The Effect of Caps on Malpractice Liability

Concerned with the information being provided to policy makers regarding malpractice caps, faculty members Michelle Mello and David Studdert and their colleagues in the Department of Health Policy and Management in HSPH set out to better understand the effects of caps on malpractice liability and to answer the broader question, ‘Do caps work?’. The multifaceted literature review they conducted considered whether caps decrease the frequency of malpractice filings; reduce the severity of claims; reduce or stabilize insurance premiums; and whether caps affect physician supply. While the broader review is currently ongoing, results from the group’s work on the equity of caps were published in the July/August 2004 issue of Health Affairs. This work involved an analysis of jury verdicts in California that were subjected to the state’s $250,000 cap on noneconomic damages, focusing on fairness and whether the burden of reductions from caps was distributed equitably across different types of injuries. They also explored whether the burden of cap reductions fell disproportionately on women and the elderly. The results showed that the reductions from caps were not distributed equally based on the types of injuries; that, in absolute dollars, the reductions imposed on grave injuries were seven times larger than those for minor injuries; and that the largest proportional reductions were for injuries that dealt with pain and disfigurement. In addition, the review showed that women and the elderly were not subjected to a disproportionate share of cap reductions. The authors suggest that fairness could be augmented by the use of sliding scales in place of or together with caps in determining awards for malpractice claims. A copy of the abstract is available at http://content.healthaffairs.org/cgi/content/abstract/23/4/54. Drs. Mello, Studdert and their colleagues are soon to launch a new project looking at alternatives to conventional tort reform including the use of an administrative-type system to resolve malpractice claims. The caps study was supported by PHSI, with additional support now being provided for this new line of inquiry.

Conference on the Implementation of Clinical Information Systems In Large Healthcare Organizations

Held as a pre-conference to the HHS Secretarial Summit on Health Information Technology in Washington, D.C. in July, PHSI convened a meeting of leaders from large healthcare organizations that have successfully implemented complex clinical information systems. Working with the Departments of Defense and Veterans Affairs, PHSI faculty and staff brought together five major organizations considered pioneers in the area of health information technology to identify lessons for rest of American healthcare. While much had been reported about the barriers to clinical IT adoption and implementation, less attention has been paid to understanding the circumstances and drivers that contribute to success. Conference participants included clinical IT leaders from Kaiser, Regenstrief, Partners and the two Federal agencies including, Dr. William Winkenwerder, Assistant Secretary for Health, Department of Defense, and Dr. Jonathan Perlin, Acting Under Secretary for Health, Department of Veterans Affairs. Dr. David Brailer, the National Health Information Technology Coordinator also joined the meeting to share his insights for moving IT adoption forward. The day was structured to share a broad, yet detailed view of the implementation of each organization's system, including attention to factors such as financial structures, management expertise, information systems expertise, medical staff involvement, institutional-readiness, funding, internal or external pressures and other factors. Key lessons learned included the fact that for each organization, IT solved key business challenges they faced: whether it was sharing information across geographic sites, or improving quality, IT adoption was not a luxury but a necessary part of providing care.

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Project Updates

Primary Care Redesign in Practice

Since stepping down in March 2004 as PHSI's first Executive Director, Dr. Rushika Fernandopulle has launched a new internal medicine practice that incorporates the principles and strategies identified as part of the PHSI's Primary Care Redesign project. Consistent with its commitment to advancing scholarship directed at improving health care quality, PHSI launched a project in March 2003 to design a new system for primary care practice. The entering goal for Project participants was to "fundamentally change everything" about how primary care was organized and delivered by placing the patient and consumer at the center. Based on the recommendations of faculty participants from the Harvard Business School engaged in similar work across a range of industries, the project utilized an approach called "skunk works" in which wholly new approaches to service and manufacturing are developed and validated. A description of the findings of the "skunk works" process and the principles guiding the structure and organization of Dr. Fernandopulle's practice are available in a recent Gazette article at http://www.news.harvard.edu/gazette/daily/2004/08/31-primarycare.html

Forum on Rising Health Care Costs Held in Washington DC

On May 26, 2004, PHSI completed the Harvard Forum on Health series with a program on rising health care costs. Kenneth Thorpe, economist and health care expert, provided a national perspective on the drivers of costs, and potential strategies to control costs were presented by health care advisors to President Bush and Senator John Kerry. In addition, innovative solutions in areas such as disease management and prescription medicine were shared by a panel of health care leaders, followed by a panel of economic, business, labor, and state experts debating current health care spending trends and the role of government in controlling costs. David Gergen, Harvard Professor and former presidential advisor, moderated the Forum. For more information and access to power point presentations and session videos, visit www.phsi.harvard.edu/chcc.php. Later this fall, PHSI will host a session for stakeholders, faculty, and other invited experts to discuss lessons learned from the Harvard Forum series and articulate a plan for transforming the health care system based on opportunities for innovation and practical strategies for implementing change.

