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.

Determinanti Sociali e Governance della Salute in Zambia: Politiche di Sviluppo ed Empowerment Partecipativo

A 30 anni dalla Dichiarazione di Alma Ata, l'Organizzazione Mondiale della Sanità, sia nei lavori della Commissione sui Determinanti Sociali della Salute che nel corso della sua 62^ Assemblea (2009) ha posto nuovamente la sua attenzione al tema dei determinanti sociali della salute e allo sviluppo di una sanità secondo un approccio "Primary Health Care", in cui la partecipazione ai processi decisionali è uno dei fattori che possono incidere sull'equità in salute tra e nelle nazioni. Dopo una presentazione dei principali elementi e concetti teorici di riferimento della tesi: Determinanti Sociali della Salute, partecipazione ed empowerment partecipativo (Cap. 1 e 2), il lavoro di tesi, a seguito dell'attività di ricerca di campo svolta in Zambia (Lusaka, Kitwe e Ndola) e presso EuropeAid (Bruxelles), si concentra sui processi di sviluppo e riforma del settore sanitario (Cap. 3), sulle politiche di cooperazione internazionale (Cap.4) e sull'azione (spesso sperimentale) della società civile in Zambia, considerando (Cap. 5): le principali criticità e limiti della/alla partecipazione, la presenza di strumenti e strategie specifiche di empowerment partecipativo, le politiche di decentramento e accountability, le buone prassi e proposte emergenti dalla società civile, le linee e i ruoli assunti dai donatori internazionali e dal Governo dello Zambia. Con questa tesi di dottorato si è voluto evidenziare e interpretare sia il dibattito recente rispetto alla partecipazione nel settore sanitario che i diversi e contraddittori gradi di attenzione alla partecipazione delle politiche di sviluppo del settore sanitario e l'emergere delle istanze e pratiche della società civile. Tutto questo incide su spazi e forme di partecipazione alla governance e ai processi decisionali nel settore sanitario, che influenzano a loro volta le politiche e condizioni di equità in salute. La metodologia adottata è stata di tipo qualitativo articolata in osservazione, interviste, analisi bibliografica e documentale.

Decentralization in Nation State Building of Indonesia

Introduction：Today, many countries, regardless of developed or developing, are trying to promote decentralization. According to Manor, as his quoting of Nickson’s argument, decentralization stems from the necessity to strengthen local governments as proxy of civil society to fill the yawning gap between the state and civil society (Manor [1999]: 30). With the end to the Cold War following the collapse of the Soviet Union rendering the cause of the “leadership of the central government to counter communism” meaningless, Manor points out, it has become increasingly difficult to respond flexibly to changes in society under the centralized system. Then, what benefits can be expected from the effectuation of decentralization? Litvack-Ahmad-Bird cited the four points: attainment of allocative efficiency in the face of different local preferences for local public goods; improvement to government competitiveness; realization of good governance; and enhancement of the legitimacy and sustainability of heterogeneous national states (Litvack, Ahmad & Bird [1998]: 5). They all contribute to reducing the economic and social costs of a central government unable to respond to changes in society and enhancing the efficiency of state administration through the delegation of authority to local governments. Why did Indonesia have a go at decentralization? As Maryanov recognizes, reasons for the implementation of decentralization in Indonesia have never been explicitly presented (Maryanov [1958]: 17). But there was strong momentum toward building a democratic state in Indonesia at the time of independence, and as indicated by provisions of Article 18 of the 1945 Constitution, there was the tendency in Indonesia from the beginning to debate decentralization in association with democratization. That said debate about democratization was fairly abstract and the main points are to ease the tensions, quiet the complaints, satisfy the political forces and thus stabilize the process of government (Maryanov [1958]: 26-27). 　　　What triggered decentralization in Indonesia in earnest, of course, was the collapse of the Soeharto regime in May 1998. The Soeharto regime, regarded as the epitome of the centralization of power, became incapable of effectively dealing with problems in administration of the state and development administration. Besides, the post-Soeharto era of “reform (reformasi)” demanded the complete wipeout of the Soeharto image. In contraposition to the centralization of power was decentralization. The Soeharto regime that ruled Indonesia for 32 years was established in 1966 under the banner of “anti-communism.” The end of the Cold War structure in the late 1980s undermined the legitimate reason the centralization of power to counter communism claimed by the Soeharto regime. The factor for decentralization cited by Manor is applicable here. 　　　Decentralization can be interpreted to mean not only the reversal of the centralized system of government due to its inability to respond to changes in society, as Manor points out, but also the participation of local governments in the process of the nation state building through the more positive transfer of power (democratic decentralization) and in the coordinated pursuit with the central government for a new shape of the state. However, it is also true that a variety of problems are gushing out in the process of implementing decentralization in Indonesia. 　　　This paper discusses the relationship between decentralization and the formation of the nation state with the awareness of the problems and issues described above. Section 1 retraces the history of decentralization by examining laws and regulations for local administration and how they were actually implemented or not. Section 2 focuses on the relationships among the central government, local governments, foreign companies and other actors in the play over the distribution of profits from exploitation of natural resources, and examines the process of the ulterior motives of these actors and the amplification of mistrust spawning intense conflicts that, in extreme cases, grew into separation and independence movements. Section 3 considers the merits and demerits at this stage of decentralization implemented since 2001 and shed light on the significance of decentralization in terms of the nation state building. Finally, Section 4 attempts to review decentralization as the “opportunity to learn by doing” for the central and local governments in the process of the nation state building. 　　　In the context of decentralization in Indonesia, deconcentration (dekonsentrasi), decentralization (desentralisasi) and support assignments (tugas pembantuan; medebewind, a Dutch word, was used previously) are defined as follows. Dekonsentrasi means that when the central government puts a local office of its own, or an outpost agency, in charge of implementing its service without delegating the administrative authority over this particular service. The outpost agency carries out the services as instructed by the central government. A head of a local government, when acting for the central government, gets involved in the process of dekonsentrasi. Desentralisasi, meanwhile, occurs when the central government cedes the administrative authority over a particular service to local governments. Under desentralisasi, local governments can undertake the particular service at their own discretion, and the central government, after the delegation of authority, cannot interfere with how local governments handle that service. Tugas pembantuan occur when the central government makes local governments or villages, or local governments make villages, undertake a particular service. In this case, the central government, or local governments, provides funding, equipment and materials necessary, and officials of local governments and villages undertake the service under the supervision and guidance of the central or local governments. Tugas pembantuan are maintained until local governments and villages become capable of undertaking that particular service on their own.

