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Étude théorique et expérimentale de la responsabilité partagée entre le médecin et l’infirmier en pratique avancée
Abstract
Le système de santé français soulève de nombreux enjeux en soins primaires, tant en termes de répartition territoriale de l’offre de soins que de dépenses et de prise en charge de certaines pathologies. Le développement de la pratique infirmière avancée - qui amène un infirmier en pratique avancée à réaliser certaines tâches médicales, complémentaires ou substituables à celles du médecin, en première ou en deuxième ligne de soins – constitue une réponse à ces enjeux. L’objectif de la thèse est d’étudier le cadre de régulation de la qualité des soins délivrés par un médecin et un infirmier en pratique avancée. Elle se compose de quatre chapitres. Le premier met en évidence les enjeux du système de santé français auxquels la pratique infirmière avancée répond et les freins posés par la régulation française actuelle au développement de la pratique. Le deuxième chapitre discute, à partir de la littérature, du régime de responsabilité efficace pour dissuader le médecin et l’infirmier d’être imprudents. Le troisième chapitre est une étude théorique de la règle de responsabilité optimale à appliquer à la pratique infirmière avancée selon le mode d’exercice de l'infirmier. Le dernier chapitre restitue une expérimentation en laboratoire qui analyse l’effet de la collaboration entre professionnels de santé sur la qualité des soins en fonction du régime de responsabilité. La thèse démontre que la pratique infirmière avancée devrait être régulée par un régime de responsabilité pour faute qui alloue les réparations du dommage selon l’interdépendance des comportements de chacun des deux praticiens. En outre, le contrôle exercé par le médecin quand l’infirmier pratique de façon salariée amène à une meilleure qualité des soins. Enfin, l'expérimentation en laboratoire met en évidence, en présence d’une règle de responsabilité, une baisse de la qualité des soins liée à la collaboration interprofessionnelle. Ce résultat devrait conduire à développer la collaboration entre professionnels de santé avec prudence
Advanced practice nurses (APNs) are finding it difficult to establish themselves once they have completed their training. Nearly half (49%) of graduates interviewed in a survey said they were not working as APNs, which raises real questions about the future of new graduates and their establishment in local areas. Under such conditions, the future of IPAs sometimes seems compromised, especially those in private practice.
We quantify patient-regarding preferences by fitting a bounded rationality model to data from an incentivized laboratory experiment, where Chinese medical doctors, German medical students and Chinese medical students decide under different payment schemes. We find a remarkable stability in patient-regarding preferences when comparing subject pools and we cannot reject the hypothesis of equal patient-regarding preferences in the three groups. The results suggest that a health economic experiment can provide knowledge that reach beyond the student subject pool, and that the preferences of decision-makers in one cultural context can be of relevance in a very different cultural context.
We review the literature on credence goods since Dulleck and Kerschbamer (2006). We consider various markets for credence goods and briefly discuss evidence on the extent of fraud. We then review theoretical and empirical contributions on the determinants of seller and consumer behavior in markets for credence goods. The topics include informational asymmetries, pro-social motivations and seller characteristics, as well as several features of the market structure and institutional environment (separation of diagnosis and treatment, liability, verifiability, reputational concerns, competition between experts and second opinions). We also describe recent developments in this area of research (such as the role of investing in more precise diagnostic technologies) and offer an outlook on future questions.
Background:
Having nurses take on tasks that are typically conducted by doctors (doctor-nurse substitution, a form of 'task-shifting') may help to address doctor shortages and reduce doctors' workload and human resource costs. A Cochrane Review of effectiveness studies suggested that nurse-led care probably leads to similar healthcare outcomes as care delivered by doctors. This finding highlights the need to explore the factors that affect the implementation of strategies to substitute doctors with nurses in primary care. In our qualitative evidence synthesis (QES), we focused on studies of nurses taking on tasks that are typically conducted by doctors working in primary care, including substituting doctors with nurses or expanding nurses' roles.
Objectives:
(1) To identify factors influencing implementation of interventions to substitute doctors with nurses in primary care. (2) To explore how our synthesis findings related to, and helped to explain, the findings of the Cochrane intervention review of the effectiveness of substituting doctors with nurses. (3) To identify hypotheses for subgroup analyses for future updates of the Cochrane intervention review.
