crisis’ impact on access to physician services in Pennsylvania will be revisited in another Project report being done by Harvard’s School of Public Health, according to William Sage, M.D., J.D., principal investigator of the Project. Duke University will be doing a Project report on the impact of the CAT Fund as well. (The interview is available online at http://physiciansnews.com/spotlight/303.html)

The report concludes that "subsidies that allow health care providers to maintain coverage would seem to be the only practical approach to alleviating the current crisis." Then it recommends that conventional tort and insurance reforms, as well as more systemic changes, be considered to control costs, improve predictability and attract malpractice insurers back to Pennsylvania in the longer term.

In the end, we’re left with little more than Gov. Rendell’s Malpractice Task Force’s recommended subsidies proposed back in December, reduced by Gov. Rendell, and still awaiting legislative approval.

Buried in the report, the authors write, "The legal system is intended to generate deterrence of substandard medical care by requiring compensation to patients wrongfully injured by health care providers through a dispute resolution process that offers justice. Assessing the performance of the legal system in achieving these social goals is beyond the scope of this report."

One can only hope that the Project on Medical Liability in Pennsylvania will produce a report designed to assess the performance of the legal system, soon, with an author as well qualified for the task as Randall R. Bovbjerg. Bovbjerg addressed these issues in an interview published inPhysician’s News Digest in June. (The interview is available online at http://physiciansnews.com/spotlight/603.html)

In the interview, Bovbjerg says: "The big problem of the current system is that it’s not doing what it says it will do to make medical care safer. It’s also not really compensating people very well because most people who have injuries don’t know it or aren’t able to sue, and payouts are somewhat haphazard. I think it’s a significant problem of justice that the system pays out different amounts in quite similar cases."

Bovbjerg also has provocative things to say about caps: "Amazingly, doctors argue fiercely that the current system is broke, it causes defensive medicine, it doesn’t help patients — but they turn around and say it’s just fine if we cut it back with caps. That doesn’t make a lot of sense to me. The biggest problem is preventable injury, but the big battle is imposing or preventing caps. It’s a very narrow debate in the short run. In the long run, I suggest to your readers, caps will not be sustained if they are perceived as being unfair takeaways — part of that zero-sum, winners vs. losers game. Judges and jurors will get around such caps, and eventually legislators will vote them out. I think that a better system would focus on preventing injury and making payments more fair, predictable and fast. That is win-win for both patients and doctors, and that will be more successful in the long run."

Bovbjerg favors the two approaches proposed in the Institute of Medicine report, Fostering Rapid Advances in Health Care: Learning from System Demonstrations, published in November of 2002. (The report is available online at http://www.nap.edu/openbook/0309087074/html/81.html) Option one is a provider-based early payments system that would offer predetermined limits on noneconomic damages and federally subsidized reinsurance to self-insured provider groups that promptly identify and compensate patients for identifiable classes of avoidable injuries. Option two is an administrative resolution that would grant all health care professionals and facilities within a state immunity from tort liability in exchange for mandatory participation in a state-sponsored system under which providers would need to disclose errors to patients, while providers or their liability carriers would be responsible for paying amounts determined by a publicly administered adjudication system.

Another Project report released in June addresses some of these broader issues. Resolving the Medical Malpractice Crisis: Fairness Considerations by Case Western Reserve University law and bioethics professor Maxwell J. Mehlman, J.D., is an interesting introduction to the philosophical underpinnings of the nation’s medical malpractice system as well as various reforms. (The report is available online at http://medliabilitypa.org/research/mehlman0603/)

Mehlman’s method is to begin with a set of abstract fairness principles, which he then applies to the current malpractice system, to a wide variety of reforms, and to the reform process itself. I found the questions raised by his analysis to be interesting and important, while his concluding determinations of whether something is "fair" or "unfair" seemed to be inadequately supported and to detract from the report’s value, making it too easy for it to be reduced to a selective recitation of the fairness determinations that suit an advocate’s agenda.

Mehlman identifies the following as the most serious fairness objections to the current system: (1) it only purports to compensate victims of medical negligence, while a fairer system would compensate for all medical injuries; (2) the punishment objective conflicts with the deterrence objective; (3) it lacks validity and consistency; (4) compensation is inconsistent and only somewhat proportional; (5) financing mechanisms are unfair and undependable; (6) it may leave some patients without adequate access to necessary health care services; (7) its lack of predictability sends erratic deterrent signals; (8) it operates by rules that providers feel are unfair; (9) some injured patients cannot obtain adequate representation; and (10) parties are not treated with dignity and respect.

News coverage of the report tended to focus almost exclusively on Mehlman’s assessment that caps are unfair, which comprises three paragraphs of a 105 page report. Mehlman’s reason for the assessment is that caps violate the cardinal principle of distributive justice: "Welfare must not be taken away from those who are worse off and given to those who are better off." In this case, Mehlman contends that wealth would be transferred from the most seriously injured patients to all patients, who could benefit from strengthening the malpractice financing system, from maintaining access, and possibly even from restraining increases in health care costs stimulated by higher premiums.

Earlier in the report, however, Mehlman details the difficulties in valuing non-economic damages and acknowledges that, currently, "awards for non-economic damages fall short of optimal fairness." He acknowledges that providers and insurers believe that injured patients receive unfairly generous compensation for pain and suffering without addressing whether or not this is the case. His reliance on the cardinal principle of distributive justice seems to lock him into the status quo, even if by some valid measure non-economic awards are inflated.

