Variability and consistency of rates of primary and repeat cesarean sections among hospitals in two states.

Hospitals in New York and Illinois have wide variations in their primary and repeat cesarean section rates. A number of factors account for these differences. To investigate whether hospitals with higher or lower rates tend to continue these patterns over time, their rates in 1988 were compared with those in 1983. It was found that a hospital''s cesarean section rate was consistent, but some regression to the mean process did occur. By 1988, teaching hospitals had lower rates than nonteaching hospitals; this difference is likely due to the greater response to calls for increasing trials of vaginal birth after a previous cesarean section by teaching hospitals. Over time this should contribute to further moderating of the rates. Data were from the Illinois and New York State Departments of Health.     

Primary Cesarean Section Rates in Uninsured, Medicaid and Insured Populations of Predominantly Rural Northern New England

Many studies in the United States during the past two decades have reported consistently lower cesarean section rates in women of lower socioeconomic status as defined by census tract, insurance status, or maternal level of educational attainment. This study sought to determine whether cesarean section rates in predominantly rural northern New England are lower for lower, compared with higher socioeconomic groups, as they are reported nationally and in more urban areas. Age-adjusted, primary cesarean section rates for privately insured, Medicaid and uninsured women were calculated using 1990 to 1992 uniform hospital discharge data for Maine, New Hampshire and Vermont. Age-adjusted cesarean section rates for insured women (15.71 percent) were significantly higher than those for Medicaid (14.35 percent) and uninsured (12.85 percent) women. These differences in the cesarean section rate between the insured and poorer populations in northern New England are much less than those reported elsewhere in the country.     

The forgotten third: liability insurance and the medical malpractice crisis

Although the most visible manifestations of medical malpractice involve patient safety and the legal process, the availability and affordability of liability insurance largely determine the direction of medical malpractice policy. Scientific and industrial developments since the first modern malpractice crisis in the 1970s reveal major problems with the structure and regulation of liability insurance. Comprehensive reforms that approach medical malpractice insurance as a health policy problem are needed, and the Medicare program may have a major role to play.     

对医疗责任保险模式的分析

医疗责任风险管理方法，包括风险的避免、减少、自留和转移。由于我国目前人身损害赔偿数额并未对综合医院的收入造成重大影响，并且综合医院每年发生的医疗过失案件数量基本稳定，所以风险自留和风险转移都是适应医疗过失损害赔偿的风险管理方式。根据风险管理原理和国际医疗责任保险发展历程，商业医疗责任保险不宜作为我国医疗责任风险管理的首选；适合医院财务安全需要的风险自留、自保信托等方式，均可采用。为了配合医疗责任保险开展，应建立独立的医疗纠纷调解与鉴定机构。     

Disparities in Cesarean Delivery by Ethnicity and Nativity in New York City

Our objective was to examine differences in risk of cesarean delivery among diverse ethnic groups in New York City. Using cross-sectional New York City birth and hospitalization data from 1995 to 2003 (n = 961,381) we estimated risk ratios for ethnic groups relative to non-Hispanic whites and immigrant women relative to US-born women. Adjusting for insurance, pre-pregnancy weight, maternal age, education, parity, birthweight, gestational age, year, medical complications, and pregnancy complications, all ethnic groups except East Asian women were at an increased risk of cesarean delivery, with the highest risk among Hispanic Caribbean women [adjusted risk ratio (aRR) = 1.27, 95 % CI (confidence interval) = 1.24, 1.30] and African American women (aRR = 1.20, 95 % CI = 1.17, 1.23). Among Hispanic groups, immigrant status further increased adjusted risk of cesarean delivery; adjusted risk ratios for foreign-born women compared to US-born women of the same ethnic group were 1.27 for Mexican women (95 % CI = 1.05, 1.53), 1.23 for Hispanic Caribbean women (95 % CI = 1.20, 1.27), and 1.12 for Central/South American women (95 % CI = 1.04, 1.21). Similar patterns were found in subgroup analyses of low-risk women (term delivery and no pregnancy or medical complications) and primiparous women. We found evidence of disparities by ethnicity and nativity in cesarean delivery rates after adjusting for multiple risk factors. Efforts to reduce rates of cesarean delivery should address these disparities. Future research should explore potential explanations including hospital environment, provider bias, and patient preference.     

