Quantifying the Economics of Medical Malpractice - A View from a Civil Law Perspective

Life is full of uncertainties. Legal rules should have a clear intention, motivation and purpose in order to diminish daily uncertainties. However, practice shows that their consequences are complex and hard to predict. For instance, tort law has the general objectives of deterring future negligent behavior and compensating the victims of someone else's negligence. Achieving these goals are particularly difficult in medical malpractice cases. To start with, when patients search for medical care they are typically sick in the first place. In case harm materializes during the treatment, it might be very hard to assess if it was due to substandard medical care or to the patient's poor health conditions. Moreover, the practice of medicine has a positive externality on the society, meaning that the design of legal rules is crucial: for instance, it should not result in physicians avoiding practicing their activity just because they are afraid of being sued even when they acted according to the standard level of care. The empirical literature on medical malpractice has been developing substantially in the past two decades, with the American case being the most studied one. Evidence from civil law tradition countries is more difficult to find. The aim of this thesis is to contribute to the empirical literature on medical malpractice, using two civil law countries as a case-study: Spain and Italy. The goal of this thesis is to investigate, in the first place, some of the consequences of having two separate sub-systems (administrative and civil) coexisting within the same legal system, which is common in civil law tradition countries with a public national health system (such as Spain, France and Portugal). When this holds, different procedures might apply depending on the type of hospital where the injury took place (essentially whether it is a public hospital or a private hospital). Therefore, a patient injured in a public hospital should file a claim in administrative courts while a patient suffering an identical medical accident should file a claim in civil courts. A natural question that the reader might pose is why should both administrative and civil courts decide medical malpractice cases? Moreover, can this specialization of courts influence how judges decide medical malpractice cases? In the past few years, there was a general concern with patient safety, which is currently on the agenda of several national governments. Some initiatives have been taken at the international level, with the aim of preventing harm to patients during treatment and care. A negligently injured patient might present a claim against the health care provider with the aim of being compensated for the economic loss and for pain and suffering. In several European countries, health care is mainly provided by a public national health system, which means that if a patient harmed in a public hospital succeeds in a claim against the hospital, public expenditures increase because the State takes part in the litigation process. This poses a problem in a context of increasing national health expenditures and public debt. In Italy, with the aim of increasing patient safety, some regions implemented a monitoring system on medical malpractice claims. However, if properly implemented, this reform shall also allow for a reduction in medical malpractice insurance costs. This thesis is organized as follows. Chapter 1 provides a review of the empirical literature on medical malpractice, where studies on outcomes and merit of claims, costs and defensive medicine are presented. Chapter 2 presents an empirical analysis of medical malpractice claims arriving to the Spanish Supreme Court. The focus is on reversal rates for civil and administrative decisions. Administrative decisions appealed by the plaintiff have the highest reversal rates. The results show a bias in lower administrative courts, which tend to focus on the State side. We provide a detailed explanation for these results, which can rely on the organization of administrative judges career. Chapter 3 assesses predictors of compensation in medical malpractice cases appealed to the Spanish Supreme Court and investigates the amount of damages attributed to patients. The results show horizontal equity between administrative and civil decisions (controlling for observable case characteristics) and vertical inequity (patients suffering more severe injuries tend to receive higher payouts). In order to execute these analyses, a database of medical malpractice decisions appealed to the Administrative and Civil Chambers of the Spanish Supreme Court from 2006 until 2009 (designated by the Spanish Supreme Court Medical Malpractice Dataset (SSCMMD)) has been created. A description of how the SSCMMD was built and of the Spanish legal system is presented as well. Chapter 4 includes an empirical investigation of the effect of a monitoring system for medical malpractice claims on insurance premiums. In Italy, some regions adopted this policy in different years, while others did not. The study uses data on insurance premiums from Italian public hospitals for the years 2001-2008. This is a significant difference as most of the studies use the insurance company as unit of analysis. Although insurance premiums have risen from 2001 to 2008, the increase was lower for regions adopting a monitoring system for medical claims. Possible implications of this system are also provided. Finally, Chapter 5 discusses the main findings, describes possible future research and concludes.