In the end, Mehlman is so committed to not reducing compensation to the most seriously injured patients that he is leery of other reforms that by his own estimation correct major unfairness in the current tort system and could reduce future injuries. Nonetheless, he does provide provisional support for scheduling the amounts or capping damages for identifiable classes of avoidable injuries if based on average jury awards in states without caps.

Taken together these two reports of the Project on Medical Liability in Pennsylvania raise more questions than answers, which is frustrating for Pennsylvanians, especially Pennsylvania physicians, in the midst of a malpractice crisis. Sage acknowledges in his PND interview that much of the Project’s work will not be completed in time for the decisions that have to be made to address the current crisis. Nonetheless, these reports can and should inform our discussion and debate as we search for a durable and fair solution to the problem.

• Following the passage of smoke-free restaurant ordinances in California, Utah, Vermont, Los Angeles, San Francisco, New York City, Boulder, Flagstaff and Mesa (Arizona), there was an increase or no change in tourism in all but Flagstaff, where the rate of increase merely slowed.

• Restaurants and bars in California, New York, Massachusetts, Arizona, Colorado, West Lake Falls (a suburb of Austin, Texas), and North Carolina showed no decrease in sales after going smoke-free. Informal discussions with Philadelphia bars and restaurants that have gone smoke-free shows that the same is true here.
• Bartenders who worked for as little as one month in smoke-free conditions after a California law banned smoking in their workplace reported a significant drop in coughing and other respiratory problems and showed improved lung function. Many bartenders would be similarly protected under Councilman Nutter’s bill.
• A survey of 2,000 smoke-free workplaces revealed that 60% of those surveyed saw a reduction in maintenance and cleaning costs following implementation of no smoking policies.
• The U.S. Environmental Protection Agency estimated that the economic benefits of most workplaces and public places going smoke-free would exceed the cost by to billion annually.
• Voluntary compliance with smoke-free ordinances has been high.

• Youth smoking rates were on the rise and teens were starting to smoke at younger ages.
• Young people were bombarded with messages inducing them to use tobacco including ads on mass transit and tobacco-sponsorship of an annual women’s tennis tournament in Philadelphia.
• Eighty-five percent of tobacco retailers were illegally selling tobacco products to minors with absolute impunity.
• Philadelphia’s public pension funds were heavily invested in tobacco stocks.

• The SEPTA board has voted unanimously to no longer accept tobacco and alcohol ads on their buses, trains and stations.
• Philadelphia City Council voted unanimously to divest the tobacco stock holdings in their public pension funds.
• There is no longer tobacco-sponsorship of an annual women’s tennis tournament in Philadelphia.
• A strong law to curb youth access to tobacco has been passed by Philadelphia City Council and effectively enforced by the Department of Licenses and Inspection decreasing illegal sales by almost 50 percent.

Dear Editor,

In a letter you recently published about online medical ratings, your headline cried: "There Has Got to Be a Better Way” for patients to share information on health care providers.

With a plethora of anonymous ratings sites available – in which anyone, including physicians themselves or a person with an axe to grind – can post a review, it’s important for consumers to have a trusted resource in which the information is verifiable and where both sides of the story can be shared.

Angie's List goes to great lengths to hold members accountable and to provide the fairest, most reliable information possible. We alert physicians when they are first added to the List, and we offer them an opportunity to respond to each report, either directly to the patient or on our site.

We've been offering local consumer ratings for 14 years, and that experience gave us an advantage as we launched health care ratings last year. We sought advice from physicians, did a ton of research and applied our tried and true accountability structure to our health care ratings. In short, we don't allow anonymous reviews; we hold both members and doctors accountable for truthfulness; we encourage physicians to contact patients who've reported about them; and we rigorously monitor for attempts to game our system.

After learning of efforts to have patients sign waivers that limit their free speech, we surveyed physicians rated on our List and found that more than 60 percent think public commentary waivers is a bad idea. Yet, nearly 20 percent said they would consider offering waivers.

In a simultaneous survey of our members, we found that 97 percent would walk away from doctors who wanted them to sign waivers.

Most physicians who oppose the ratings say patients can't accurately judge or report on the level of care they receive. Others are concerned about anonymous reviews that lack accountability. To the first, we say, patients can and are giving great insights into the care they receive. To the second, we say, we've got that covered. 

Consumer ratings are only increasing, and most physicians are cautiously welcoming them. Done right, consumer ratings offer physicians great insight into how their patients feel about customer care. The ratings provide consumers with great insight into how their local doctors deliver service.

Physicians who strive to provide high quality care should embrace consumer ratings and work with ratings providers rather than try to shield themselves. When reliable information flows freely, everybody wins.