社会因素对剖宫产率的影响及对策

目的:通过对信阳市妇幼保健院近5年剖宫产率及手术指征的分析,探讨社会因素导致剖宫产率升高的原因及降低剖宫产率的对策。方法:采用定基比的回顾性分析法。结果:社会因素是促使剖宫产率逐年上升的主要原因;剖宫产手术的安全系数提高,社会舆论负面导向,迷信思想作祟,产妇缺乏信心以及医患纠纷风险和医院经济利益等原因造成剖宫产率居高不下。结论:国家应出台相应的鼓励自然分娩政策,社会各界倡导自然分娩方式;卫生行政部门应强化监督职能;医务人员需提高助产技术;进行健康教育和孕期保健知识培训,克服产妇对自然分娩的畏惧思想可提高自然分娩率。     

Maternal health insurance coverage as a determinant of obstetrical anesthesia care

This study measures the association between health insurance and the likelihood of receiving different obstetrical anesthesia protocols among 121,351 singleton live births in upstate New York during 1992. Mothers receiving a cesarean under Medicaid were approximately twice as likely to receive general anesthesia as those with traditional private coverage. Those receiving a cesarean under an HMO were least likely to receive general anesthesia with adjusted odds of 0.73 (confidence interval [CI] = 0.68-0.79), compared to those with traditional private insurance. Those delivering vaginally under Medicaid, HMO, or no coverage had adjusted odds of receiving an epidural of 0.45 (CI = 0.43-0.48), 0.68 (CI = 0.64-0.71), and 0.44 (CI = 0.38-0.52), respectively, compared to those under traditional private insurance. Although there was some differences by race, the strongest determinant of anesthesia remained insurance type. Insurance-mediated disparities in obstetrical anesthesia care are evident in upstate New York and warrant further study nationally.     

Hospital-sponsored groups offer viable malpractice insurance

Hospital - sponsored insurance organizations can offer their members many advantages, especially reasonable and stable malpractice insurance coverage and premium rates. To do so, they must ensure their financial stability through the support of the insured and through adequate reinsurance, compete effectively with commercial insurance companies, comply with federal regulations regarding reimbursement to hospitals for premiums, and develop effective internal management.     

海峡两岸医疗责任保险合同的比较研究

基于医疗责任保险的实践和医疗机构的现状,采用比较法分析我国台湾和大陆海峡两岸的医疗责任保险格式合同条款,指出大陆医疗责任保险格式合同在保险模式、责任范围、医务人员范围的界定、期内首次索赔申请、保险费计取、赔偿处理中的抗辩与和解控制等条款应予以修改的方案,以期大陆医疗责任保险格式合同更适合医疗责任保险的现实需求.     

Liability and liability insurance for medical malpractice

Physicians typically carry virtually complete malpractice insurance coverage. This contradicts standard theoretical predictions that under a negligence rule of liability there should be no demand for insurance, and insurance policies under moral hazard will contain co-payment provisions. It is argued that judicial 'errors' in defining negligence generate a demand for liability and legal defense insurance. Physician co-payment undermines the insurer's incentives for legal defense and thus induces a trade-off between loss reduction by injury prevention and by legal defense. Fee-for-service reimbursement further distorts the physician's choice between injury prevention and insurance. Implications for the deterrent function of the tort system are discussed.     

Increased cesarean section rates and emerging patterns of health insurance in Shanghai, China.

OBJECTIVES: This study examined the trend in cesarean section deliveries and the factors associated with it in the Minhang District of Shanghai, China. METHODS: A representative sample of the members of 2716 households in the district were interviewed in the fall of 1993. This study analyzed the data from 1959 married women of reproductive age with at least one live birth. RESULTS: During the past 3 decades, the proportion of infants born by cesarean section increased from 4.7% to 22.5%. Logistic regression analysis revealed that the highest cesarean section rate, which occurred in the most recent period of 1988 through 1993, was associated with form of medical payment, self-reported complications during pregnancy, higher birthweight, and maternal age. Government insurance pays all costs of cesarean sections and accounted for the highest proportion of the cesarean section rate. CONCLUSIONS: The high rates of cesarean sections in China are surprising given the lack of the factors that usually lead to cesarean sections. The increasing cesarean section rates may be an early indication that emerging forms of health insurance and fee-for-service payments to physicians will lead to an excessive emphasis on costly, high-technology medical care in China.     

谈我国医疗责任保险问题及对策

发展医疗责任保险,对医疗执业过失给患者造成的损害进行充分赔偿,保障患者和医疗机构及其医务人员的合法权益,优化医疗公共秩序方面有重要的促进作用。由于我国医院主体是公立医院,侵权法人身损害赔偿相对于综合医院尚未到重大程度,并且综合性医院每年发生的医疗过失案件基本确定,选择合适医疗责任保险模式,如医疗责任保险信托等,能促进医疗责任保险的发展。实践表明,商业性医疗责任保险不宜成为我国医疗责任保险的主体。建立独立的医疗过失纠纷调解鉴定机构,才能保证医疗责任保险顺利开展。     

Cesarean section use and source of payment: an analysis of California hospital discharge abstracts.

