A Measure of Malpractice tells the story and presents the results of the Harvard Medical Practice Study, the largest and most comprehensive investigation ever undertaken of the performance of the medical malpractice system. The Harvard study was commissioned by the government of New York in 1986, in the midst of a malpractice crisis that had driven insurance premiums for surgeons and obstetricians in New York City to nearly $200,000 a year.
The Harvard-based team of doctors, lawyers, economists, and statisticians set out to investigate what was actually happening to patients in hospitals and to doctors in courtrooms, launching a far more informed debate about the future of medical liability in the 1990s. Careful analysis of the medical records of 30,000 patients hospitalized in 1984 showed that approximately one in twenty-five patients suffered a disabling medical injury, one quarter of these as a result of the negligence of a doctor or other provider. After assembling all the malpractice claims filed in New York State since 1975, the authors found that just one in eight patients who had been victims of negligence actually filed a malpractice claim, and more than two-thirds of these claims were filed by the wrong patients.
The study team then interviewed injured patients in the sample to discover the actual financial loss they had experienced: the key finding was that for roughly the same dollar amount now being spent on a tort system that compensates only a handful of victims, it would be possible to fund comprehensive disability insurance for all patients significantly disabled by a medical accident. The authors, who came to the project from very different perspectives about the present malpractice system, are now in agreement about the value of a new model of medical liability. Rather than merely tinker with the current system which fixes primary legal responsibility on individual doctors who can be proved medically negligent, legislatures should encourage health care organizations to take responsibility for the financial losses of all patients injured in their care.
Americans at the end of the twentieth century worried that managed care had fundamentally transformed the character of medicine. In The Medical Delivery Business, Barbara Bridgman Perkins uses examples drawn from maternal and infant care to argue that the business approach in medicine is not a new development. Health care reformers throughout the century looked to industrial, corporate, and commercial enterprises as models for the institutions, specialties, and technological strategies that defined modern medicine.
In the case of perinatal care, the business model emphasized specialized over primary care, encouraged the use of surgical and technological procedures, and unnecessarily turned childbirth into an intensive care situation. Active management techniques, for example, encouraged obstetricians to accelerate labor with oxytocin to augment their productivity. Despite the achievements of the childbirth and women’s health movement in the 1970s, aggressive medical intervention has remained the birth experience for millions of American women (and their babies) every year.
The Medical Delivery Business challenges the conventional view that a dose of the market is good for medicine. While Perkins is sympathetic to the goals of progressive and feminist reformers, she questions whether their strategies will succeed in making medicine more equitable and effective. She argues that the medical care system itself needs to be fundamentally "re-formed," and the reforms must be based on democracy, caring, and social justice as well as economics.
According to Jill A. Fisher, this major change in the way medical research is performed is the outcome of two problems in U.S. health care: decreasing revenue for physicians and decreasing access to treatment for patients. As physicians report diminishing income due to restrictive relationships with insurers, increasing malpractice insurance premiums, and inflated overhead costs to operate private practices, they are attracted to pharmaceutical contract research for its lucrative return. Clinical trials also provide limited medical access to individuals who have no or inadequate health insurance because they offer "free" doctors' visits, diagnostic tests, and medications to participants. Focusing on the professional roles of those involved, as well as key research practices, Fisher assesses the risks and advantages for physicians and patients alike when pharmaceutical drug studies are used as an alternative to standard medical care.
A volume in the Critical Issues in Health and Medicine series, edited by Rima D. Apple and Janet Golden
Stanford’s pioneering behavioral scientist draws on a lifetime of research and experience guiding the NIH to make the case that America needs to radically rethink its approach to health care if it wants to stop overspending and overprescribing and improve people’s lives.
American science produces the best—and most expensive—medical treatments in the world. Yet U.S. citizens lag behind their global peers in life expectancy and quality of life. Robert Kaplan brings together extensive data to make the case that health care priorities in the United States are sorely misplaced. America’s medical system is invested in attacking disease, but not in addressing the social, behavioral, and environmental problems that engender disease in the first place. Medicine is important, but many Americans act as though it were all important.
The United States stakes much of its health funding on the promise of high-tech diagnostics and miracle treatments, while ignoring strong evidence that many of the most significant pathways to health are nonmedical. Americans spend millions on drugs for high cholesterol, which increase life expectancy by only six to eight months on average. But they underfund education, which might extend life expectancy by as much as twelve years. Wars on infectious disease have paid off, but clinical trials for chronic conditions—costing billions—rarely confirm that new treatments extend life. Meanwhile, the National Institutes of Health spends just 3 percent of its budget on research on the social and behavioral determinants of health, even though these factors account for 50 percent of premature deaths.
America’s failure to take prevention seriously costs lives. More than Medicine argues that we need a shakeup in how we invest resources, and it offers a bold new vision for longer, healthier living.
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