Angie Hicks Founder of Angie’s List ]]> http://www.physiciansnews.com/2009/05/07/letter-to-the-editor-angies-list-view-on-online-ratings/feed/ 0 http://www.physiciansnews.com Tue, 07 Feb 2012 16:44:06 +0000 en hourly 1 http://wordpress.org/?v=3.2.1 http://www.physiciansnews.com/2011/11/01/i-have-cancer-and-i%e2%80%99ve-never-felt-better/ http://www.physiciansnews.com/2011/11/01/i-have-cancer-and-i%e2%80%99ve-never-felt-better/#comments Tue, 01 Nov 2011 17:54:25 +0000 Physicians News http://www.physiciansnews.com/?p=4363 By Tracy Krulik In 1998 I wound up in a South Florida emergency room following a week of nausea, vomiting, and frail-octogenarian-like weakness. After a brief exam, an overnight stay in the hospital, and an endoscopy, the internist sent me home with motility drugs to combat his diagnosed cause of my problems -- gastroparesis. That was the start of my nine-year illness, which was misdiagnosed at every turn. Mine is a story of how I survived a medical odyssey that included a tumor on my pancreas as well as metastases to my liver and chest. During that decade I endured bouts of similar attacks as well as gallstones, hypoglycemia, a bizarre affliction of multiple trigger fingers, hives, and a laser of pain in the upper left quadrant of my abdomen. Doctor after doctor diagnosed me with gastroparesis, IBS, or functional dyspepsia and put me on motility drugs, proton-pump inhibitors, and Elavil to ease the pain. One attack in 2004 was so intense that my then-gastroenterologist sent me for an abdominal CT scan, which showed attenuation on my pancreas. I was immediately sent to the hospital with a diagnosis of pancreatitis. My doctor was heading out of town to celebrate New Year’s Eve in Las Vegas, so his partner cared for me in the hospital. (The old warning still is true: Don’t get sick over a holiday.) An MRI taken the next day returned normal, but the doctor had me stay in the hospital another night for observation and more time on an IV to help my pancreas calm down in case it was indeed inflamed. I went home the following morning. Increasing my Elavil from 25 mg to 50 mg got rid of most of the pain, so for the next two and half years I just stayed on my meds and tried my best to ignore any discomfort. During that time, about a year after my hospitalization, I decided to officially switch over to my doctor’s partner for care after my doctor asked me why I had been taking Elavil. Apparently he wasn’t following my care as closely as I would have hoped. By 2007 the pain overpowered the Elavil, so I visited the doctor once again. Not liking the word “pancreatitis” in my chart, my gastroenterologist wanted me to get a repeat CT scan to compare to the one from 2004. I fought against further testing. Frankly, I was sick and tired of being poked and prodded, but the doctor fought back harder. In the end I gave in, and I’m lucky I did. The doctor called me a week later to tell me that the mass that was on my pancreas two and half years earlier was still there. My response: “What mass?” When his partner sent me to the hospital in 2004 for pancreatitis, he didn’t tell me there was a mass on my pancreas; he said my pancreas looked swollen. Regardless, my doctor was pleased that the mass appeared smaller on the film than it had in 2004, so he didn’t believe it was cancer, but he still wanted me to get a follow-up test. On August 31, I underwent an endoscopic ultrasound with biopsy. The week of my 36^th birthday, I heard the results from my doctor: “You have cancer, but not really cancer.” What? By now, you in the medical community might have figured out what I have—neuroendocrine cancer, islet cell to be specific (just like Steve Jobs). The doctors assumed that I had an insulinoma given my bouts of hypoglycemia, and I was told that by removing the tumor, I would be cured. Luckily for me the tumor was located on the tail of my pancreas, which meant that I would not need a Whipple procedure. To be safe we also needed to do one more test -- an octreoscan -- to confirm that the disease had not spread. If it had there would be no chance for a cure, but I was told that it would be extremely rare for that to happen. If you don’t know, with an octreoscan, the patient is infused with Indium-tagged octreotide, which is a natural hormone that can be picked up by neuroendocrine tumors if they have a specific receptor. If my tumor had that receptor, it would show up under the scanner. As it turns out, my tumor did, and so did the mets that had formed in the right lobe of my liver and in my mediastinum. I went to an oncologist the next day. “If I were you, I’d leave the tumors where they are and just take a monthly injection of octreotide [to flood the tumors and stop them from secreting insulin],” the oncologist said. “You won’t live until you’re 80, but you’ll live a full life.” I started looking for a different oncologist as soon as I left the building. While other oncologists agreed with that doctor that removing the visible mets would not cure me due to the inevitability of micromets, no one else agreed that I should leave the primary tumor on my pancreas. It had made me incredibly sick for nearly a decade after all. Not only should I feel healthy again once it was removed, but with my body stronger, my immune system could be better equipped to combat the disease. In November 2007, I had a distalpancreatecomy with splenectomy, and the well-differentiated tumor was removed. I began receiving monthly injections of octreotide (Sandostatin LAR) two weeks later. The oncologist I selected at the Moffitt Cancer Center believed that I would soon need a stronger treatment such as targeted radiation therapy -- only available at the time in clinical trial in the Netherlands -- because the octreotide could only be effective (if at all) for a year or two at most. But when I underwent tests to apply for the trial, the CT scan could not pick up any mets. Octreoscan still showed some uptake, but that would not be sufficient to participate in the trial. My oncologist instead had me continue with octreotide and return every six months for repeat scans. I switched to an oncologist at Johns Hopkins in 2010, and he questioned the efficacy of octreotide for me. Because a three-day fast did not confirm the diagnosis of insulinoma, he didn’t believe that my tumors were secreting insulin, so the octreotide was probably of little to no value. He believed that my disease was simply indolent. I stopped taking octreotide that September and worried a bit that the tumors would begin to grow again, but they haven’t. Four years ago my life was completely upended, but when I recovered from the surgery to remove the primary tumor, I felt superhuman with newfound energy and strength. I felt so good that I sought out whole foods that were entirely plant-based to make me stronger and committed to training for long-distance cycling events. I am now in the best shape of my life -- with cancer. I’m not sure why my disease stopped growing, but it has. Was it because the primary tumor was removed while the mets were still extremely small? Was it my plant-based diet and a new addiction to cycling? Was it the power of a positive attitude and reduced stress? Was it a combination of all of the above? Or none? I don’t know, but I know that I’m not changing a thing. My body appears to be in balance, enabling my immune system to fight the disease on its own. I’m going to continue doing everything I can with my lifestyle choices to keep it that way. I’m not sure what aspect of my story is of most interest to doctors, but I do think there is a lot to learn from it. The next time you chalk up chronic abdominal problems to IBS or some other “un-provable” condition, ask yourself it there might be an unusual root cause. Had my doctors found the tumor before it spread, I would have been spared from a decade of illness and an incurable form of cancer. Ironically, I don’t believe that I’d be as healthy as I am today had my doctors found the tumor sooner. I wouldn’t be able to appreciate what “healthy” really feels like without seeing the other side. And for all I know, my healthy lifestyle is what’s keeping me alive. ### Tracy Krulik is a fourteen-year cancer survivor who didn’t know she had it for the first nine years. A freelance writer and self-titled CEO of her health, Tracy is putting the finishing touches on her memoir I Have Cancer. And I’ve Never Felt Better! For more information visit http://tracykrulik.com.  ]]> http://www.physiciansnews.com/2011/11/01/i-have-cancer-and-i%e2%80%99ve-never-felt-better/feed/ 0 http://www.physiciansnews.com/2009/05/08/commentary-malpractice-lawsuits-down-in-pa-but-there%e2%80%99s-still-a-long-way-to-go/ http://www.physiciansnews.com/2009/05/08/commentary-malpractice-lawsuits-down-in-pa-but-there%e2%80%99s-still-a-long-way-to-go/#comments Fri, 08 May 2009 14:06:18 +0000 Physicians News http://www.physiciansnews.com/?p=2382 Alan Lyndon is a contributing writer for Physicians News.]]> http://www.physiciansnews.com/2009/05/08/commentary-malpractice-lawsuits-down-in-pa-but-there%e2%80%99s-still-a-long-way-to-go/feed/ 1 http://www.physiciansnews.com/2009/05/07/letter-to-the-editor-angies-list-view-on-online-ratings/ http://www.physiciansnews.com/2009/05/07/letter-to-the-editor-angies-list-view-on-online-ratings/#comments Thu, 07 May 2009 20:50:00 +0000 Physicians News http://www.physiciansnews.com/?p=2376