Search methods:
We searched CINAHL and PubMed, contacted experts in the field, scanned the reference lists of relevant studies and conducted forward citation searches for key articles in the Social Science Citation Index and Science Citation Index databases, and 'related article' searches in PubMed.
Selection criteria:
We constructed a maximum variation sample (exploring variables such as country level of development, aspects of care covered and the types of participants) from studies that had collected and analysed qualitative data related to the factors influencing implementation of doctor-nurse substitution and the expansion of nurses' tasks in community or primary care worldwide. We included perspectives of doctors, nurses, patients and their families/carers, policymakers, programme managers, other health workers and any others directly involved in or affected by the substitution. We excluded studies that collected data using qualitative methods but did not analyse the data qualitatively.
Data collection and analysis:
We identified factors influencing implementation of doctor-nurse substitution strategies using a framework thematic synthesis approach. Two review authors independently assessed the methodological strengths and limitations of included studies using a modified Critical Appraisal Skills Programme (CASP) tool. We assessed confidence in the evidence for the QES findings using the GRADE-CERQual approach. We integrated our findings with the evidence from the effectiveness review of doctor-nurse substitution using a matrix model. Finally, we identified hypotheses for subgroup analyses for updates of the review of effectiveness.
Main results:
We included 66 studies (69 papers), 11 from low- or middle-income countries and 55 from high-income countries. These studies found several factors that appeared to influence the implementation of doctor-nurse substitution strategies. The following factors were based on findings that we assessed as moderate or high confidence.Patients in many studies knew little about nurses' roles and the difference between nurse-led and doctor-led care. They also had mixed views about the type of tasks that nurses should deliver. They preferred doctors when the tasks were more 'medical' but accepted nurses for preventive care and follow-ups. Doctors in most studies also preferred that nurses performed only 'non-medical' tasks. Nurses were comfortable with, and believed they were competent to deliver a wide range of tasks, but particularly emphasised tasks that were more health promotive/preventive in nature.Patients in most studies thought that nurses were more easily accessible than doctors. Doctors and nurses also saw nurse-doctor substitution and collaboration as a way of increasing people's access to care, and improving the quality and continuity of care.Nurses thought that close doctor-nurse relationships and doctor's trust in and acceptance of nurses was important for shaping their roles. But nurses working alone sometimes found it difficult to communicate with doctors.Nurses felt they had gained new skills when taking on new tasks. But nurses wanted more and better training. They thought this would increase their skills, job satisfaction and motivation, and would make them more independent.Nurses taking on doctors' tasks saw this as an opportunity to develop personally, to gain more respect and to improve the quality of care they could offer to patients. Better working conditions and financial incentives also motivated nurses to take on new tasks. Doctors valued collaborating with nurses when this reduced their own workload.Doctors and nurses pointed to the importance of having access to resources, such as enough staff, equipment and supplies; good referral systems; experienced leaders; clear roles; and adequate training and supervision. But they often had problems with these issues. They also pointed to the huge number of documents they needed to complete when tasks were moved from doctors to nurses.
Authors' conclusions:
Patients, doctors and nurses may accept the use of nurses to deliver services that are usually delivered by doctors. But this is likely to depend on the type of services. Nurses taking on extra tasks want respect and collaboration from doctors; as well as proper resources; good referral systems; experienced leaders; clear roles; and adequate incentives, training and supervision. However, these needs are not always met.
The 2015 Paris Agreement represents a historic deal in the form of a strong international response to address climate change. This outcome came as a surprise for some, as several controversial issues had been postponed from previous conferences, and were expected to complicate the talks in Paris. One related to the Warsaw International Mechanism on Loss and Damage (L&D), and potential legal remedies for L&D in the form of compensation payments. This issue had been particularly contentious with some developing countries advocating ideas for climate damage liability, which developed countries were unwilling to include in an agreement. Although the negotiations on L&D secured many positive outcomes, Decision 1/CP.21 adopting the Paris Agreement notes that there is no possibility of claiming liability and financial compensation for developing countries. This article, however, argues that, rather than triggering endless compensation claims disputes, a liability mechanism could actually serve as a commitment and reciprocity device, ultimately increasing global policy ambition. In this regard, this article reports the results of two experiments testing the effects of liability rules on the climate policy investment decisions of two players that differ in wealth and vulnerability. Results show that liability rules imposing a responsibility for precaution on both parties increase cooperation significantly, consequentially minimizing risk of L&D occurrence in the first place. Liability rules could thus not only help to address future losses, but also to drive global mitigation and adaptation ambition.
