 We took this picture a couple days ago in the swamps of Florida. So this individual right here is the author of this activity. You may know him as Jeff Petty, but we called him Gator Hunter Man on this excursion. So this was an airboat that has a 450 horsepower engine running a big fan that will push you anywhere you want to go. What started off as just a Gator observing trip quickly turned into a Gator hunting trip when this fellow that was with us decided to go ahead and use a crossbow to try and kill Gator. Fortunately the driver, when we arrived there the driver was pretty pro Gator hunting. So he was willing to let this guy do it. Of course it cost an extra $500, but it was well worth it. With that in mind, they always had the AAO, they always have a bunch of audience kind of questions. So the question now is what was the best part? Was it the conference center, the lectures, the food, or the alligator hunting? And this was a video, but I don't think it's going to work. We can try of us coming up on a Gator, and anyway, we saw about 40 Gators from 9 p.m. to 2 a.m. and got a couple hours of sleep after that, that's not going to work. So anyway, with that in mind, there was no like a legend connection between hunting alligators and tort reform. It just happened to work out that way. So the AMA estimates that indirect and direct costs of malpractice are about 5-10% of total Medicare medical costs, which comes to about anywhere between 80 and $180 billion. And that estimate is largely based on a study by two Stanford economists, McClellan and Kessler, that took states that had instituted tort reform, mostly caps on non-economic damages. And they compared them to states that hadn't instituted any kind of tort reform. And then they looked at hospitalized patients for cardiac problems, specifically heart attacks. And they compared the cost of the malpractice, everything from the cost, the increased cost of the patient to potential malpractice claims, and they lumped all that together. And then they made the assumption that those cardiac patients in those states could represent all hospitalized patients, in fact, all healthcare costs, and that's how they came up with that number. At the very least, it's a rough estimate, which wasn't a very well, you know. It's hard to assume that those costs would carry over to other kinds of patients, especially outpatient settings. The other studies since then by the Congressional Budget Office and the GAOs and other appropriations kind of study group that says that it's probably more like half a percent or somewhere around 20 billion. And what these studies basically did is they used the same format where they looked at states that had instituted tort reform and states that hadn't. But in this study, they included all kinds of hospitalized patients. So again, we're just looking at hospitalized patients. And compared to the costs between the two, and that's how they came up with this number. So, you know, it's such a difficult, you know, number to come up with as far as how much of medical cost is related to malpractice. But I guess the kind of questions I have for you is what it really mattered. Does it really matter what the cost of medical malpractice is in the U.S. to say that we do need tort reform? A lot of people argue that that's why we need to do it. And I would submit that there's other reasons why we need to bring in some tort reform. So I thought I'd define a few things for you and then give you some data on the amount of medical malpractice. So I'm not talking about medical malpractice costs, but true medical malpractice in the United States and how much data on some claims, states that have implemented tort reform, lessons learned from other subspecialties, and then at the end I'll talk a little bit about some alphamology stats. And if there's any comments or questions as we go along, please just stop me and raise your hand. And I'm interested to see what your viewpoints are and things you've learned as well. It's a really big topic and I don't have that many slides. Tort reform can be defined as a civil common law claims that provide a means for a harmed individual to be compensated. And reform is the idea that the current law needs changing and many of the possibilities for tort reform come in the idea of caps where you limit the amount of non-economic damages that an individual that's been harmed can be awarded. Tort reform can come in limiting the amount of time that they have to bring a case to the justice system. Tort reform also can be in the form of removing inefficiencies in the system. As of right now it's estimated that 50% of the money awarded to a plaintiff actually goes to the plaintiff. The rest go to the attorneys and other costs involved. And there's many other forms of tort reform that are proposed and we'll talk about some of those. So definition of medical malpractice. This is Captain Dave by the way, he's the gator hunter. You've seen the movie Swamp or the show Swamp People, he's kind of your stereotypical. Anyway, it was great. So professional negligence is basically the definition of medical malpractice. You can be shown to be negligent in your profession and you can be found to guilty of medical malpractice. However, it's very difficult to prove negligence. You have to show that the duty was owed to the patient, the duty was breached, the breach caused an injury and damages occurred. If any of these four criteria are not met then you cannot be found guilty of medical malpractice, at least in a perfect system. Yeah. So the duty was owed is basically that the patient was owed a certain amount of, I don't know how to word it, but that you owed a duty to the patient and that you were expected to provide care for the patient, surgical expertise to the patient. There was some sort of duty that they could expect from you. There are instances where a patient might not be a formal patient in your practice, but they come up to you and ask you advice. Your neighbor asks you advice on a certain problem. And I think the minute that you assume the role of a physician to that person, you begin to have a duty to that person. So