Kenya after the 2007 "post-election violence" : constitutional reform and the National Accord and Reconciliation Act

Immediately after the announcement of the re-election of President Kibaki on the evening of 30 December 2007, Kenya was thrust into the worst civil unrest experienced by the country since independence – a development that became known as the "Post-Election Violence" (PEV). However, after a subsequent process of reconciliation, the PEV came to an end within a relatively short period. The present-day politics of Kenya are being conducted within the framework of a provisional Constitution that took shape through peaceful mediation. How did Kenya manage to put a lid on a period of turmoil that placed the country in unprecedented danger? This paper traces the sequence of events that led to mediation, explains the emergency measures that were needed to maintain law and order, and indicates the remaining problems that still need to be solved.

Improving the competitiveness of the Spanish port system by optimising the cargo handling service

Port services, and in particular the cargo handling service, are responsible for the greatest share of costs incurred during the passage of cargo through a port. The provision of these services reliably and efficiently is crucial in a sector in which there is great opacity. This study has provided the responsible administration ? the Port Authority ? with a tool enabling objective decision making both when it comes to issuing the corresponding licenses and during the period of service provision. Furthermore, we have proposed a series of measures whose application would improve the conditions of service provision and reduce the costs incurred by the passage of cargo through the port.

Uncertainties in the modal estimation from output-only data in civil structures

Cualquier estructura vibra según unas frecuencias propias definidas por sus parámetros modales (frecuencias naturales, amortiguamientos y formas modales). A través de las mediciones de la vibración en puntos clave de la estructura, los parámetros modales pueden ser estimados. En estructuras civiles, es difícil excitar una estructura de manera controlada, por lo tanto, las técnicas que implican la estimación de los parámetros modales sólo registrando su respuesta son de vital importancia para este tipo de estructuras. Esta técnica se conoce como Análisis Modal Operacional (OMA). La técnica del OMA no necesita excitar artificialmente la estructura, atendiendo únicamente a su comportamiento en servicio. La motivación para llevar a cabo pruebas de OMA surge en el campo de la Ingeniería Civil, debido a que excitar artificialmente con éxito grandes estructuras no sólo resulta difícil y costoso, sino que puede incluso dañarse la estructura. Su importancia reside en que el comportamiento global de una estructura está directamente relacionado con sus parámetros modales, y cualquier variación de rigidez, masa o condiciones de apoyo, aunque sean locales, quedan reflejadas en los parámetros modales. Por lo tanto, esta identificación puede integrarse en un sistema de vigilancia de la integridad estructural. La principal dificultad para el uso de los parámetros modales estimados mediante OMA son las incertidumbres asociadas a este proceso de estimación. Existen incertidumbres en el valor de los parámetros modales asociadas al proceso de cálculo (internos) y también asociadas a la influencia de los factores ambientales (externas), como es la temperatura. Este Trabajo Fin de Máster analiza estas dos fuentes de incertidumbre. Es decir, en primer lugar, para una estructura de laboratorio, se estudian y cuantifican las incertidumbres asociadas al programa de OMA utilizado. En segundo lugar, para una estructura en servicio (una pasarela de banda tesa), se estudian tanto el efecto del programa OMA como la influencia del factor ambiental en la estimación de los parámetros modales. Más concretamente, se ha propuesto un método para hacer un seguimiento de las frecuencias naturales de un mismo modo. Este método incluye un modelo de regresión lineal múltiple que permite eliminar la influencia de estos agentes externos. A structure vibrates according to some of its vibration modes, defined by their modal parameters (natural frequencies, damping ratios and modal shapes). Through the measurements of the vibration at key points of the structure, the modal parameters can be estimated. In civil engineering structures, it is difficult to excite structures in a controlled manner, thus, techniques involving output-only modal estimation are of vital importance for these structure. This techniques are known as Operational Modal Analysis (OMA). The OMA technique does not need to excite artificially the structure, this considers its behavior in service only. The motivation for carrying out OMA tests arises in the area of Civil Engineering, because successfully artificially excite large structures is difficult and expensive. It also may even damage the structure. The main goal is that the global behavior of a structure is directly related to their modal parameters, and any variation of stiffness, mass or support conditions, although it is local, is also reflected in the modal parameters. Therefore, this identification may be within a Structural Health Monitoring system. The main difficulty for using the modal parameters estimated by an OMA is