The Law and Economics of Eco-labels

Eco-labels and certification are one of the many environmental policy tools that have been under scrutiny in recent years. This is because the damages of environmental degradation are becoming more apparent over time. Hence there is a pressure to come up with tools that help solve even small parts of the problem. Eco-labels have been around for over 30 years. However the market, the environment and eco-labels have changed drastically during this period. Moreover, in the last 5 years there has been a sudden increase in eco-labels making them more visible in the market and to the average consumer. All this has made evident that little is known about the effectiveness of eco-labels as environmental policy tools. Hence, there is a call to find answers regarding the actual effects of eco-labels on the market and on the environment. While this work cannot address whether eco-labels have an environmental impact it addresses the effects of eco-labels on the markets. Moreover, this work aimed to find the role of law in eco-labelling. In addition, it aims to find a legal solution that would improve the performance of eco-labelling and certification.

Three Essays in Economics of Gender

During recent decades, economists' interest in gender-related issues has risen. Researchers aim to show how economic theory can be applied to gender related topics such as peer effect, labor market outcomes, and education. This dissertation aims to contribute to our understandings of the interaction, inequality and sources of differences across genders, and it consists of three empirical papers in the research area of gender economics. The aim of the first paper ("Separating gender composition effect from peer effects in education") is to demonstrate the importance of considering endogenous peer effects in order to identify gender composition effect. This fact is analytically illustrated by employing Manski's (1993) linear-in-means model. The paper derives an innovative solution to the simultaneous identification of endogenous and exogenous peer effects: gender composition effect of interest is estimated from auxiliary reduced-form estimates after identifying the endogenous peer effect by using Graham (2008) variance restriction method. The paper applies this methodology to two different data sets from American and Italian schools. The motivation of the second paper ("Gender differences in vulnerability to an economic crisis") is to analyze the different effect of recent economic crisis on the labor market outcome of men and women. Using triple differences method (before-after crisis, harder-milder hit sectors, men-women) the paper used British data at the occupation level and shows that men suffer more than women in terms of probability of losing their job. Several explanations for the findings are proposed. The third paper ("Gender gap in educational outcome") is concerned with a controversial academic debate on the existence, degree and origin of the gender gap in test scores. The existence of a gap both in mean scores and the variability around the mean is documented and analyzed. The origins of the gap are investigated by looking at wide range of possible explanations.

The Law and Economics of Hedge Fund Regulation: A Comparison between the U.S. and the EU

This doctoral dissertation seeks to assess and address the potential contribution of the hedge fund industry to financial instability. In so doing, the dissertation investigates three main questions. What are the contributions of hedge funds to financial instability? What is the optimal regulatory strategy to address the potential contribution of hedge funds to financial instability? And do new regulations in the U.S. and the EU address the contribution of hedge funds to financial instability? With respect to financial stability concerns, it is argued that despite their benefits, hedge funds can contribute to financial instability. Hedge funds’ size and leverage, their interconnectedness with Large Complex Financial Institutions (LCFIs), and the likelihood of herding behavior in the industry can potentially undermine financial stability. Nonetheless, the data on hedge funds’ size and leverage suggest that these features are far from being systemically important. In contrast, the empirical evidence on the interconnectedness of hedge funds with LCFIs and their herding behavior is mixed. Based on these findings, the thesis focuses on one particular aspect of hedge fund regulation: direct vs. indirect regulation. In this respect, a major contribution of the thesis to the literature consists in the explicit discussion of the relationships between hedge funds and other market participants. Specifically, the thesis locates the domain of the indirect regulation in the inter-linkages between hedge funds and prime brokers. Accordingly, the thesis argues that the indirect regulation is likely to address the contribution of hedge funds to systemic risk without compromising their benefits to financial markets. The thesis further conducts a comparative study of the regulatory responses to the potential contribution of hedge funds to financial instability through studying the EU Directive on Alternative Investment Fund Managers (AIFMD) and the hedge fund-related provisions of the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010.

