Does litigation increase or decrease health care quality?: a national study of negligence claims against nursing homes

Abstract

Background: The tort system is supposed to help improve the quality and safety of health care, but whether it actually does so is controversial. Most previous studies modeling the effect of negligence litigation on quality of care are ecologic.

Objective: To assess whether the experience of being sued and incurring litigation costs affects the quality of care subsequently delivered in nursing homes.

Research design, subjects, measures: We linked information on 6471 negligence claims brought against 1514 nursing homes between 1998 and 2010 to indicators of nursing home quality drawn from 2 US national datasets (Online Survey, Certification, and Reporting system; Minimum Data Set Quality Measure/Indicator Reports). At the facility level, we tested for associations between 9 quality measures and 3 variables indicating the nursing homes' litigation experience in the preceding 12-18 months (total indemnity payments; total indemnity payments plus administrative costs; ≥ 1 paid claims vs. none). The analyses adjusted for quality at baseline, case-mix, ownership, occupancy, year, and facility and state random effects.

Results: Nearly all combinations of the 3 litigation exposure measures and 9 quality measures--27 models in all--showed an inverse relationship between litigation costs and quality. However, only a few of these associations were statistically significant, and the effect sizes were very small. For example, a doubling of indemnity payments was associated with a 1.1% increase in the number of deficiencies and a 2.2% increase in pressure ulcer rates.

Conclusions: Tort litigation does not increase the quality performance of nursing homes, and may decrease it slightly.

Figure 1

Detectable forms of deterrence in studies of medical malpractice litigation, by type of measures used

Figure 2

Timeline for the measures of quality-of-care and litigation experience used in the analyses of nursing homes* * The Figure shows temporal aspects of the variables used to estimate the effect of a nursing home’s claims experience during an “exposure” period on subsequent quality of care. MDS refers to the Minimum Data Set quality indicator/quality measure system. OSCAR refers to the to the Online Survey Certification and Reporting system. Q refers to quarters, the time interval used to construct the analytic dataset containing MDS measures. IP refers to inspection periods, the time interval used to construct the analytic dataset containing OSCAR measures.