you need to keep that in mind at any time that you're acting as a physician to another individual. Did that answer your question? Do you have any other insight to add to that? Many times attorneys will name multiple people in a lawsuit, anybody that's ever interacted with the patient. And so a lot of times this will not be met because for those individuals that were kind of on the periphery. Dr. Smith. Okay. A lot of this stemmed from me being named in a civil case and while I was being deposed I was waiting for the plaintiff's attorney to show up and I was sitting there speaking with the defense attorneys. We were just chatting and I brought up this idea of tort reform because it's something I've been interested in and they actually taught me a lot of this stuff. So I wanted to share this with you. I thought this was surprising to me, but there's also, it's good to know this data because people will, you know, defense or plaintiff attorneys and stuff and make quote this, just be aware of the limitations of these studies. The California medical insurance feasibility study was brought about in the 70s because California was thinking of going to a no fault insurance type of system and that's basically an insurance type of system where as a physician you don't carry malpractice insurance, every individual carries, kind of shares the burden of malpractice costs and they pay into this pot and then at least in New Zealand they also have this, that the government then pays out to individuals that have been harmed. So you bring your case to the government and no fault is that there, you can't find any, California was thinking of doing this back in the 70s and so they did this study to say, okay, how many, what's our potential out pay? Are we going to end up owning more than we, you know, as California as the costs already are and they found that 5% of hospitalized patients were somehow injured from their treatments. That's not to say that they, you know, that malpractice was involved but that patients were injured, about 5%, so one in 20 and then one in six of these injuries, you know, could be shown to be from medical malpractice, so about 0.8% of total hospitalized patients could potentially have a malpractice case, you know, that they could bring. So that was surprising to California so they abandoned their idea of no fault insurance, assuming that they would probably see this big jump in malpractice cases. A later study from out of Harvard analyzed 31,000 hospital records in New York and they were, so what happened is a group of nurses went through all these hospital records and they identified patients that may have underwent some type of injury and then those patients' records then went to two independent physicians and the physicians then rated the injuries as to whether that you could clearly define that there was some sort of negligence and they put them on a one to five scale and then if both physicians ranked the case as a 3.5 or higher, so clear, you know, fairly high evidence of negligence, both of them had to agree on that, then it was said, yes, these were likely negligent cases and they found that a 4% of all hospitalized patients were again likely injured from their treatments but a fourth of those, about 1% of total hospitalized patients were likely negligent and despite this, they went back and they studied all of these patients about 14% of the cases that they found to be negligent actually did bring a malpractice claim, so there is this misconception of everyone that has a clear cut medical malpractice case brings a lawsuit and in reality it's about, you know, 14% at least in that study. There's been a Utah and Colorado study that did similar methods to Harvard and again they found about 1%, the same 1% of hospitalized patients could be victims of medical malpractice. Yes, they did and it was like 2% or 3%. But again, this idea of frivolous lawsuits, there are actually very few frivolous lawsuits, most of them can be shown that there was an injury, so frivolous has this again, this definition that's very nebulous and who knows what constitutes a frivolous lawsuit just because a lawsuit doesn't end up getting paid out and we'll talk about the rates of medical malpractice claims that actually get, that have indemnity associated with them. There's very few that actually get paid out and this idea of a bunch of frivolous lawsuits is probably not true. Other questions? Okay, so this is us in Walmart trying on some camel before our gay-gayder hunt at night. Texas, Florida and Missouri have the best data as to the amount of malpractice claims because these states require all the insurance companies to submit every claim to them, whether it's been paid out or just closed without indemnity. They show that over the last 15 years, the amount of claims, the number of claims has actually remained steady. There isn't this climb in amount of medical malpractice claims when you control for population and economic growth. So there is an increasing amount of malpractice claims, but when you control for other factors, it's not really changed. And the size of claims, however, has increased and when you control for other factors, they feel like this is likely from the increasing cost of health care. So this is a really busy slide. This was a study that came out of the this group here, let's see, Milo and Cachalea, April, MedPak.gov kind of a study. And they went through and looked at all the all the different types of tort reform that have been instituted throughout the different states. And without going through all of it, I'll just mention the main ones that there is a limit or cap. And I think these are states, these jurisdictions, 37 jurisdictions, and then they mention a few that are kind of a little different. All states have a statute of limitations. 