Evaluation of Options

• • The views expressed in this report are those of the authors. EXECUTIVE SUMMARY The report synthesizes the evidence and theoretical predictions regarding the potential of several leading medical malpractice reform ideas to positively affect the performance of the medical liability system and its impact on health care delivery. For most reforms, the report analyzes evidence from well‐designed, controlled studies. Where such studies are unavailable, the analysis encompasses anecdotal reports, case studies, and descriptive findings regarding the operation of proposed systems or close analogues in the U.S. and foreign countries. For reforms that have not yet been tested, the report describes theoretical predictions about the likely effects of the reforms based on relevant scholarship in law and economics. The analysis covers 8 reforms that have been widely implemented by states: caps on noneconomic damages, pretrial screening panels, certificate of merit requirements, attorney fee limits, joint‐and‐ several liability rule reform, collateral source rule reform, periodic payment, and statutes of limitation/repose. It also examines 6 more innovative, less tested reforms: schedules of noneconomic damages, health courts, disclosure‐and‐offer programs, safe harbors for adherence to evidence‐based clinical practice guidelines, subsidized reinsurance that is made conditional upon meeting particular patient safety goals, and enterprise medical liability. The reforms are evaluated for their effects on the following outcome variables: malpractice claims frequency and costs, medical liability system overhead costs, health care providers' liability costs, defensive medicine (including health care utilization and spending), supply of health care services (including physician supply and patient health insurance coverage), and quality of care. We find that although the evidence base for evaluating most traditional state tort reforms is substantial and mature, for most reforms, the evidence does not identify significant effects on the key outcome variables. The exception is caps on noneconomic damages, which have well‐documented effects on several of the outcomes. The evidence base for evaluating the innovative tort reforms is extremely small, as most have not been tested in the U.S., analogous systems are not clearly predictive of how they would function, and much depends on the choices made about system design. However, based on theoretical predictions and the limited evidence available, most of these reforms are promising enough to merit controlled experimentation in the U.S., such as through demonstration projects.