Consumer Preferences and Decisions

With support from PHSI, Karen Donelan, Senior Scientist in Health Policy at the Massachusetts General Hospitalhas convened an interdisciplinary group of faculty to identify the current state of research on the health care consumer, specifically focused on consumer preferences and decisions, and to develop a research agenda for advancing scholarship in this area. One of the group’s first assignments will be to explore the goals of consumer activation from the perspective of the range of stakeholders interested in this area. The group will also focus on approaches for assessing and improving information tools for consumer use in selecting physicians and hospitals. The group expects to produce a “state of the art” bibliography on the health care consumer to be available on the PHSI website later this year.

Examining Other Paradigms Seminar Series Hosts Steven Spear: Creating High Reliability Healthcare Organizations

On October 5, 2004, Steven J. Spear, HBS assistant professor, presented "Creating High Reliability Healthcare Organizations: How Pilot Sites Achieved Greater Safety and Quality with Less Cost of Care", as part of PHSI's Examining Other Paradigms Seminar Series. Dr. Spear explained the findings of the Pittsburgh Regional Healthcare Initiative (PRHI) that took the lessons learned from non-healthcare organizations that improved their reliability – especially the example of the Toyota Production System --and applied those lessons to the healthcare setting. The results of the pilots led to favorable results in several areas including pre-surgical nursing, ICU line infections, patient fall rates, in-hospital nutrition, and discharge preparation. Dr. Spear also discussed the opportunities for broader implementation of the lessons learned in medical systems and the implications of high reliability on clinical care and medical education. The seminar was held in the Bray Room in the New Research Building at Harvard Medical School. Video for Dr. Spear's presentation will be available by October 25 at http://www.phsi.harvard.edu/quality.php.

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News & Events

New Streaming Video Resources Added to PHSI Website
Visit the PHSI website for access to streaming video of the following spring events:

Reassessing the Value Equation: The Consequences Of Biomedical Innovation and Health Care Spending, April 28, 2004.

Second Annual Symposium on Racial and Ethnic Health Disparities in the US: From Research to Practice, May 7, 2004.

Harvard Forums on Health, complete series video available at:

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For more information on the projects and events described in this newsletter, or to unsubscribe, please contact us at phsi@harvard.edu.