Dear Editor,

In a letter you recently published about online medical ratings, your headline cried: "There Has Got to Be a Better Way” for patients to share information on health care providers.

With a plethora of anonymous ratings sites available – in which anyone, including physicians themselves or a person with an axe to grind – can post a review, it’s important for consumers to have a trusted resource in which the information is verifiable and where both sides of the story can be shared.

Angie's List goes to great lengths to hold members accountable and to provide the fairest, most reliable information possible. We alert physicians when they are first added to the List, and we offer them an opportunity to respond to each report, either directly to the patient or on our site.

We've been offering local consumer ratings for 14 years, and that experience gave us an advantage as we launched health care ratings last year. We sought advice from physicians, did a ton of research and applied our tried and true accountability structure to our health care ratings. In short, we don't allow anonymous reviews; we hold both members and doctors accountable for truthfulness; we encourage physicians to contact patients who've reported about them; and we rigorously monitor for attempts to game our system.

After learning of efforts to have patients sign waivers that limit their free speech, we surveyed physicians rated on our List and found that more than 60 percent think public commentary waivers is a bad idea. Yet, nearly 20 percent said they would consider offering waivers.

In a simultaneous survey of our members, we found that 97 percent would walk away from doctors who wanted them to sign waivers.

Most physicians who oppose the ratings say patients can't accurately judge or report on the level of care they receive. Others are concerned about anonymous reviews that lack accountability. To the first, we say, patients can and are giving great insights into the care they receive. To the second, we say, we've got that covered. 

Consumer ratings are only increasing, and most physicians are cautiously welcoming them. Done right, consumer ratings offer physicians great insight into how their patients feel about customer care. The ratings provide consumers with great insight into how their local doctors deliver service.

Physicians who strive to provide high quality care should embrace consumer ratings and work with ratings providers rather than try to shield themselves. When reliable information flows freely, everybody wins.