POLICY RELEVANCE
The research results presented in this paper suggest that policymakers would be well advised to further intensify negotiations on a climate-related compensation mechanism beyond that already committed to in the Paris Agreement. Our findings show that a compensation mechanism that implements a rather simple negligence rule makes climate cooperation more attractive and rewarding, potentially leading rich and poor nations to boost their investments in mitigation and adaptation for climate protection. Thus, far from opening up a Pandora’s box of endless compensation claims towards industrialized countries, a liability mechanism could make global climate cooperation more effective, and in the longer run also less costly.
Investigations into the existence and impact of defensive medicine in obstetrics have produced mixed and often conflicting implications. The most widely-cited and accepted results in this literature find that less severe malpractice environments cause an increase in the use of cesarean section. This has been interpreted as “offensive medicine”; taking advantage of lenient malpractice environments by providing unnecessary services in order to raise revenue. In this article we show that an assumption concerning births with an unknown method of delivery, which is not explicitly stated in the literature, is pivotal in obtaining these results. Using data on tort reforms and birth outcomes from 1989 to 2001 in 24 US states, we show that for the 98.4% of births with a confirmed method of delivery, the estimated effects of tort reform on C-section rates are insignificant. Therefore, without this assumption, there is little evidence to support an interpretation of offensive medicine.
In the economic analysis of law, damage is defined as an externality. The basic idea, therefore, is that legal rules should
give the health care providers, the physician or the hospital, incentives to invest in care in order to prevent damage. One
of the important questions in law and economics is, therefore, through what kind of legal rules the health care providers
can be given appropriate incentives for optimal care, and thus to internalise the risk for medical malpractice. This prevention
of medical malpractice can be achieved either through liability rules or through regulation. Possibly, other alternatives
might fit better in order to avoid or lower the risk of medical malpractice as well.
We compare the performance of liability rules for managing environmental disasters when third parties are harmed and cannot always be compensated. A firm can invest in safety to reduce the likelihood of accidents. The firm's investment is unobservable to authorities. Externality and asymmetric information call for public intervention to define rules aimed at increasing prevention. We determine the investment in safety under No Liability, Strict Liability and Negligence, and compare it to the first best. Additionally, we investigate how the (dis)ability of the firm to fully cover potential damages affects the firm's behavior. An experiment tests the theoretical predictions. In line with theory, Strict Liability and Negligence are equally effective; both perform better than No Liability; investment in safety is not sensitive to the ability of the firm to compensate potential victims. In contrast with theory, prevention rates absent liability are much higher and liability is much less effective than predicted.
This experiment investigates decisions made by prospective economists and physicians in an allocation problem which can be framed either medically or neutrally. The potential recipients differ with respect to their minimum needs as well as to how much they benefit from a treatment. We classify the allocators as either 'selfish', 'Rawlsian', or 'maximizing the number of recipients'. Economists tend to maximize their own payoff, whereas the physicians' choices are more in line with maximizing the number of recipients and with Rawlsianism. Regarding the framing, we observe that professional norms surface more clearly in familiar settings. Finally, we scrutinize how the probability of being served and the allocated quantity depend on a recipient's characteristics as well as on the allocator type.
JEL Classification: A13, I19, C91, C72
The NHS Plan welcomes the use of team rewards but does not specify how team based incentives are to be implemented or make clear what types of teams such incentives are to be given to. This paper looks for insights from economic theory on how to define teams and optimal incentive schemes within them. We give a brief description of the incentive mechanisms suggested in the NHS Plan and discuss the implications of the economic theory of team-incentives to the NHS. One implication is that the optimal compensation scheme depends on the type of team. Hence, the definition of teams in the NHS should precede the identification of the system of team rewards. We therefore examine which types of teams might be suitable for team rewards. We then consider issues in the use of financial incentives for such teams.
