This study examines the impact of malpractice claims on C-section rates and annual delivery volume in Florida between 1992 and 2000. Using an individual physician-level panel dataset, this study provides evidence on whether the timing of claims and award size matter in physician responses. I did not find any evidence that physicians change their practice patterns by increasing C-section rates in response to a malpractice claim. However, the closing of a claim led to a decrease of six annual deliveries 3 years afterwards with 14 fewer deliveries occurring with large awards (>U.S.$250,000).
The absence of a significant impact on C-section rates may be due to the limited ability of a malpractice claim to convey specific information to a physician that would warrant a change in practice style. Furthermore, even after controlling for clinical risk factors, there may be other factors such as patient preferences for a C-section, which could be similar for physicians with and without a malpractice claim. Finally, performing a C-section by itself may not necessarily reduce the risk of malpractice litigation, which may depend on a physician's bedside manner and tone of voice. Given the small magnitude of effects found in prior studies and the rising prevalence of C-sections nationwide, this null finding suggests that additional research using more recent data is needed.
The absence of effects on delivery volume until 3 years after a claim closing suggests a delayed response that is not affected by the injury occurrence or claim opening. However, the small negative impact on physician delivery volume suggests that a fear effect of incurring a future claim outweighs the income effect, which predicts an increase in deliveries. Physicians with a closed malpractice claim performed six fewer deliveries after 3 years, which represents about 5 percent of average delivery volume. Larger award sizes (>U.S.$250,000) have a somewhat greater effect on delivery volume across specifications. A reduction of 14 deliveries represents about 11 percent of average delivery volume. A supply-side response can occur if a physician chooses to accept fewer high-risk patients several years after a claim closing. However, this finding is also consistent with a demand-side response where public disclosure of the malpractice award in Florida leads to reputation loss and reduced patient demand. Either response or both responses could have occurred, but this study could not make this distinction.
Although this small decrease in the average volume of deliveries appears to have implications for access to care, a key question is whether other providers may be picking up the additional deliveries that are not being performed by physicians with malpractice claims. As shows, the number of obstetrician–gynecologists increased over time, so that physicians without claims appear to be picking up these deliveries. This study does not find evidence that access to care statewide is compromised for inpatient deliveries, which is consistent with prior research (Dranove and Gron 2005
). Between 1992 and 2000, the average delivery volume of obstetrician–gynecologists increased from 112 to 142 births, while the number of deliveries by family practitioners declined from 80 to 41 births over the same period. However, the growth in the overall supply of physicians coupled with the increase in average volume suggests that the small reduction of inpatient deliveries was fully absorbed by other obstetrician–gynecologists.
Several data limitations should be mentioned. First, these results from Florida cannot be generalized to other states, which may have different malpractice reform environments. Second, the dataset excluded outpatient procedures and deliveries, which might account for possible shifting of care by obstetrician–gynecologists to outpatient settings, but evidence of such a shift is limited (Mello et al. 2007
). Other variables that were excluded due to data limitations include malpractice premiums and physician income, which are assumed to be time invariant in the model. Physicians in regions with higher premiums, other things being equal, may be more sensitive to malpractice claims than other physicians. Third, the administrative dataset is limited to a set of ICD-9 codes to infer the clinical risk profile of a patient. When this profile is aggregated to the physician level, the ability to conduct patient-level risk adjustment is lost. Finally, the study sample excludes claims from uninsured physicians and self-insured entities such as teaching hospitals.
This study builds on the prior work of Dranove and Gron (2005)
by analyzing whether malpractice claims at the individual level have an impact on obstetrical practice patterns in Florida. Although access may be diminished for physicians with a high award claim, the effect on access to care is not compromised as other obstetrician–gynecologists are picking up these additional deliveries. Finally, the somewhat greater reduction in delivery volume in response to higher awards suggests that tort reforms with damage caps at the U.S.$250,000 level would have some effect on limiting the reduction in average delivery volume. However, access to obstetrical care in Florida does not appear to be comprised by malpractice claims.