malpractice suit. The cap may apply to the plaintiff, limiting the amount she may receive, or to each defendant, limiting the total amount for which each may be liable. Pretrial screening panels Panel reviews a malpractice case at an early stage and provide an opinion about whether a claim has sufficient merit to proceed to trial. Typically, a negative opinion does not bar a case from going forward, but can be introduced by the defendant as evidence at the trial. Certificate of merit requirements Requires a plaintiff to present, at the time of filing the claim or soon thereafter, an affidavit certifying that a qualified medical expert believes that there is a reasonable and meritorious cause for the suit. Attorney fee limits Limits the amount of a malpractice award that a plaintiff’s attorney may take in a contingent-fee arrangement. The limitation is typically expressed as a percentage of the award; it may also incorporate a maximum dollar value. Joint-and-several liability reform In cases involving more than one defendant, such as a physician and a hospital, this reform limits the financial liability of each defendant to the percentage fault that the jury allocates to that defendant. Without this reform, the plaintiff may collect the entire amount of the judgment from one defendant if the other(s) default on their obligation to pay, even if the paying defendant bore only a small share of the responsibility for what happened to the plaintiff. Collateral-source rule reform Eliminates a traditional rule that if an injured plaintiff receives compensation for her injury from other sources, such as health insurance, that payment should not be deducted from the amount that a defendant who is found liable for that injury must pay. Periodic payment Allows or requires insurers to pay out malpractice awards over a long period of time, rather than in a lump sum. This enables insurers to purchase annuities (sometimes called “structured settlements”) from other insurance companies which cost less than paying the whole award up front. Insurers are also able to retain any amounts that the plaintiff does not actually collect during her lifespan. Statutes of limitations/repose Limits the amount of time a patient has to file a malpractice claim. Statutes of limitations bar lawsuits unless they are filed within a specified time after the injury occurs or is discovered. Statutes of repose bar lawsuits unless they are filed within a specified time after the medical encounter occurred, regardless of whether an injury has yet been discovered. 11 Innovative Reforms Reforms that are relatively new in use, or have had limited or no implementation, in the U.S. “Health courts” Medical court model: A model of a “health court” that replaces a lay judge and fact finder (either a judge or jury) with a judge and fact finder who has both medical and legal training. Administrative model: A more commonly proposed “health court” model today that routes medical injury claims into an alternative, typically administrative, adjudication process that can include a combination of specialized judges, decision and damages guidelines, neutral experts, and a compensation standard that is broader than the negligence standard. Communication-and-resolution programs (sometimes termed disclosure, apology, and offer programs) Institutional programs that support clinicians in discussing unanticipated care outcomes (and their causes) with patients and families and in taking rapid steps towards resolution, including proactively offering compensation when appropriate. Safe harbors for adherence to evidence-based practice guidelines Provide legal protection against medical malpractice claims if a defendant healthcare provider can show that an applicable and approved clinical practice guideline was followed in the care in question Mandatory pre-suit notification laws Require plaintiffs to provide advance notice (typically ranging 1 to 6 months) to a physician or healthcare organization of their intent to sue. Apology laws Protect providers from having apologies or expressions of sympathy (and sometimes admissions of responsibility) made after an adverse event from being admitted into evidence in a lawsuit. The protection can be sometimes lost if contradictory statements are later made. State-facilitated alternate dispute resolution The state provides an agency or other body that can receive reports of potential errors or adverse events from patients or providers. The state then helps the parties come to resolution through a confidential mediation process. Judge-directed negotiation Malpractice litigants are required to meet early and often with the presiding judge to discuss settlement. Litigants must appear with knowledge of the case and full authority to settle. A single judge retains responsibility for the case over its entire lifecycle and takes an unusually active role in mediating negotiations. A neutral attorney (hired by the court system) with clinical training supports the judge in understanding clinical matters. Our evaluation is based on existing empirical studies of state tort reforms, including several literature reviews and syntheses by recognized experts in the field; 1-8 case studies and anecdotal reports of particular federal, state and institutional programs; legal scholarship on the structure and theoretical basis of reforms; and, where no evidence is available, our own judgments. In synthesizing extant empirical research, we do not include