Narrow self-interest is often used as a simplifying assumption when studying people making decisions in social contexts. Nonetheless, people exhibit a wide range of different motivations when choosing unilaterally among interdependent outcomes. Measuring the magnitude of the concern people have for others, sometimes called Social Value Orientation (SVO), has been an interest of many social scientists for decades and several different measurement methods have been developed so far. Here we introduce a new measure of SVO that has several advantages over existent methods. A detailed description of the new measurement method is presented, along with norming data that provide evidence of its solid psychometric properties. We conclude with a brief discussion of the research streams that would benefit from a more sensitive and higher resolution measure of SVO, and extend an invitation to others to use this new measure which is freely available.
This study examines the impact of malpractice reforms on physician behavior using a new measure of liability risk and a nationally representative, individual-level data set on physician behavior. We match our liability measure to data on physician behavior from the Physician Practice Costs and Income Survey (PPCIS). Data from the PPCIS bracket a period of substantial state-level legal reform between 1983 and 1988, which provides identifying variation in our liability measure. We estimate the impact of liability reform on hours worked. We find an estimated elasticity of hours worked to liability exposure of - .285 for the full sample of physicians. The effect for physicians ages 55 or older is much larger: we find an elasticity of - 1.224 for this category. We find that an increase in .70-$1.05 increase in malpractice premiums. (c) 2009 by The University of Chicago. All rights reserved..
Advanced practice registered nurses have assumed an increasing role as providers in the health care system, particularly for underserved populations. The aim of this systematic review was to answer the following question: Compared to other providers (physicians or teams without APRNs) are APRN patient outcomes of care similar? This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by nurse practitioners and certified nurse midwives in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of clinical nurse specialists in acute care settings can reduce length of stay and cost of care for hospitalized patients. These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help to address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.
The law and economics literature on multiple causation generally distinguishes between causal uncertainty and joint causation. For cases of causal uncertainty it has been shown that proportional liability, a fractional share rule, may lead to socially optimal incentives for the level of care. However, for cases of joint causation fractional share rules tend to be inefficient. This paper argues that the crucial distinction is not so much between the uncertainty or jointness of the causal elements, but rather between the additivity or non-additivity of risk factors. We develop an approach that integrates causal uncertainty and joint causation. We show that an apportionment rule that assigns liability in proportion to the probability of causation always yields efficient incentives when the risk factors are additive. In non-additive cases the proportional rule has an efficient equilibrium outcome (and this equilibrium is unique for almost all parameter settings) when tortfeasors act independently and simultaneously. But it is not always efficient when tortfeasors act in concert or act sequentially. We apply our approach to four recent cases from English jurisprudence. These cases illustrate that both causal uncertainty and joint causation may involve additive as well as non-additive risks.
We conduct an experiment where participants choose between actions that provide private benefits but may also impose losses on others. Three legal environments are compared: no law, strict liability for harm caused to third parties, and an efficiently designed negligence rule where damages are paid only when the harmful action generates a net social loss. Legal obligations are either perfectly enforced (Severe Law) or only weakly so (Mild Law), i.e., expected sanctions are then nondeterrent. We find that behavior can be rationalized in terms of individuals trading-off private benefits, net of legal liability, against the net uncompensated losses caused to others. The weight associated with non-incentivized efficiency concerns is increased by the introduction of a liability rule, whether deterrent or not, and there is evidence that the effect is stronger under strict liability than under the negligence rule.
Les usagers du système de soins ont-ils de plus en plus recours aux tribunaux pour obtenir des indemnités à la suite d’accidents médicaux ? La France est-elle en train de subir une dérive «à l’américaine»? Une recherche récente faite à partir de 50000 décisions de justice rendues dans la dernière décennie répond à cette question et analyse en particulier l’impact des dispositions issues de la loi du 4 mars 2002 relative aux droits des malades et à la qualité du système de santé sur les modalités et l’ampleur des recours engagés, et sur les réparations obtenues.
Objective
To evaluate the impact of tort reform on defensive medicine, quality of care, and physician supply.
Data Sources
Empirical, peer‐reviewed English‐language studies in the MEDLINE and HeinOnline databases that evaluated the association between tort reform and our study outcomes.
Study Design
We performed a systematic review in accordance with the PRISMA guidelines.
