+?-'
Department of Health and Human Servces

OFFICE OF

INSPECTOR GENERAL

MEDICAL MAPRACTCE INSURACE

AN TH

COMMUN 
HEALTH CENTRS

A MAAGEMNT ADVISORY REPORT 
" 5.RVr('t

Richard P. Kusserow 
INSPECTOR GENERAL 
-l1f"-JIa 
NOVEMBER 1991  OFFCE OF INSPECfOR GENRA

The mission of the Offce of Inspector General (OIG), as mandated by Public Law 95-
452, as 
amended. is to protect the integrity of the Department of Health and Human Servces
' (HHS)
programs as well as the health and welfare of beneficiaries served by those programs. This 
statutory mission is carried out through a nationwide network of audits, investigations. and 
inspections conducted by three OIG operating components: 
the Offce of Audit Servces. the 
Office of Investigations, and the Offce of Evaluation and Inspections. The OIG also informs 
the Secretary of HHS of program. and management problems. and recommends courses to 
correct them. 
OFFCE OF AUDIT SERVICE 
The OIG's Offce of Audit Servces (OAS) provides all auditing servces for HHS, either by
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carryng out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse. and 
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE OF INTIGATIONS 
The OIG's Offce of Investigations (01) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers. The investigative efforts of 01 lead 
to criminal convictions 
administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the 
Medicaid program. 
AN 
OFFICE OF EVALUATION  INSPECIONS 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department. 
the Congress, and the public. The findings and recommendations contained in these inspection 
reports generate rapid, accurate, and up-to-date information on the efficiem.:y. vulnerability.
and effectiveness of departmental programs. 
This report was prepared in the Boston Regional Offce under the direction of Regional
Inspector General Mark R. Yessian, Ph.D.. and Deputy Regional Inspector General \-fartha 
K vaal. Project staff included:

Region I  IIcadquarters 
Dana L. \'iller.  Projecl Leader  \'faruta Zitans 
Timothy J. Corbett  ,, 
Department of Health and Human Servces

OFFICE OF

INSPECTOR GENERAL

MEDICAL MAPRACTCE INSURACE

AN TH

COMMUNITY HEALTH CENTERS

A MAAGEMENT ADVISORY REPORT 
5HV/("ts 
Richard P. Kusserow 
INSPECfOR GENERAL 
.I.-llfi--J1Q 
OEI01-91-01550  INTRODUCTION

PUROSE 
The purpose of this report is to summarize current concerns. and available information 
regarding the costs of medical malpractice insurance at federally funded community and 
migrant health centers. 
BACKGROUN 
This report was prepared in response to a request from Kevin E. Moley, Assistant 
Secretary for Management and Budget, for information on medical malpractice insurance 
costs at community and migrant health centers. 
Five hundred and fifty community and migrant health center grantees receive funding 
through Sections 329 and 330 of the Public Health Servce Act. These centers provide 
primary health servces in medically underserved areas throughout the' country. 
Until the early 1980'  federally employed National Health Servce Corps (NHSC) 
members comprised a significant portion of the centers' medical staffs. As Federal 
employees, members were covered for liability under the Federal Tort Claims Act. 
Budget cuts and policy changes in the NHSC over the past decade have increased centers 
malpractice insurance expenses in two ways. First, the number of 
corps providers 
available for service has been cut considerably. Consequently, centers have been forced 
to hire an increasing percentage of non-corps providers. Second, the Public Health

Servce has required that the majority of remaining corps members be employed directly 
by centers, rather than by the Federal government.  As a result, the cost of medical 
malpractice insurance--for both directly hired corps members and the increased number 
of non-corps providers--has been shifted to the centers. 
At the same time, medical malpractice insurance costs nationwide have risen substantially. 
Premiums for obstetricians, for example, rose by as much as 300 percent between 1982 
and 1987.  In FY 1989, centers spent approximately $50 milion--l0 percent of their total 
Federal grant funding, or 4.4 percent of total revenues--on malpractice insurance 
premiums? Alternative insurance approaches might reduce costs, and thereby result in 
an increase in the amount of funding available for direct services to center clients. 
METHODOLOY 
To gather information for this report, we spoke with staff at several congressional offices 
national and regional primary care associations, Federal agencies, and advocacy groups. 
We reviewed published reports and proposed legislation from these offices, and examined 
data from a recent OIG survey (see appendix A).  FINDINGS

