Essays on malpractice law and physician behavior

Abstract

This dissertation contributes to an understanding of the manner in which various dimensions of malpractice law shape physician behavior and how this behavior, in turn, impacts health outcomes. In Chapter 1, I explore the association between regional variations in physician practices and the geographical scope of the standards of care to which physicians are held in malpractice actions. To investigate this general association, I explore whether treatment utilization rates in a state converge towards national utilization levels as states abandon the use of "locality rules" to adopt laws requiring physicians to comply with national standards of care. I focus the analysis on the case of cesarean delivery and find robust evidence of convergence in cesarean section utilization, whereby as much as 40 - 60% of the gap between state and national cesarean rates is closed upon the abandonment of a locality rule. In Chapter 2, I estimate the returns to regional cesarean intensities, drawing on an arguably exogenous source of variation in cesarean rates resulting from the adoption of national-standard laws. I first document robust evidence of triage in regional cesarean utilization, whereby physicians in high intensity regions begin to perform cesareans on mothers who are less in need of this intensive delivery alternative. Second, I find no evidence to suggest that an increase in regional cesarean rates otherwise leads to an increase in average neonatal outcomes.

(cont.) Third, I find evidence suggesting that increases in regional cesarean rates may be crowding out mothers otherwise in need of cesarean delivery. In Chapter 3, I consider another dimension to malpractice law and estimate the relationship between different levels of malpractice pressure, as identified by the adoption of non-economic damage caps and related malpractice laws, and certain decisions faced by obstetricians during the delivery of a child. Contrary to the conventional wisdom, I find no evidence to support the claim that malpractice pressure induces physicians to perform a substantially greater number of cesarean sections. However, I do find evidence of positive defensive behavior in the utilization of episiotomies during vaginal deliveries and in the durations of maternal lengths of stay.