Data Collection/Extraction Methods
Title and abstract screening was followed by full‐text screening of relevant citations. We created evidence tables, grouped studies by outcome, and qualitatively compared the findings of included studies. We assigned a higher rating to study designs that controlled for unobservable sources of confounding.
Principal Findings
Thirty‐seven studies met screening criteria. Caps on damages, collateral‐source rule reform, and joint‐and‐several liability reform were the most common types of tort reform evaluated in the included studies. We found that caps on noneconomic damages were associated with a decrease in defensive medicine, increase in physician supply, and decrease in health care spending, but had no effect on quality of care. Other reform approaches did not have a clear or consistent impact on study outcomes.
Conclusions
We conclude that traditional tort reform methods may not be sufficient for health reform and policy makers should evaluate and incorporate newer approaches.
Existing literature considers the effect of changes in malpractice pressure by focusing on physician supply, and concludes that changes in tort laws have limited but some impact on physician movement. Using a panel dataset which follows a random sample of 28,227 family medicine physicians in the United States from 1992–2007, this paper evaluates whether changes in malpractice premiums impact a physician's decision to relocate their practice. Our findings suggest that even large premium growth has no impact on the physician relocation decision. Generally, these results suggest that family medicine physicians do not use relocation as a strategy to avoid malpractice pressure. However, some physicians are more inclined to relocate than others. Results indicate that group and hospital practice physicians are more likely to move to another state when premiums are high compared to solo and partnership practice physicians.
Medical liability systems have been accused of increasing health expenditure insofar as they induce the practice of defensive medicine. Despite the large evidence on the role of medical malpractice liability, the identification of its causal effect on physicians' treatment decisions is a difficult task. In this paper we study for the first time in a controlled laboratory setting the effect of introducing the risk of being sued for medical malpractice on the provision of physicians' medical services. In our experimental sessions both medical and non-medical students choose how many medical services to provide for heterogeneous patients. We implement exogenous variations in the presence of medical malpractice liability and expected probability of being sued, and thus we exploit the within-subject variation in the provision of medical services to infer the causal effect of malpractice liability. Furthermore, we analyze the impact of malpractice liability under different physicians' payment methods, which allows us to discuss the interplay between medical liability and payment systems. Our behavioral data show that introducing malpractice liability pressure does lead physicians to choose a higher amount of medical services, regardless of the physicians' payment system. However, we also find that the payment system in which malpractice liability is implemented makes the difference under the societal perspective, with relevant implications for health policy.
Providers of obstetrical services in the United States account for a disproportionately large share of physicians' liability claims and payments. The authors conducted the first national assessment of how malpractice liability pressure, as measured by insurance premiums, might affect the use of prenatal care. Effects on two measures of infant health, low birth weight and a low 5-minute Apgar score, also were examined. The study population included women from numerous demographic groups differing in socioeconomic and health insurance status. Data were taken chiefly from the National Natality Files for 1990-1992. Maternal characteristics were used to control for variable outcomes caused by differences in family preferences for child health, family income, and the price of other inputs into infant health, such as wages. A reduction in malpractice insurance premiums resulting from feasible policy reform would lower the incidence of late prenatal care by 3 to 5.9% in black women and by 2.2% to 4.7% in white women. For black women, higher malpractice premiums correlated with more late prenatal care and also a reduction in total prenatal care visits. There were no discernible adverse infant health effects associated with lower prenatal care utilization. In white women there was some evidence that higher malpractice premiums were associated with a larger increase in late prenatal care for lower income groups and those with greater Medicaid coverage (unmarried women are an example). In addition, malpractice premiums tended to affect the number of prenatal care visits more in unmarried than in married women, though the differences were not large. Virtually no statistically significant relationship was found between malpractice premiums and the frequency of low birth weight or low Apgar scores in white mothers. These findings are, in a broad sense, consistent with the expectation that malpractice liability pressure reduces access to, and utilization of, prenatal care. Nevertheless the effect is a relatively small one. The effects of malpractice premiums on prenatal care utilization tend to differ according to demographic features that relate strongly to socioeconomic and insurance status. Finally, this survey turned up no evidence that the lower use of prenatal care associated with negative defensive practices adversely affects infant health.