the uncertainties associated to this estimation process. Thus, there are uncertainties in the value of the modal parameters associated to the computing process (internal) and the influence of environmental factors (external), such as the temperature. This Master’s Thesis analyzes these two sources of uncertainties. That is, firstly, for a lab structure, the uncertainties associated to the OMA program used are studied and quantified. Secondly, for an in-service structure (a stress-ribbon footbridge), both the effect of the OMA program and the influence of environmental factor on the modal parameters estimation are studied. More concretely, a method to track natural frequencies of the same mode has been proposed. This method includes a multiple linear regression model that allows to remove the influence of these external agents.

New Pact for Europe: Towards a New Pact for Europe. Second report, October 2014

As the new EU leadership takes office, Europe faces a complex web of economic, political, social and global challenges which require new responses – above all, the need to restore the public’s faith and trust after the years of crisis which have prompted growing dissatisfaction with the Union, with many people now seeing it as part of the problem rather than part of the solution to those challenges. In 2012, a consortium of 11 European foundations initiated by the King Baudouin Foundation and Bertelsmann Stiftung, and supported by the European Policy Centre, decided to launch a project to promote a Europe-wide debate on the future of EU integration: an ambitious participatory initiative whose ultimate goal is to develop realistic reform proposals to shore up a Union hit by multiple storms in recent years, which have left many people questioning its capacity to respond effectively to those challenges. Two years later, we are proud to be able to present the outcome of this endeavour: the result of a joint reflection process involving the public, politicians, policy-makers, business leaders, trade unionists, EU experts, opinion-formers and other civil society representatives in many EU Member States. Obviously, not all the ideas and proposals generated by this process could be included in this report, but we hope that it faithfully reflects the feedback we received in all the debates. The discussions we have had led to the report that you now hold in your hands, which calls for a New Pact for Europe – between EU Member States and between the EU and its citizens – to enhance the Union’s capacity to deliver effective solutions to the many challenges facing Europe, and to do so in a way that benefits all EU countries and groups within society. This report is designed to feed into the on-going discussions about the EU’s future as the new leadership team takes charge, providing what we hope will be seen as a valuable contribution to the debate on how to introduce ambitious while at the same time workable and realistic reforms to make the EU more effective in responding to the challenges we face. We hope that it will be taken up for discussion by the new European Parliament, the new leadership of the European Commission, European Council and European External Action Service, and also by policy-makers in the Member States. And it does not by any means mark the end of the process. The report will be discussed again with policy-makers and stakeholders in a majority of Member States. Their feedback is important to us and will impact the future progress of the initiative.

"Creeping" civil war in the North Caucasus. OSW Commentary No. 50, 2011-03-15

Over the last year, the situation in Russia’s North Caucasus has become further destabilised. Attacks and armed clashes happen daily, and destabilisation is spreading to an increasingly large area. The extent of violence in the region is so great that it can already be stated that a de facto civil war is taking place, the warring parties being the Islamic armed underground movement which operates under the banner of the so-called Emirate of the North Caucasus, and the secular governments of the individual republics, who are supported by local and federal branches of the Russian Federation’s Interior Ministry and Federal Security Service. Moscow has no idea how to successfully tackle the Caucasus rebellion. Force has proved to be costly and unproductive, while the attempts made since early 2010 to integrate the region with the rest of Russia by implementing development programmes have not brought the desired results, because of widespread corruption and faint interest from businessmen who are afraid to invest in such an unsafe region. A growing problem for Moscow, particularly for the prestige of the state, is attacks by militants on areas near Sochi, where the 2014 Winter Olympics is to take place. It must be assumed that over the next 3 years before the Olympics, Moscow’s priority in the region will be to ensure the safety of Olympic preparations, and then the games themselves. It cannot be ruled out that the North Caucasus Federal District with its ‘troubled republics’ will be surrounded by a kind of cordon sanitaire (Sochi is situated in the neighbouring Southern Federal District). This could in turn strengthen these republics’ isolation, maintain the state of permanent instability, and postpone the prospects of solving the region’s acute economic and social problems.