Essays in the Economics of Ageing

In the first paper, I assess if financial incentives may be used as an effective device to induce workers to postpone retirement by evaluating the Italian so called “super bonus” reform. The bonus consisted in economic incentives given for a limited period to private sector workers who had reached the requirements for seniority pension. Crucially for this study, public workers were not entitled to the bonus. Using data from the Bank of Italy Survey on Household Income andWealth, and exploiting the DID-Probit strategy proposed by Blundell et al. (JEEA, 2004), I assess the effect of the bonus on the decision to postpone retirement, by comparing private and public workers before and after the reform. Results suggest a reduction of 12ppt in the proportion of private workers who decided to retire among those qualifying for retirement. Results also suggest, not trivially, that most of the effect of the reform is driven by low-income workers. Finally, I propose an estimate of the extensive margin elasticity of Italian older workers. The second study estimates a structural reduced form of the “option value” model developed by Stock and Wise (1990) using Italian data from the Survey of Health, Ageing and Retirement in Europe (SHARE).Exploiting exogenous changes in social security wealth (SSW) results show a significant effect in the expected direction of SSW and of marginal incentives to retire. Results are robust even after controlling for individual heterogeneity and its correlation with financial incentives. Using detailed information on individuals, the results also highlights the importance of individual and job characteristics, which have been very little explored by this literature, as determinants of retirement. This suggests the potential of “tagging” in the design of social security incentives in order to reduce choice distortions and improve the overall efficiency of the system.

A Law and Economics Analysis of Lobbying Regulation Towards an optimal structure through the Cost Indicator Index

This research primarily represents a contribution to the lobbying regulation research arena. It introduces an index which for the first time attempts to measure the direct compliance costs of lobbying regulation. The Cost Indicator Index (CII) offers a brand new platform for qualitative and quantitative assessment of adopted lobbying laws and proposals of those laws, both in the comparative and the sui generis dimension. The CII is not just the only new tool introduced in the last decade, but it is the only tool available for comparative assessments of the costs of lobbying regulations. Beside the qualitative contribution, the research introduces an additional theoretical framework for complementary qualitative analysis of the lobbying laws. The Ninefold theory allows a more structured assessment and classification of lobbying regulations, both by indication of benefits and costs. Lastly, this research introduces the Cost-Benefit Labels (CBL). These labels might improve an ex-ante lobbying regulation impact assessment procedure, primarily in the sui generis perspective. In its final part, the research focuses on four South East European countries (Slovenia, Serbia, Montenegro and Macedonia), and for the first time brings them into the discussion and calculates their CPI and CII scores. The special focus of the application was on Serbia, whose proposal on the Law on Lobbying has been extensively analysed in qualitative and quantitative terms, taking into consideration specific political and economic circumstances of the country. Although the obtained results are of an indicative nature, the CII will probably find its place within the academic and policymaking arena, and will hopefully contribute to a better understanding of lobbying regulations worldwide.

Social Welfare and Behavioral Public Policies

In this work I discuss several key aspects of welfare economics and policy analysis and I propose two original contributions to the growing field of behavioral public policymaking. After providing a historical perspective of welfare economics and an overview of policy analysis processes in the introductory chapter, in chapter 2 I discuss a debated issue of policymaking, the choice of the social welfare function. I contribute to this debate by proposing an original methodological contribution based on the analysis of the quantitative relationship among different social welfare functional forms commonly used by policy analysts. In chapter 3 I then discuss a behavioral policy to contrast indirect tax evasion based on the use of lotteries. I show that the predictions of my model based on non-expected utility are consistent with observed, and so far unexplained, empirical evidence of the policy success. Finally, in chapter 4 I investigate by mean of a laboratory experiment the effects of social influence on the individual likelihood to engage in altruistic punishment. I show that bystanders’ decision to engage in punishment is influenced by the punishment behavior of their peers and I suggest ways to enact behavioral policies that exploit this finding.