Multiple causation is one of the most intricate issues in contemporary tort law. Apportioning a loss suffered by a victim among multiple tortfeasors is indeed difficult, and courts do not always follow clear and consistent principles. Here, we argue that the axiomatic approach provided by the theory of cooperative games can be used to clarify that issue. We previously considered the question from a purely game-theoretic point of view. Here we analyze it from a legal perspective. We consider in particular the difficult case of successive causation to which we associate a general class of games called sequential liability games. We show that our model rationalizes the two-step process proposed by Restatement (Third) of Torts, apportionment by causation and apportionment by responsibility. More precisely, we show that the weighted Shapley value is the legal counterpart of this two-step process.
Transport economics and policy analysis is a field which has seen major advances in methodology in recent decades, covering issues such as estimating cost functions, modelling of demand, dealing with externalities, examining industry ownership and structure, pricing and investment decisions and measuring economic impacts. This Handbook contains reviews of all these methods, with an emphasis on practical applications, commissioned from an international cast of experts in the field. © The Editor and Contributors Severally 2015. All rights reserved.
Previous research suggests that "direct" reforms to the liability system-reforms designed to reduce the level of compensation to potential claimants-reduce medical expenditures without important consequences for patient health outcomes. We extend this research by identifying the mechanisms through which reforms affect the behavior of health care providers. Although we find that direct reforms improve medical productivity primarily by reducing malpractice claims rates and compensation conditional on a claim, our results suggest that other policies that reduce the time spent and the amount of conflict involved in defending against a claim can also reduce defensive practices substantially. In addition, we find that "malpractice pressure" has a more significant impact on diagnostic rather than therapeutic treatment decisions. Our results provide an empirical foundation for simulating the effects of untried malpractice reforms on health care expenditures and outcomes, based on their predicted effects on the malpractice pressure facing medical providers,
This paper discusses aspects of recruiting subjects for economic laboratory experiments, and shows how the Online Recruitment System for Economic Experiments can help. The software package provides experimenters with a free, convenient, and very powerful tool to organize their experiments and sessions.
This article presents a model of physician and insurer behavior in which the practice of defensive medicine, both positive and negative, can arise. Accounting for negative defensive medicine, and insurers' reaction to it, leads to different predictions of the effects of changing malpractice pressure compared to past models. Rising malpractice pressure causes both health care spending and quality to increase up to a threshold, and decrease thereafter. This non-monotonicity implies that malpractice reform is not a "silver bullet" capable of achieving both cost reductions and quality improvements for all consumers. The results can further explain inconsistent findings in the empirical literature and suggest alternative specifications for estimating the effects of malpractice reform.
There is a large empirical literature examining the relationship between medical liability reform and the supply of physician services. Despite the general consensus that malpractice reform leads to an increase in physician supply, usually targeted amongst a subset of physicians, debates rage at the state level over the effectiveness of any given reform. This paper reviews the evidence on the relationship between tort reform and physician supply and assess the implications for any given state. Although our difference in difference methodology prevents drawing conclusions about the impact of reforms on overall physician supply, we find that noneconomic damage caps increase the supply of physicians in high risk specialties. However, these effects, even for the high risk specialties, vary significantly across states. It is unclear whether these differences represent heterogeneous treatment effects across states, or simply random error in the estimates. New approaches are needed to estimating state-specific effects of tort reform to have the most impact on local policy debates.
Medical malpractice insurance differs from most other types of insurance in that it tends to be community, rather than experience, rated. Also unusual is the lack of deductibles and coinsurance as part of the typical malpractice policy. Rather than focusing on the desirability of experience versus community rating, this paper instead examines the characteristics of this market that allow for community rating, as well as the lack of deductibles and coinsurance. Specifically, we present a theoretical model that includes a reputation factor that can lessen, or in some cases eliminate, the moral hazard problem that is so prevalent in other markets. This model also illustrates the incentive to practice various types of defensive medicine, even when the measures are unobservable to insurers. Using state data, the empirical section examines whether reputation factors do increase the use of defensive medicine. The evidence is mixed, indicating that reputational factors do influence whether family physicians engage in the riskier facets of a family practice, such as obstetrics and surgery. There is, however, little evidence, that physicians prescribe additional laboratory testing as a response to reputation factors.