This study assessed the relation between payment source and cesarean section use by analyzing California data on hospital deliveries. Of 461,066 deliveries in 1986, cesarean sections were performed in 24.4 percent. Women with private insurance had the highest cesarean section rates (29.1 percent). Successively lower rates were observed for women covered by non-Kaiser health maintenance organizations (26.8 percent), Medi-Cal (22.9 percent), Kaiser (19.7 percent), self-pay (19.3 percent), and Indigent Services (15.6 percent). Vaginal birth after cesarean (VBAC) occurred more than twice as frequently in women covered by Kaiser (19.9 percent) and Indigent Services (24.8 percent), compared to those with private insurance (8.1 percent). Sizable, although less pronounced, associations between payment source and cesarean section use were noted for the indications of breech presentation, dystocia, and fetal distress. Accounting for maternal age and race/ethnicity did not alter these findings. Variations in the use of cesarean section have a substantial financial impact on health care payors.     

Premium copayments and the trade-off between wages and employer-provided health insurance

This paper estimates the trade-off between salary and health insurance costs using data on Illinois school teachers between 1991 and 2008 that allow us to address several common empirical challenges in this literature. Teachers paid about 17 percent of the cost of individual health insurance and about 46 percent of the cost of their family members’ plans through premium contributions, but we find no evidence that teachers’ salaries respond to changes in insurance costs. Consistent with a higher willingness to pay for insurance, we find that premium contributions are higher in districts that employ a higher-tenured workforce. We find no evidence that school districts respond to higher health insurance costs by reducing the number of teachers.     

Trends in obstetric operative procedures, 1980 to 1987.

OBJECTIVES. Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical procedures has increased. However, little information has been published on the national trends of other operative obstetric procedures occurring during deliveries. METHODS. We analyzed data from the National Hospital Discharge Survey to examine trends in the use of forceps, vacuum extraction, and cesarean section from 1980 through 1987. RESULTS. The rate of cesarean sections increased by 48%, while the rate of forceps procedures declined by 43%. Although the risk of cesarean section was significantly increased for older women, the risk of forceps and vacuum extraction procedures did not vary by age. Women with private insurance were significantly more likely to receive a cesarean section (rate ratio [RR] = 1.2), forceps procedure (RR = 1.7), and vacuum extraction procedure (RR = 1.8) than were women without private insurance. CONCLUSIONS. As pressure mounts to decrease the national cesarean section rate from 24% to 15% by the year 2000, attention should also be given to surveillance of other operative delivery procedures.     

No-fault medical liability in Virginia and Florida. A preliminary evaluation

State governments are experimenting with a variety of innovative approaches to the current tort system for medical malpractice liability. One such approach is to apply the concept of no-fault liability to medical practice. States such as Virginia and Florida have already adopted a limited version of such a concept. This article examines the problems of the current tort system, different types of no-fault medical insurance alternatives and their advantages, and the experiences of the states of Virginia and Florida with their limited no-fault malpractice insurance systems. The author concludes that the concept of no-fault compensation for medical malpractice is a promising remedy. However, it is a medicine that will require more testing before it can be pronounced a cure for the disease that plagues the current system.     

Changes in physician supply and scope of practice during a malpractice crisis: evidence from Pennsylvania

The extent to which liability costs cause physicians to restrict their scope of practice or cease practicing is controversial in policy debates over malpractice "crises." We used insurance department administrative data to analyze specialist physician scope-of-practice changes and exits in Pennsylvania in 1993-2002. In most specialties the proportions of high-risk specialists restricting their scope of practice did not increase during the crisis; however, the supply of obstetrician-gynecologists decreased by 8 percent in the three years following premium increases in 1999. We discuss methodological issues that could explain the disparate findings regarding physician supply effects in studies using administrative data sets and survey data.     

Hospitals' behavior in a tort crisis: observations from Pennsylvania

Pennsylvania, like many states around the country, is in the throes of a "tort crisis." The cost of professional liability insurance for physicians and hospitals is escalating rapidly, as its availability shrinks. Many hospitals are poorly situated to bear these rising costs, especially in an environment of flat reimbursement rates and poor investment returns. This paper examines the impact of the liability crisis on Pennsylvania hospitals and the strategies being used to weather the storm, including alternative risk financing and closer ties between hospitals and affiliated physicians. It concludes by connecting these trends to larger medical malpractice policy issues.     

论我国强制医疗责任保险立法的必要性

强制医疗责任保险根据我国相关配套法律法规以及社会现实情况,其设立有充足的必要性.推行强制的医疗责任保险制度可以有两种方式——以行政命令手段或以法律手段,且立法强制医疗责任保险必须解决科学厘定保险费率,制定和完善专门调整医疗过失的民事特别法以及加快制定与医疗过失责任的法规相匹配的医疗体制改革的政策和实施措施.