Angie Hicks Founder of Angie’s List ]]> http://www.physiciansnews.com/2009/05/07/letter-to-the-editor-angies-list-view-on-online-ratings/feed/ 0 http://www.physiciansnews.com/2003/07/01/pew-reports-raise-more-questions-than-answers/ http://www.physiciansnews.com/2003/07/01/pew-reports-raise-more-questions-than-answers/#comments Tue, 01 Jul 2003 06:58:24 +0000 Physicians News http://clients.ikodum.com/phynews/?p=29

By Jeffrey Barg

A recent report of the Project on Medical Liability in Pennsylvania, funded by The Pew Charitable Trusts, provides independent confirmation of many of the things physicians have been saying about the malpractice crisis.Understanding Pennsylvania’s Medical Malpractice Crisis: Facts About Liability Insurance, the Legal System and Health Care in Pennsylvania, released in June, documents the crisis in the availability and affordability of malpractice insurance. (The report is available online at http://medliabilitypa.org/research/report0603/) The report cites the CAT Fund as a contributing factor and identifies the largest driver of the increased cost of malpractice coverage as the unusually large cost of investigating, defending and paying legal claims in Pennsylvania.

The report, authored by leading malpractice researcher Randall R. Bovbjerg, J.D., and Anna Bartow, M.D., cites numerous problems with the CAT Fund. "In recent years, its pay-as-you-go financing necessitated large annual assessments to cover accumulating claims from prior periods," states the report. "In addition, legislative cutbacks in the extent of the Fund’s future obligations have induced rate increases for private insurers." Other problems with the CAT Fund cited in the report include:

• "Unlike other states with public compensation funds, such as Indiana, Pennsylvania has committed substantial resources to paying malpractice claims but has not instituted limits on those claims by adopting caps on damages, shorter statutes of limitations, or similar measures."

• "Pennsylvania . . . is disadvantaged in attracting physicians because new doctors pay a high assessment to cover losses generated by their predecessors, a problem that continues under MCARE."

• "Plaintiff’s lawyers . . . complain that the Fund often resists paying meritorious cases, while many providers and primary carriers opine that it is harder to mount a joint defense with the Fund than with another private insurer. These tendencies may help explain why malpractice cases in Pennsylvania are resolved so slowly."

The report concludes that while problems in the insurance industry have contributed to the crisis, the primary causes of the crisis are the costs of investigating, defending and paying legal claims in Pennsylvania. Data show that Pennsylvania ranks high in terms of (1) malpractice filings and trial rates in urban counties; (2) the rate of claims paid; (3) average settlement amounts; (4) malpractice payouts adjusted for population; (5) the rate of growth in malpractice payouts per population; and (6) average time elapsed from incident to payment of the claim. Philadelphia plaintiffs were more than twice as likely to win jury trials as the national average and the number of awards plus settlements of million or more in Philadelphia were only slightly less than for the entire state of California.

The report does not explain why, other than the influence of CAT Fund, Pennsylvania’s malpractice system is more costly than most other states’ or what the impact of the malpractice crisis is. This information gap is a significant impediment to the report’s usefulness to policy-makers. It does note that there is no data to suggest that Pennsylvania’s malpractice system is more costly than other states’ because of lower quality health care in the state. There is no evidence of the cost of health care rising because of the crisis, or of a shortage of physicians or hospital beds, according to the report.

The report does warn, however, that access problems may occur, in part because of the great financial strains physicians and hospitals are undergoing. These access problems may already be occurring in certain areas of the state such as rural areas and inner cities, for certain patient subgroups such as Medicaid patients and the uninsured, or in certain medical subspecialties such as obstetrics, orthopedics and neurosurgery — all of which may have been undetectable in the report’s aggregate and somewhat dated data, the report’s authors admit.

The issue of the malpractice crisis’ impact on access to physician services in Pennsylvania will be revisited in another Project report being done by Harvard’s School of Public Health, according to William Sage, M.D., J.D., principal investigator of the Project. Duke University will be doing a Project report on the impact of the CAT Fund as well. (The interview is available online at http://physiciansnews.com/spotlight/303.html)

The report concludes that "subsidies that allow health care providers to maintain coverage would seem to be the only practical approach to alleviating the current crisis." Then it recommends that conventional tort and insurance reforms, as well as more systemic changes, be considered to control costs, improve predictability and attract malpractice insurers back to Pennsylvania in the longer term.

In the end, we’re left with little more than Gov. Rendell’s Malpractice Task Force’s recommended subsidies proposed back in December, reduced by Gov. Rendell, and still awaiting legislative approval.

Buried in the report, the authors write, "The legal system is intended to generate deterrence of substandard medical care by requiring compensation to patients wrongfully injured by health care providers through a dispute resolution process that offers justice. Assessing the performance of the legal system in achieving these social goals is beyond the scope of this report."

One can only hope that the Project on Medical Liability in Pennsylvania will produce a report designed to assess the performance of the legal system, soon, with an author as well qualified for the task as Randall R. Bovbjerg. Bovbjerg addressed these issues in an interview published inPhysician’s News Digest in June. (The interview is available online at http://physiciansnews.com/spotlight/603.html)

In the interview, Bovbjerg says: "The big problem of the current system is that it’s not doing what it says it will do to make medical care safer. It’s also not really compensating people very well because most people who have injuries don’t know it or aren’t able to sue, and payouts are somewhat haphazard. I think it’s a significant problem of justice that the system pays out different amounts in quite similar cases."