To explore damage rules’ deterrent effect, we use a public good experiment to tailor allowable punishment to rules used in actual civil litigation. The experimental treatments are analogous to: (1) damages limited to harm to an individual litigant, (2) damages limited to harm to a group available in aggregate litigation, such as class actions, and (3) treble damages. We compare our treatments with a standard voluntary contribution mechanism, where antisocial behavior goes unchecked. For (1) and (2) we also manipulate the probability of a player being entitled to claim damages. The treatments with damages limited to harm to an individual do not prevent the deterioration in cooperation over time commonly found in public good experiments without punishment, yet deterioration is slower. In the class action damages treatment, cooperation is stable over time if the probability of having to pay damages is sufficiently high. The same holds for the treble damages treatment. In all treatments, a money maximising agent would be expected to completely freeride and make no contribution to the public good. Our results can thus not be explained by an incentive effect. Rather we find that social preferences interact with the severity of sanctions, even if imposing the sanction is not altruistic, but instead financially benefits the sanctioning authority. The results persist in a variation of (1) and (2) in which the player imposing damages has the option to not retain them for herself but to have them forfeited with no benefit to her. We can therefore rule out that the beneficial effect of sanctions hinges on the participants knowing that the player imposing sanctions cannot intend to enrich herself.
This study analyzes organization of economic activity within and between markets and hierarchies. It considers the transaction to be the ultimate unit of microeconomic analysis, and defines hierarchical transactions as ones for which a single administrative entity spans both sides of the transaction, some form of subordination prevails and, typically, consolidated ownership obtains. Discusses the advantages of the transactional approach by examining three issues: price discrimination, insurance, and vertical integration. Develops the concept of the organizational failure framework, and demonstrates why it is always the combination of human with environmental factors, not either taken by itself, that causes transactional problems. The study also describes each of the transactional relations of interest, and presents the advantages of internal organization with respect to the transactional condition. The analysis explains why primary work groups of the peer group and simple hierarchy types arise. The same transactional factor which impede autonomous contracting between individuals also impede market exchange between technologically separable work groups. Peer groups can be understood as an internal organizational response to the frictions of intermediate product markets, while conglomerate organization can be seen as a response to failures in the capital market. In both contexts, the same human factors, such as bounded rationality and opportunism, occur. Examines the reasons for and properties of the employment relation, which is commonly associated with voluntary subordination. The analysis attempts better to assess the employment relation in circumstances where workers acquire, during the course of the employment, significant job-specific skills and knowledge. The study compares alternative labor-contracting modes and demonstrates that collective organization is helpful in enhancing the acquisition of idiosyncratic knowledge and skills by the work force. The study then examines more complex structures -- the movement from simple hierarchies to the vertical integration of firms, then multidivisional structures, conglomerates, monopolies and oligopolies. Discusses the market structure in relation to technical and organizational innovation. The study proposes a systems approach to the innovation process. Its purpose is to permit the realization of the distinctive advantages of both small and large firms which apply at different stages of the innovation process. The analysis also examines the relation of organizational innovation to technological innovation. (AT)
Increasing litigiousness in France, following in the USA’s footsteps?
Given the peculiarities of the French and American legal systems and the significant differences between the legal procedures regarding medical liability, it is hard to compare the evolution of litigation in this area. However, the feeling that medical work is increasingly subject to litigation is widespread in both countries. There are obviously several reasons for this impression, but they are probably due in part to confusion between collective liability and individual liability, a confusion that is strengthened when physicians see their insurance premiums rising.
Reforms to the Joint and Several Liability rule (JSL) are one of the most common tort reforms and have been implemented by most US states. JSL allows plaintiffs to claim full recovery from one of the defendants, even if that defendant is only partially responsible for the tort. We develop a theoretical model that shows that the efficiency of the JSL rule depends critically on both whether the care taken by potential tortfeasors is observed, and on how the actions of the potential tortfeasors interact to cause the harm. We then provide evidence that reforms of the JSL rule have been accompanied by reductions in the accidental death rate in the U. S. This result is consistent with the hypothesis that the reform of JSL causes potential tortfeasors to take more care.