28 states have placed limitations on attorneys fees. There's some periodic payments that can be, you know, awarded or, you know, that kind of injunction can be made on different defendants. This, let's see, the one that we're in here, this alternative dispute resolution, arbitration, mediation settlement, and 17 of them, including us have made this requirement for a screening panel before trial. And some states have made it where if you go through this screening panel and the panel finds that the case is non-maritorious, if you decide to move forward as a plaintiff, then you are then subject to the loser pays rules, which they, if the plaintiff then ends up losing the case, they then pay for the defendants attorney fees. And there's data on that, whether that makes any difference. 22 states have a requirement for some sort of certificate of merit. And so that's a similar kind of thing where you have an outside party saying, yes, this case has merit. Let's go ahead and, you know, if you move forward. Texas has had some interesting legislature. They capped their non-economic damages at $250,000 in 2003. And then they just recently adopted this loser pays, which you might see in the literature as English law. A long time ago, Britain made the same kind of law that you know, if a plaintiff loses, then they pay all the court fees. Interestingly enough, in Texas, the average OBGYN malpractice premium was $131,000. After this cap was instituted, it dropped by about half. They also, there has been studies that have showed that patients have better access to health care now with more subspecialists remaining in Texas. They've had an increased number of physicians and they've like quadrupled the number of out of state physicians applying for a Texas medical license. A lot of people are happy, a lot of physicians are happy about the tort reform that's gone there. The same study that I mentioned earlier, this is their summary statement at the beginning. And I think it's kind of my take home here that although the evidence base for evaluating most traditional state tort reforms is substantial and mature. So there's there's evidence out there. For most of the reforms, it does not identify a significant effect on the key outcome variables. So if you're talking about costs of health care, tort reform probably doesn't make a big dent is what they're saying here. The exception was non economic damages. And there was there was two other policies that did that kind of make a dent. And I'll I'll mention those in a second. The evidence base is small. And they haven't really been tested in the US. Analogist systems such as in Europe, are not clearly predictive of how they would function in the US. But based on theoretical predictions and limited evidence, most of the reforms are promising enough to merit controlled experimentation in the US. So there is most everyone is of the idea. And it's it's been interesting to see the politics on either side of the aisle, you know, say start to come forward with a tort reform as a as a feasible, you know, option. And there seems to be a lot of voter support. So I think we're going to continue to see these kind of reforms being placed in each state. Caps seem to make a difference. Pre trial screenings such as what we have here seems seems to make a small difference in the cost of health care. And enterprise insurance, which is this idea of taking the physician out of the out of kind of out of the hot seat, if you will. And instead of myself carrying individual malpractice insurance, a hospital or some sort of a large group would carry the malpractice insurance. And and then they would, you know, provide all of the medical or the the attorneys services and and defend you much like the VA has or large universities like we are here. So a similar kind of setup that we have here at the university or at the VA would then be adopted by by everyone in the in the US. The big kickback the people that don't like this actually are the private physicians, because they're worried that they're going to then lose control of the way they practice medicine. If you have some large body that's controlling your malpractice insurance and they can then dictate the way you practice medicine, saying what you're doing is dangerous. And, you know, we're not going to have you do that. Or we don't we don't cover that type of practice. So you cannot do that type of procedure, etc. So anesthesia back in 1999, they found that they did an analysis of all their medical medical malpractice claims. They found that one third of them were due to these adverse respiratory events, and they identified preventable measures that they could implement to change those adverse respiratory events, and they worked to develop them. And since then, their premiums have dropped, you know, by more than half. And the rates of adverse events are much improved, and they've received alcohol aids from different safety boards that have showed that anesthesia is now one of the safest medical practices out there. And so there is a way we can take control as physicians to lower medical malpractice insurance costs by limiting the things that we do that have been shown to be harmful to patients. And I think we've done a lot of that, you know, that, you know, you mark the above the eye that you're going to be operating on. That's as a direct result from, you know, lawsuits. And so the argument that pro medical malpractice individuals make to physicians is that medical malpractice has actually improved the way we practice medicine. And it's made things safer for patients. And you'll read a lot of arguments about that. And I, you know, are they valid? You know, in my opinion, in some cases, yes, it is a, it is a method by which we're motivated to change the way we practice. And the last couple of slides here, ophthalmology, this is more of a, you know, omics trying to sell you to sell you their their policies. But I think it's kind of it's just educational as to, you know, on average, about 70 to maybe 80% of claims are closed without any kind of payment. And the average payment in optimal, this is ophthalmology specific, average payment in ophthalmology somewhere, you know, among those numbers. So as practices go, we're actually low on the malpractice payout amount. And the, and so we have a pretty good, you know, track record. But I'm sure we could improve. So the main, the main discussion I'd like to hear is, do you feel like there are benefits from having tort