Bovbjerg also has provocative things to say about caps: "Amazingly, doctors argue fiercely that the current system is broke, it causes defensive medicine, it doesn’t help patients — but they turn around and say it’s just fine if we cut it back with caps. That doesn’t make a lot of sense to me. The biggest problem is preventable injury, but the big battle is imposing or preventing caps. It’s a very narrow debate in the short run. In the long run, I suggest to your readers, caps will not be sustained if they are perceived as being unfair takeaways — part of that zero-sum, winners vs. losers game. Judges and jurors will get around such caps, and eventually legislators will vote them out. I think that a better system would focus on preventing injury and making payments more fair, predictable and fast. That is win-win for both patients and doctors, and that will be more successful in the long run."

Bovbjerg favors the two approaches proposed in the Institute of Medicine report, Fostering Rapid Advances in Health Care: Learning from System Demonstrations, published in November of 2002. (The report is available online at http://www.nap.edu/openbook/0309087074/html/81.html) Option one is a provider-based early payments system that would offer predetermined limits on noneconomic damages and federally subsidized reinsurance to self-insured provider groups that promptly identify and compensate patients for identifiable classes of avoidable injuries. Option two is an administrative resolution that would grant all health care professionals and facilities within a state immunity from tort liability in exchange for mandatory participation in a state-sponsored system under which providers would need to disclose errors to patients, while providers or their liability carriers would be responsible for paying amounts determined by a publicly administered adjudication system.

Another Project report released in June addresses some of these broader issues. Resolving the Medical Malpractice Crisis: Fairness Considerations by Case Western Reserve University law and bioethics professor Maxwell J. Mehlman, J.D., is an interesting introduction to the philosophical underpinnings of the nation’s medical malpractice system as well as various reforms. (The report is available online at http://medliabilitypa.org/research/mehlman0603/)

Mehlman’s method is to begin with a set of abstract fairness principles, which he then applies to the current malpractice system, to a wide variety of reforms, and to the reform process itself. I found the questions raised by his analysis to be interesting and important, while his concluding determinations of whether something is "fair" or "unfair" seemed to be inadequately supported and to detract from the report’s value, making it too easy for it to be reduced to a selective recitation of the fairness determinations that suit an advocate’s agenda.

Mehlman identifies the following as the most serious fairness objections to the current system: (1) it only purports to compensate victims of medical negligence, while a fairer system would compensate for all medical injuries; (2) the punishment objective conflicts with the deterrence objective; (3) it lacks validity and consistency; (4) compensation is inconsistent and only somewhat proportional; (5) financing mechanisms are unfair and undependable; (6) it may leave some patients without adequate access to necessary health care services; (7) its lack of predictability sends erratic deterrent signals; (8) it operates by rules that providers feel are unfair; (9) some injured patients cannot obtain adequate representation; and (10) parties are not treated with dignity and respect.

News coverage of the report tended to focus almost exclusively on Mehlman’s assessment that caps are unfair, which comprises three paragraphs of a 105 page report. Mehlman’s reason for the assessment is that caps violate the cardinal principle of distributive justice: "Welfare must not be taken away from those who are worse off and given to those who are better off." In this case, Mehlman contends that wealth would be transferred from the most seriously injured patients to all patients, who could benefit from strengthening the malpractice financing system, from maintaining access, and possibly even from restraining increases in health care costs stimulated by higher premiums.

Earlier in the report, however, Mehlman details the difficulties in valuing non-economic damages and acknowledges that, currently, "awards for non-economic damages fall short of optimal fairness." He acknowledges that providers and insurers believe that injured patients receive unfairly generous compensation for pain and suffering without addressing whether or not this is the case. His reliance on the cardinal principle of distributive justice seems to lock him into the status quo, even if by some valid measure non-economic awards are inflated.

In the end, Mehlman is so committed to not reducing compensation to the most seriously injured patients that he is leery of other reforms that by his own estimation correct major unfairness in the current tort system and could reduce future injuries. Nonetheless, he does provide provisional support for scheduling the amounts or capping damages for identifiable classes of avoidable injuries if based on average jury awards in states without caps.

Taken together these two reports of the Project on Medical Liability in Pennsylvania raise more questions than answers, which is frustrating for Pennsylvanians, especially Pennsylvania physicians, in the midst of a malpractice crisis. Sage acknowledges in his PND interview that much of the Project’s work will not be completed in time for the decisions that have to be made to address the current crisis. Nonetheless, these reports can and should inform our discussion and debate as we search for a durable and fair solution to the problem.

• Following the passage of smoke-free restaurant ordinances in California, Utah, Vermont, Los Angeles, San Francisco, New York City, Boulder, Flagstaff and Mesa (Arizona), there was an increase or no change in tourism in all but Flagstaff, where the rate of increase merely slowed.

• Restaurants and bars in California, New York, Massachusetts, Arizona, Colorado, West Lake Falls (a suburb of Austin, Texas), and North Carolina showed no decrease in sales after going smoke-free. Informal discussions with Philadelphia bars and restaurants that have gone smoke-free shows that the same is true here.
• Bartenders who worked for as little as one month in smoke-free conditions after a California law banned smoking in their workplace reported a significant drop in coughing and other respiratory problems and showed improved lung function. Many bartenders would be similarly protected under Councilman Nutter’s bill.
• A survey of 2,000 smoke-free workplaces revealed that 60% of those surveyed saw a reduction in maintenance and cleaning costs following implementation of no smoking policies.
• The U.S. Environmental Protection Agency estimated that the economic benefits of most workplaces and public places going smoke-free would exceed the cost by to billion annually.
• Voluntary compliance with smoke-free ordinances has been high.