Malpractice Liability Clinical IT Primary Care Redesign Harvard Forums on Health Consumer Preferences Examining Other Paradigms Streaming Video	Fall 2004 The Effect of Caps on Malpractice Liability Concerned with the information being provided to policy makers regarding malpractice caps, faculty members Michelle Mello and David Studdert and their colleagues in the Department of Health Policy and Management in HSPH set out to better understand the effects of caps on malpractice liability and to answer the broader question, ‘Do caps work?’. The multifaceted literature review they conducted considered whether caps decrease the frequency of malpractice filings; reduce the severity of claims; reduce or stabilize insurance premiums; and whether caps affect physician supply. While the broader review is currently ongoing, results from the group’s work on the equity of caps were published in the July/August 2004 issue of Health Affairs. This work involved an analysis of jury verdicts in California that were subjected to the state’s $250,000 cap on noneconomic damages, focusing on fairness and whether the burden of reductions from caps was distributed equitably across different types of injuries. They also explored whether the burden of cap reductions fell disproportionately on women and the elderly. The results showed that the reductions from caps were not distributed equally based on the types of injuries; that, in absolute dollars, the reductions imposed on grave injuries were seven times larger than those for minor injuries; and that the largest proportional reductions were for injuries that dealt with pain and disfigurement. In addition, the review showed that women and the elderly were not subjected to a disproportionate share of cap reductions. The authors suggest that fairness could be augmented by the use of sliding scales in place of or together with caps in determining awards for malpractice claims. A copy of the abstract is available at http://content.healthaffairs.org/cgi/content/abstract/23/4/54. Drs. Mello, Studdert and their colleagues are soon to launch a new project looking at alternatives to conventional tort reform including the use of an administrative-type system to resolve malpractice claims. The caps study was supported by PHSI, with additional support now being provided for this new line of inquiry. back to table of contents Conference on the Implementation of Clinical Information Systems In Large Healthcare Organizations Held as a pre-conference to the HHS Secretarial Summit on Health Information Technology in Washington, D.C. in July, PHSI convened a meeting of leaders from large healthcare organizations that have successfully implemented complex clinical information systems. Working with the Departments of Defense and Veterans Affairs, PHSI faculty and staff brought together five major organizations considered pioneers in the area of health information technology to identify lessons for rest of American healthcare. While much had been reported about the barriers to clinical IT adoption and implementation, less attention has been paid to understanding the circumstances and drivers that contribute to success. Conference participants included clinical IT leaders from Kaiser, Regenstrief, Partners and the two Federal agencies including, Dr. William Winkenwerder, Assistant Secretary for Health, Department of Defense, and Dr. Jonathan Perlin, Acting Under Secretary for Health, Department of Veterans Affairs. Dr. David Brailer, the National Health Information Technology Coordinator also joined the meeting to share his insights for moving IT adoption forward. The day was structured to share a broad, yet detailed view of the implementation of each organization's system, including attention to factors such as financial structures, management expertise, information systems expertise, medical staff involvement, institutional-readiness, funding, internal or external pressures and other factors. Key lessons learned included the fact that for each organization, IT solved key business challenges they faced: whether it was sharing information across geographic sites, or improving quality, IT adoption was not a luxury but a necessary part of providing care. back to table of contents Project Updates Primary Care Redesign in Practice Since stepping down in March 2004 as PHSI's first Executive Director, Dr. Rushika Fernandopulle has launched a new internal medicine practice that incorporates the principles and strategies identified as part of the PHSI's Primary Care Redesign project. Consistent with its commitment to advancing scholarship directed at improving health care quality, PHSI launched a project in March 2003 to design a new system for primary care practice. The entering goal for Project participants was to "fundamentally change everything" about how primary care was organized and delivered by placing the patient and consumer at the center. Based on the recommendations of faculty participants from the Harvard Business School engaged in similar work across a range of industries, the project utilized an approach called "skunk works" in which wholly new approaches to service and manufacturing are developed and validated. A description of the findings of the "skunk works" process and the principles guiding the structure and organization of Dr. Fernandopulle's practice are available in a recent Gazette article at http://www.news.harvard.edu/gazette/daily/2004/08/31-primarycare.html Forum on Rising Health Care Costs Held in Washington DC On May 26, 2004, PHSI completed the Harvard Forum on Health series with a program on rising health care costs. Kenneth Thorpe, economist and health care expert, provided a national perspective on the drivers of costs, and potential strategies to control costs were presented by health care advisors to President Bush and Senator John Kerry. In addition, innovative solutions in areas such as disease management and prescription medicine were shared by a panel of health care leaders, followed by a panel of economic, business, labor, and state experts debating current health care spending trends and the role of government in controlling costs. David Gergen, Harvard Professor and former presidential advisor, moderated the Forum. For more information and access to power point presentations and session videos, visit www.phsi.harvard.edu/chcc.php. Later this fall, PHSI will host a session for stakeholders, faculty, and other invited experts to discuss lessons learned from the Harvard Forum series and articulate a plan for transforming the health care system based on opportunities for innovation and practical strategies for implementing change. Consumer Preferences and Decisions With support from PHSI, Karen Donelan, Senior Scientist in Health Policy at the Massachusetts General Hospitalhas convened an interdisciplinary group of faculty to identify the current state of research on the health care consumer, specifically focused on consumer preferences and decisions, and to develop a research agenda for advancing scholarship in this area. One of the group’s first assignments will be to explore the goals of consumer activation from the perspective of the range of stakeholders interested in this area. The group will also focus on approaches for assessing and improving information tools for consumer use in selecting physicians and hospitals. The group expects to produce a “state of the art” bibliography on the health care consumer to be available on the PHSI website later this year. Examining Other Paradigms Seminar Series Hosts Steven Spear: Creating High Reliability Healthcare Organizations On October 5, 2004, Steven J. Spear, HBS assistant professor, presented "Creating High Reliability Healthcare Organizations: How Pilot Sites Achieved Greater Safety and Quality with Less Cost of Care", as part of PHSI's Examining Other Paradigms Seminar Series. Dr. Spear explained the findings of the Pittsburgh Regional Healthcare Initiative (PRHI) that took the lessons learned from non-healthcare organizations that improved their reliability – especially the example of the Toyota Production System --and applied those lessons to the healthcare setting. The results of the pilots led to favorable results in several areas including pre-surgical nursing, ICU line infections, patient fall rates, in-hospital nutrition, and discharge preparation. Dr. Spear also discussed the opportunities for broader implementation of the lessons learned in medical systems and the implications of high reliability on clinical care and medical education. The seminar was held in the Bray Room in the New Research Building at Harvard Medical School. Video for Dr. Spear's presentation will be available by October 25 at http://www.phsi.harvard.edu/quality.php. back to table of contents News & Events New Streaming Video Resources Added to PHSI Website Visit the PHSI website for access to streaming video of the following spring events: Reassessing the Value Equation: The Consequences Of Biomedical Innovation and Health Care Spending, April 28, 2004. Second Annual Symposium on Racial and Ethnic Health Disparities in the US: From Research to Practice, May 7, 2004. Harvard Forums on Health, complete series video available at: back to table of contents For more information on the projects and events described in this newsletter, or to unsubscribe, please contact us at phsi@harvard.edu.