reform to patients? Like would it help patients to have tort reform? Or would it, would it make it harder for them to bring meritorious cases, you know, to the justice system and be compensated for the injury that they've, I don't know, I think both sides have an argument. And it's probably somewhere in the middle. Any comments? Or I think that's all I had. This was, this is actually an interesting website. It's a bunch of attorneys talking about tort reform. So you get to see, see there, I really like this, this quote, and it's a long one, but I'll just run, run through real quick. There's at least the perception that litigation is too easily brought and very expensive to defend. So she's a, is a, I love these attorneys like, well, at least there's this perception. It's not true, but there's people out there that think this. There's also a perception that those of us who are lawyers have a vested interest in the system and are unwilling to look at the flaws of that system. Right? I mean, they make a lot of money off medical malpractice. So she actually started this whole website here. So, and this was, you know, a hundred people had commented and made all these arguments. And so she comes back, she says, I return to my original question with a twist. What are we trying to accomplish with our American civil justice system? Do we want a system that provides a just, speedy, and inexpensive determination of every dispute? You know, that comes right out of civil procedure and something that they, you know, when tort law was originally designed, that's what they wanted to achieve. Do we want a system that permits people to resolve differences in court? If so, do we have that kind of a system? She suggests not. And maybe what we should try to do is define the problem. Is it too much litigation or is it the problem that costs? You know, I think those are valid points and I think that's where we need to work at, is changing the system and making it work for the patients that actually were injured. You know, that's what we're trying to prevent. You know, as physicians, we make mistakes. It's, you know, it's part of the job. We're, to air as human, right? That came out, you know, ten years ago and has been put into law. And the fact of the matter is people are injured by medicine and it's not a perfect system. And helping people understand that it's not perfect is, I think, part of the solution to this as well. I think that's all I had. I had another video of hunting a gator, but I don't think it's gonna work. We'll try it. Yeah, I don't think it's gonna pull up. It's a different format. It came from my phone. Anyway, questions or comments? Yeah. So we went through this. So this is kind of that summary slide. I don't know if you saw this one. It's just what's been done throughout the US. So that as far as decreasing costs, these were the three that actually seem to make a difference in costs. Now, whether other reforms may have a better impact on patient being able to come forward with a claim or, or, or yeah, that's a note like a no fault insurance system. They did look at that and they found that actually that would probably increase the overall cost of health care. But, you know, it certainly has its advantages, but there's a lot of disadvantages. Dr. Warren. Yeah, right. So I didn't dive into that, but that's a huge topic right now. And so first off, defensive medicine is really difficult to put a number on. Because you, so they did a study in Pennsylvania. They surveyed all the doctors in Pennsylvania and they asked them how many of you have changed the way you practice medicine because of your concern for litigation. 94% said yes, I have changed the way I practice because of the fear of litigation. 94%. So that, that study was widely publicized as to, oh, defensive medicine is causing this huge, you know, increase in the cost of health care. And then when they, when it came down to it, they did more in depth studies other than just a survey asking that simple question. And they found that the cost of defensive medicine is actually probably quite low and it doesn't play a big role in the way we practice medicine. That the much larger ways we play, we practice medicine are influenced by who were around and where we trained. And so that there's, there's data on both sides, but a hard number has been really difficult to come up with. And maybe you could, maybe we could do, you know, a survey and here's how many of you have changed the way you practice medicine because of the fear for liability? You know? And then how much, what, what percent of your practice is probably, you know, are you ordering a bunch of tests that, you know, are just a few or, you know, is it, are they expenses or practices that you probably would have done anyway, but you were more likely to do. You know, you can see all these different arguments that people are, are making. They, the main test that has been ordered because of the fear of liability is imaging. And that, you know, CT scans and MRIs have really jumped because of this fear of liability. And when you take the total cost of those tests and compare them to all the other costs of health care, it came out quite low. Dr. David? Yeah, yeah. Did you have another? Yeah, right? Yeah, actually. So arbitration was lumped in that pre-trial screenings. They, all those kind of pre-trial arbitration, there's a couple other terms they used. They all were found to be helpful. Arbitration, mediation, settlement conferences, this, and then this, they call this medical, let's see, this pre-screening, pre-screening panel. Yeah, they lumped that in. Yeah, so those are, those are, as Dr. Mifflin was mentioned, those have been helpful. Dr. Hatch? That's true. Yeah, that's true. And that's what that last quote was kind of discussing is, you know, large or small, in court, do we want? It's just, it's a lot of patients are falling through the cracks. Yeah, the ones that probably deserve some compensation, especially for just health care costs, you know, things that they had to pay for, that they wouldn't have had, you know, we not made an error in the first place. Yeah, at least here.