• Youth smoking rates were on the rise and teens were starting to smoke at younger ages.
• Young people were bombarded with messages inducing them to use tobacco including ads on mass transit and tobacco-sponsorship of an annual women’s tennis tournament in Philadelphia.
• Eighty-five percent of tobacco retailers were illegally selling tobacco products to minors with absolute impunity.
• Philadelphia’s public pension funds were heavily invested in tobacco stocks.

• The SEPTA board has voted unanimously to no longer accept tobacco and alcohol ads on their buses, trains and stations.
• Philadelphia City Council voted unanimously to divest the tobacco stock holdings in their public pension funds.
• There is no longer tobacco-sponsorship of an annual women’s tennis tournament in Philadelphia.
• A strong law to curb youth access to tobacco has been passed by Philadelphia City Council and effectively enforced by the Department of Licenses and Inspection decreasing illegal sales by almost 50 percent.

By Jeffrey Barg

A recent report of the Project on Medical Liability in Pennsylvania, funded by The Pew Charitable Trusts, provides independent confirmation of many of the things physicians have been saying about the malpractice crisis.Understanding Pennsylvania’s Medical Malpractice Crisis: Facts About Liability Insurance, the Legal System and Health Care in Pennsylvania, released in June, documents the crisis in the availability and affordability of malpractice insurance. (The report is available online at http://medliabilitypa.org/research/report0603/) The report cites the CAT Fund as a contributing factor and identifies the largest driver of the increased cost of malpractice coverage as the unusually large cost of investigating, defending and paying legal claims in Pennsylvania.

The report, authored by leading malpractice researcher Randall R. Bovbjerg, J.D., and Anna Bartow, M.D., cites numerous problems with the CAT Fund. "In recent years, its pay-as-you-go financing necessitated large annual assessments to cover accumulating claims from prior periods," states the report. "In addition, legislative cutbacks in the extent of the Fund’s future obligations have induced rate increases for private insurers." Other problems with the CAT Fund cited in the report include:

• "Unlike other states with public compensation funds, such as Indiana, Pennsylvania has committed substantial resources to paying malpractice claims but has not instituted limits on those claims by adopting caps on damages, shorter statutes of limitations, or similar measures."

• "Pennsylvania . . . is disadvantaged in attracting physicians because new doctors pay a high assessment to cover losses generated by their predecessors, a problem that continues under MCARE."

• "Plaintiff’s lawyers . . . complain that the Fund often resists paying meritorious cases, while many providers and primary carriers opine that it is harder to mount a joint defense with the Fund than with another private insurer. These tendencies may help explain why malpractice cases in Pennsylvania are resolved so slowly."

The report concludes that while problems in the insurance industry have contributed to the crisis, the primary causes of the crisis are the costs of investigating, defending and paying legal claims in Pennsylvania. Data show that Pennsylvania ranks high in terms of (1) malpractice filings and trial rates in urban counties; (2) the rate of claims paid; (3) average settlement amounts; (4) malpractice payouts adjusted for population; (5) the rate of growth in malpractice payouts per population; and (6) average time elapsed from incident to payment of the claim. Philadelphia plaintiffs were more than twice as likely to win jury trials as the national average and the number of awards plus settlements of $1 million or more in Philadelphia were only slightly less than for the entire state of California.

The report does not explain why, other than the influence of CAT Fund, Pennsylvania’s malpractice system is more costly than most other states’ or what the impact of the malpractice crisis is. This information gap is a significant impediment to the report’s usefulness to policy-makers. It does note that there is no data to suggest that Pennsylvania’s malpractice system is more costly than other states’ because of lower quality health care in the state. There is no evidence of the cost of health care rising because of the crisis, or of a shortage of physicians or hospital beds, according to the report.

The report does warn, however, that access problems may occur, in part because of the great financial strains physicians and hospitals are undergoing. These access problems may already be occurring in certain areas of the state such as rural areas and inner cities, for certain patient subgroups such as Medicaid patients and the uninsured, or in certain medical subspecialties such as obstetrics, orthopedics and neurosurgery — all of which may have been undetectable in the report’s aggregate and somewhat dated data, the report’s authors admit.

The issue of the malpractice crisis’ impact on access to physician services in Pennsylvania will be revisited in another Project report being done by Harvard’s School of Public Health, according to William Sage, M.D., J.D., principal investigator of the Project. Duke University will be doing a Project report on the impact of the CAT Fund as well. (The interview is available online at http://physiciansnews.com/spotlight/303.html)

The report concludes that "subsidies that allow health care providers to maintain coverage would seem to be the only practical approach to alleviating the current crisis." Then it recommends that conventional tort and insurance reforms, as well as more systemic changes, be considered to control costs, improve predictability and attract malpractice insurers back to Pennsylvania in the longer term.

In the end, we’re left with little more than Gov. Rendell’s Malpractice Task Force’s recommended subsidies proposed back in December, reduced by Gov. Rendell, and still awaiting legislative approval.

Buried in the report, the authors write, "The legal system is intended to generate deterrence of substandard medical care by requiring compensation to patients wrongfully injured by health care providers through a dispute resolution process that offers justice. Assessing the performance of the legal system in achieving these social goals is beyond the scope of this report."