We develop a simple multi-task principal-agent model to analyze the interplay between optimal reimbursement schemes for hospitals and liability rules (basic model). We then extend our model and assume that the hospital is intrinsically motivated to exert positive effort for quality and cost reduction. This effort, however, is biased towards quality. Moreover, the intrinsic motivation may be crowded out by monetary incentives. In such a setting, we find that a pure prospective payment system (PPS) that has become widespread in recent years can only be optimal in the unlikely case where malpractice liability holds hospitals fully responsible for expected harm. For other cases, we confirm the prejudice that PPS may lead to inefficiently low quality. Then, the traditional fee-for-service (FFS) system is superior if the intrinsic motivation is high and relatively little biased towards quality, whereas mixed systems should be chosen otherwise. Our model sheds light on why countries like the USA with a tough liability system haven been less reluctant to switch from FFS to PPS than Germany, for instance.
We develop and evaluate a simple gamble-choice task to measure attitudes toward risk, and apply this measure to examine differences in risk attitudes of male and female university students. In addition, we examine stereotyping by asking whether a person's sex is read as a signal of risk preference. Subjects choose which of five 50/50 gambles they wish to play. The gambles include one sure thing; the remaining four increase (linearly) in expected payoff and risk. Each subject also is asked to guess which of the five gambles each of the other subjects chose, and is paid for correct guesses. The experiment is conducted under three different frames: an abstract frame where the two highest-payoff gambles carry the possibility of losses, an abstract frame with no losses, and an investment frame that mirrors the payoff structure of the former. We find that women are significantly more risk averse than men in all three settings, and predictions of both women and men tend to confirm this difference. While average guesses reflect the average difference in choices, only 27 percent of guesses are accurate, which is slightly higher than chance.
We extend the theoretical literature on the impact of malpractice liability by allowing for two treatment technologies, a safe and a risky one. The safe technology bears no failure risk, but leads to patient-specific disutility since it cannot completely solve the health problems. By contrast, the risky technology (for instance a surgery) may entirely cure patients, but fail with some probability depending on the hospital's care level. Tight malpractice liability increases care levels if the risky technology is chosen at all, but also leads to excessively high incentives for avoiding the liability exposure by adopting the safe technology. We refer to this distortion toward the safe technology as negative defensive medicine. Taking the problem of negative defensive medicine seriously, the second best optimal liability needs to balance between the over-incentive for the safe technology in case of tough liability and the incentive to adopt little care for the risky technology in case of weak liability. In a model with errors in court, we find that gross negligence where hospitals are held liable only for very low care levels outperforms standard negligence, even though standard negligence would implement the first best efficient care level.
This paper provides a coherent framework for classifying cases with multiple tortfeasors in relation to the efficient allocation of liability across the tortfeasors. We construct a simple model in which various tortfeasors contribute to a loss, and consider efficient liability rules under various assumptions.
Concerns about reducing the rate of growth of health expenditures have reignited interest in medical liability reforms and their potential to save money by reducing the practice of defensive medicine. It is not easy to estimate the costs of the medical liability system, however. This article identifies the various components of liability system costs, generates national estimates for each component, and discusses the level of evidence available to support the estimates. Overall annual medical liability system costs, including defensive medicine, are estimated to be $55.6 billion in 2008 dollars, or 2.4 percent of total health care spending.
To assess the efficacy and the cost of a French team work experiment between nurses and GPs for managing type 2 diabetes patients.
Based on a case control study design we compare the evolution of process (standard follow-up procedures) and final (glycemic control) outcomes, and of cost, between two consecutive periods between type 2 diabetes patients followed within the team work experiment (intervention group) or by "standard" GPs (controlled group).
After a 11 months of follow-up, patients in the intervention group, compared with those in the controlled group, have more chances to remain or to become: correctly followed-up (with OR comprise between 2.1 and 6.8, p≤5%) and under glycemic control (with OR comprise between 1.8 and 2.7, p≤5%). The latter result is obtained only when a visit for education and counselling has been delivered by a nurse in supplement to systematic electronic patient registry and electronic clinical GPs reminder. All these results are obtained without difference in costs between the intervention and the controlled group.
This experimentation of team working can be considered both effective and efficient. Our findings may have implications in the design of future larger primary care team work experiment to be launched by French health authorities.