The Economics of EU Railway Reform. Bruges European Economic Policy (BEEP) Briefing 8/2004

The EU began railway reform in earnest around the turn of the century. Two ‘railway packages’ have meanwhile been adopted amounting to a series of directives and a third package has been proposed. A range of complementary initiatives has been undertaken or is underway. This BEEP Briefing inspects the main economic aspects of EU rail reform. After highlighting the dramatic loss of market share of rail since the 1960s, the case for reform is argued to rest on three arguments: the need for greater competitiveness of rail, promoting the (market driven) diversion of road haulage to rail as a step towards sustainable mobility in Europe, and an end to the disproportional claims on public budgets of Member States. The core of the paper deals respectively with market failures in rail and in the internal market for rail services; the complex economic issues underlying vertical separation (unbundling) and pricing options; and the methods, potential and problems of introducing competition in rail freight and in passenger services. Market failures in the rail sector are several (natural monopoly, economies of density, safety and asymmetries of information), exacerbated by no less than 7 technical and legal barriers precluding the practical operation of an internal rail market. The EU choice to opt for vertical unbundling (with benefits similar in nature as in other network industries e.g. preventing opaque cross-subsidisation and greater cost revelation) risks the emergence of considerable coordination costs. The adoption of marginal cost pricing is problematic on economic grounds (drawbacks include arbitrary cost allocation rules in the presence of large economies of scope and relatively large common costs; a non-optimal incentive system, holding back the growth of freight services; possibly anti-competitive effects of two-part tariffs). Without further detailed harmonisation, it may also lead to many different systems in Member States, causing even greater distortions. Insofar as freight could develop into a competitive market, a combination of Ramsey pricing (given the incentive for service providers to keep market share) and price ceilings based on stand-alone costs might be superior in terms of competition, market growth and regulatory oversight. The incipient cooperative approach for path coordination and allocation is welcome but likely to be seriously insufficient. The arguments to introduce competition, notably in freight, are valuable and many e.g. optimal cross-border services, quality differentiation as well as general quality improvement, larger scale for cost recovery and a decrease of rent seeking. Nevertheless, it is not correct to argue for the introduction of competition in rail tout court. It depends on the size of the market and on removing a host of barriers; it requires careful PSO definition and costing; also, coordination failures ought to be pre-empted. On the other hand, reform and competition cannot and should not be assessed in a static perspective. Conduct and cost structures will change with reform. Infrastructure and investment in technology are known to generate enormous potential for cost savings, especially when coupled with the EU interoperability programme. All this dynamism may well help to induce entry and further enlarge the (net) welfare gains from EU railway reform. The paper ends with a few pointers for the way forward in EU rail reform.

Patterns of civil society after authoritarianism: a comparison of Portugal and Spain, 1970s-2000s. CES Papers - Open Forum #17, 2013-2014

In this paper we argue that patterns of civil society in post-authoritarian democracies are the result of divergent pathways to democracy. Through a comparison of contemporary Portugal (social revolution) and Spain (reform), we show that revolutionary pathways to democracy have a positive impact on the self-organizing abilities of popular groups, thus also contributing to a higher quality of democracy. There are three mechanisms in social revolutionary processes that contribute to this. The first stems from the fact that the masses are the key actor in the revolutionary transformation process, with the power to shape (at least partially) the new rules and institutions of the emerging democratic regime. This results in greater legal recognition and institutional embeddedness between civil society organizations and the state, making it easier, in turn, for resources to be transferred to those organizations. Secondly, as a result of changes to the social and economic structure, revolutions engender more egalitarian societies. Likewise, citizens are given more resources and capacities for collective action. Finally, revolutions tend to crystalize a political culture between elites and the masses in which the principles of egalitarian participation and social change through the action of the people are accepted. This all leads to greater opportunities, resources and legitimacy for the civic action of the common people during the subsequent democratic regime.

Immigration reform : verifying the status of aliens applying for federal benefits : report to congressional committees /

"B-229066"--P. [1]

Forecasts of passenger traffic of the domestic trunk air carriers, domestic operations, scheduled service, 1965-1975 /

"September 1965."

Civil affairs handbook.

Consists of separtate handbooks for 21 countries, issued in sections.

Study of Civil War sites in the Shenandoah Valley of Virginia : pursuant to Public Law 101-628.

"September 1992."