mE COST OF MEDICA MARAcrCE INSURACE PREMIUS LIIT 
SERVICES AT CENTRS. 
The rising cost of medical malpractice insurance--particularly for obstetrical care--has 
been identified as an increasingly serious financial burden, which limits the provision 
of servces at community and migrant health centers. 
In response to a June 
1991 Office of Inspector General survey: 
56 percent of centers cited the high cost of medical malpractice insurance as a 
factor that significantly limits their abilty to provide pregnancy care; 
27 percent of centers indicated that the cost of medical malpractice insurance 
has become a more serious limitation to care since 1988; and 
9 rural centers reported that they have been forced to omit or discontinue 
obstetrical servces entirely because of problems related to malpractice 
insurance. 
Research by the Institute of Medicine supports these findings.s Centers have found 
increasingly difficult to recruit and retain staff, because the limited funds that might 
have been spent on salaries are being spent instead on insurance premiums. Centers 
that contract with providers for care have been unable to meet the rising hourly wages 
that are necessary to support these physicians' personal malpractice insurance 
premiums. Some centers have been unable to obtain coverage at any cost. 
HEAm 
TO DATE, THE PUBLIC  SERVICE HAS NOT ROUINELY COLLECTD 
DATA FROM CENTRS ON mE NUMBER AN DOLLA VALUE OF MEDICA
MARAcrCE CLAS 
AGAINST THEM. 
While the Public Health Service (PHS) has required centers to report data on the 
costs of premiums as part of the annual center grant application process, it has not 
collected information on claims experience. Thus, it has not compiled comprehensive 
data on the centers' claims histories. 
Beginning in fiscal year 1992, the PHS wil require centers to report total claims paid 
in their annual applications. Only current year information will be collected. 
The PHS and the General Accounting Office (GAO) have recently begun a 
comprehensive study of the premiums and claims experience of the centers over the 
past five years. They intend to survey all centers regarding their premiums and claims  histories. A GAO project update on this effort was published in May 1991; a final 
GAO report is expected in spring 1992. 
COLLCT AR 
MOST CENTRS FOR WHICH DATA HAVE BEEN  PAYING 
DISPROPORTIONATELY HIGH MEDICA MARAcrCE INSURCE 
PREIUS. 
Data from those centers that have been studied indicate that successful medical 
malpractice claims against them represent roughly 10 percent of the costs of premiums 
paid. By contrast, medical malpractice claims paid on behalf of all providers 
nationally represent 56 percent of premiums paid.  Exlanations for the smaller 
amount paid on behalf of center providers might include: 
a smaller average number of claims brought against center providers than 
7 and/or 
against non-center providers; 
a lower average amount paid in 
successful claims against center providers. 
Current estimates of the number and dollar value of center claims are based, however 
on limited information. In the past five years, several studies have attempted to 
collect claims data (see appendix B). These studies are limited by small sample sizes 
low response rates, and limited 
focus. Their findings are outlined below. 
Seera 
regional priar cae asocations have conducted studies during the past 
year. Although limited in geographic scope, these provide the most recent and most 
comprehensive data currently available on centers' premiums and claims histories. All 
of these studies have demonstrated that centers have paid high premiums relative 
both the low number of claims fied against them and the 
small size of successful 
claims paid. 
The Northwest Regional 
Priar Cae  ation reported in July 1991 
survey responses from 28 of the 31 community and migrant health centers in 
Alaska, Oregon, Idaho, and Washington. Between 1988 and 1990, $4 milion 
was spent on malpractice insurance premiums. Four claims had been paid in 
the total amount of $15 000, against initial claims of $55 000. Four claims were 
stil pending for $215 500. If all pending claims were ultimately paid in full 
total claims paid would represent 6 percent of annual premiums. 
The Virgia Priar Cae Asocation has reported that the 17 centers in that 
state have paid approximately $1.1 milion in professional liability premiums 
over the past 7 years. Four claims have been filed during that time, and none 
has been paid. 
The Asocation for Utah Community Heath has reported that the  -5 . 
5 community health centers in that state have spent approximately $100 00 on 
malpractice insurance premiums in 1991. No claims have ever been paid, and 
no claims are pending.