One can only hope that the Project on Medical Liability in Pennsylvania will produce a report designed to assess the performance of the legal system, soon, with an author as well qualified for the task as Randall R. Bovbjerg. Bovbjerg addressed these issues in an interview published inPhysician’s News Digest in June. (The interview is available online at http://physiciansnews.com/spotlight/603.html)

In the interview, Bovbjerg says: "The big problem of the current system is that it’s not doing what it says it will do to make medical care safer. It’s also not really compensating people very well because most people who have injuries don’t know it or aren’t able to sue, and payouts are somewhat haphazard. I think it’s a significant problem of justice that the system pays out different amounts in quite similar cases."

Bovbjerg also has provocative things to say about caps: "Amazingly, doctors argue fiercely that the current system is broke, it causes defensive medicine, it doesn’t help patients — but they turn around and say it’s just fine if we cut it back with caps. That doesn’t make a lot of sense to me. The biggest problem is preventable injury, but the big battle is imposing or preventing caps. It’s a very narrow debate in the short run. In the long run, I suggest to your readers, caps will not be sustained if they are perceived as being unfair takeaways — part of that zero-sum, winners vs. losers game. Judges and jurors will get around such caps, and eventually legislators will vote them out. I think that a better system would focus on preventing injury and making payments more fair, predictable and fast. That is win-win for both patients and doctors, and that will be more successful in the long run."

Bovbjerg favors the two approaches proposed in the Institute of Medicine report, Fostering Rapid Advances in Health Care: Learning from System Demonstrations, published in November of 2002. (The report is available online at http://www.nap.edu/openbook/0309087074/html/81.html) Option one is a provider-based early payments system that would offer predetermined limits on noneconomic damages and federally subsidized reinsurance to self-insured provider groups that promptly identify and compensate patients for identifiable classes of avoidable injuries. Option two is an administrative resolution that would grant all health care professionals and facilities within a state immunity from tort liability in exchange for mandatory participation in a state-sponsored system under which providers would need to disclose errors to patients, while providers or their liability carriers would be responsible for paying amounts determined by a publicly administered adjudication system.

Another Project report released in June addresses some of these broader issues. Resolving the Medical Malpractice Crisis: Fairness Considerations by Case Western Reserve University law and bioethics professor Maxwell J. Mehlman, J.D., is an interesting introduction to the philosophical underpinnings of the nation’s medical malpractice system as well as various reforms. (The report is available online at http://medliabilitypa.org/research/mehlman0603/)

Mehlman’s method is to begin with a set of abstract fairness principles, which he then applies to the current malpractice system, to a wide variety of reforms, and to the reform process itself. I found the questions raised by his analysis to be interesting and important, while his concluding determinations of whether something is "fair" or "unfair" seemed to be inadequately supported and to detract from the report’s value, making it too easy for it to be reduced to a selective recitation of the fairness determinations that suit an advocate’s agenda.

Mehlman identifies the following as the most serious fairness objections to the current system: (1) it only purports to compensate victims of medical negligence, while a fairer system would compensate for all medical injuries; (2) the punishment objective conflicts with the deterrence objective; (3) it lacks validity and consistency; (4) compensation is inconsistent and only somewhat proportional; (5) financing mechanisms are unfair and undependable; (6) it may leave some patients without adequate access to necessary health care services; (7) its lack of predictability sends erratic deterrent signals; (8) it operates by rules that providers feel are unfair; (9) some injured patients cannot obtain adequate representation; and (10) parties are not treated with dignity and respect.

News coverage of the report tended to focus almost exclusively on Mehlman’s assessment that caps are unfair, which comprises three paragraphs of a 105 page report. Mehlman’s reason for the assessment is that caps violate the cardinal principle of distributive justice: "Welfare must not be taken away from those who are worse off and given to those who are better off." In this case, Mehlman contends that wealth would be transferred from the most seriously injured patients to all patients, who could benefit from strengthening the malpractice financing system, from maintaining access, and possibly even from restraining increases in health care costs stimulated by higher premiums.

Earlier in the report, however, Mehlman details the difficulties in valuing non-economic damages and acknowledges that, currently, "awards for non-economic damages fall short of optimal fairness." He acknowledges that providers and insurers believe that injured patients receive unfairly generous compensation for pain and suffering without addressing whether or not this is the case. His reliance on the cardinal principle of distributive justice seems to lock him into the status quo, even if by some valid measure non-economic awards are inflated.

In the end, Mehlman is so committed to not reducing compensation to the most seriously injured patients that he is leery of other reforms that by his own estimation correct major unfairness in the current tort system and could reduce future injuries. Nonetheless, he does provide provisional support for scheduling the amounts or capping damages for identifiable classes of avoidable injuries if based on average jury awards in states without caps.

Taken together these two reports of the Project on Medical Liability in Pennsylvania raise more questions than answers, which is frustrating for Pennsylvanians, especially Pennsylvania physicians, in the midst of a malpractice crisis. Sage acknowledges in his PND interview that much of the Project’s work will not be completed in time for the decisions that have to be made to address the current crisis. Nonetheless, these reports can and should inform our discussion and debate as we search for a durable and fair solution to the problem.