L’elusione fiscale nell’IVA e l’antielusione nell’esperienza comunitaria e nazionale in Europa

La ricerca oggetto della tesi riguarda la disamina delle esperienze comunitarie e nazionali in Europa in materia di elusione IVA ed antielusione IVA, al fine di esaminare le utilizzabili esperienze in materia per la Cina che dovrebbe iniziare a prendere le giuste azioni per fronteggiare il problema della crescente diffusione dei fenomeni dell’elusione IVA, in particolare nel contesto della riforma perdurante dell’IVA cinese verso il modello moderno. A questo fine, prima la tesi ha analizzato dettagliatamente le seguenti principali questioni sulla base delle esperienze comunitarie e nazionali dei determinati Stati Membri dell’UE: la definizione dell’elusione fiscale generale (a tale proposito, più rilevanti le differenze tra elusione fiscale ed altri relativi concetti come risparmio d’imposta, evasione fiscale e simulazione e la relazione intrinseca tra elusione fiscale ed altri relativi concetti come frode alla legge ed abuso del diritto), la definizione dell’elusione IVA (a tale proposito, più rilevanti gli aspetti di particolare interesse ai fini della definizione dell’elusione IVA), i principi e metodologie dell’elusione IVA, le applicazioni delle varie misure antielusive rivolte all’elusione IVA nell’ordinamento comunitario e negli ordinamenti interni degli alcuni principali Stati Membri dell’UE (a tale proposito, più rilevanti l’applicazone del principio Halifax, quale norma antielusiva generale basata sul principio di divieto dell’abuso del diritto, e la considerazione delle altre soluzioni antielusive applicabili nell’IVA, comprese correzioni normative e clausole antielusive specifiche), gli effetti dell’antielusione IVA e i limiti entro cui l’autorità impositiva può esercitare l’antielusione IVA per la tutela degli interessi legittimi dei soggetti passivi come certezza giuridica ed autonomia contrattuale. Poi, la tesi ha avanzato le proposte relative al perfezionamento delle soluzioni antielusive IVA nell’ordinamento tributario cinese, dopo presentati i principali regimi attuali dell’IVA cinese e analizzate le situazioni attuali realtive all’elusione IVA e all’antielusione IVA nel sistema fiscale cinese.

Il diritto alla detrazione e le frodi Iva

Il presente lavoro parte dalla constatazione che l’Imposta sul valore aggiunto è stata introdotta con lo scopo specifico di tassare il consumo in modo uniforme a livello europeo. La globalizzazione dell’economia con l’abolizione delle frontiere ha tuttavia favorito la nascita non solo di un mercato unico europeo, ma anche di “un mercato unico delle frodi”. L’esistenza di abusi e frodi in ambito Iva risulta doppiamente dannosa per l’Unione europea: tali condotte incidono quantitativamente sull'ammontare delle risorse proprie dell’Unione e sulle entrate fiscali dei singoli Stati membri nonché violano il principio di concorrenza e producono distorsioni nel mercato unico. È in questo contesto che intervengono i giudici nazionali e la Corte di Giustizia, al fine di porre un freno a tali fenomeni patologici. Quest’ultima, chiamata a far rispettare il diritto comunitario, ha sviluppato una misura antifrode e antiabuso consistente nel diniego del diritto alla detrazione qualora lo stesso venga invocato dal soggetto passivo abusivamente o fraudolentemente. Vedremo però che il problema non può essere facilmente ridotto a formule operative: al di là dello schema, fin troppo scontato, dell’operatore apertamente disonesto e degli operatori con esso dichiaratamente correi, rimane il territorio grigio dei soggetti coinvolti, qualche volta inconsapevolmente qualche volta consapevolmente, ma senza concreta partecipazione nella frode da altri orchestrata. Permane a questo punto la domanda se sia coerente - in un sistema impositivo che privilegia i profili oggettivi, prescindendo, salvo gli aspetti sanzionatori, da quelli soggettivi- negare il diritto alla detrazione Iva per asserita consapevolezza di comportamenti fraudolenti altrui o se non vi siano regole più adatte al fine di porre un freno alle frodi e dunque più conformi al principio di proporzionalità.