Astion 
The Rhode Island Heath Center  has reported that the 
4 community health centers in that state have spent $351 00 on malpractice 
premiums in 1991. In their entire history, the centers have paid less than 
$25 00 in claims. If the $25 000 had been paid in 1991, it would represent 
7 percent of annual premiums. No claims are pending. 
Astion 
The Conneccut Prar Cae  has reported that 10 of the 
14 centers in that state responded to a recent survey. These have paid 
$590,00 in premiums in 1991. In the history of the centers, only 5 claims have 
00. 
ever been fied; only one of these was paid, in the amount of $35  This 
claim represents 6 percent of 1991 premiums. 
Asation 
The National  of Community Heath Centers released two reports in the 
mid-1980's on its members' medical malpractice premiums and claims experience. 
The data they present are both limited and dated. 
The Medical Malpractice Claims Experience of Community and Migrant Health Centers 
A Comparative  was released in 1986. This report was based on responses from 
Stuy, 
41 percent of all centers to a survey on claims experience, and responses from 
32 percent of all centers to a survey on risk management/access to coverage. 
A total of 95 claims had been brought against 67 (26 percent) of the 
respondents during their entire operating histories. Of the 
resolved cases 
46 percent had been found for the plaintiff. No dollar amounts for the claims 
paid were provided. 
The study compared the rate of claims against center physicians, by specialty, to 
national averages obtained from physician organizations. The data suggested 
that claims were fied against center providers less frequently than against non-
center providers.

prepared by Tilinghast, an independent actuarial 
Risk Financing Alternatives Study, 

consultant, was released in 1987. This report was based on survey responses from 
18 percent of all centers. 
In 1986, responding centers paid $3.5 milion in professional liability premiums; 
their paid claims amounted to $71 000 (approximately 2 percent of premiums). 
The study concluded that this ratio of claims to premiums was far lower than 
the industry average.
 The Heath Resurce and Servce  Administrtion (HRSA) published  Claims of 
Medical Injur, Filed under the Federal 
Tort Claims Act against the Indian Health Service 
and the National Health Service Corps 1986, in 1987. This 
, between FY 1980 and FY 
study reviewed combined data on the claims against federally employed providers in 
both community health center and Indian Health Servce settings. These data were 
available because these providers were covered for malpractice liabilty under the 
Federal Tort Claims Act. This study did not examine the claims histories of non-
federally employed community health center providers. 
The report found that 374 claims had been brought against federally employed 
providers in both settings during the 7 year period. Of these, 12 percent had 
been approved and paid; 72 percent had been denied.  Suits had resulted 
from 59 percent of the denied claims. Fort-one percent of the suits were 
either settled or found for the plaintiff. 
Recorded payments for claims and suits totaled $6.8 milion. The report did 
not offer any comparative or contextual background for understanding the 
significance of this sum. 
David Smith Donna Denno, and Dana Hughes of the Bureau of Heath Cae 
Deliery and Asistace; and Saa Rosnbaum of the Chdren s Defens Fund have 
Community-Based Experience with the Federal Tort 
produced a draft report entitled 

Claims Act and Malpractice. 
 This report presents a comparative analysis of the FY 
1980-1986 data from the HRSA report on NHSC and IHS physician claims data; 1985 
data from the American Medical Association on private physician premiums and 
claims; and data from a GAO report on the costs of private sector medical 
malpractice claims closed in 1984.

The report estimates that the cost of commercial insurance for these federally 
employed providers would have been between five and ten times greater than 
was the cost incurred by covering them under the Federal Tort Claims Act. 
The Intitute of Medicie (10M) published "Obstetrical Care for Low-Income 
Women: The Effects of Medical Malpractice on Community Health Centers " as part 
of  Medical Professional Liabilty and the Delivery of Obstetrcal Care  in 1989. This 
report was based on a survey of approximately 10 percent of all centers. 
Fourteen percent of the respondents reported that claims had been filed 
against them at some point in their operating histories. No information was 
provided on either the number of claim 
paid or pending, or the dollar values 
of claims.

The report concluded that medical malpractice costs 
adversely affected centers 
provision of obstetrical services.  These studies consistently indicate that responding centers have paid high malpractice 
premiums, that they have had few claims against them, and that the monetary values 
of these claims have been relatively small. 
The data these studies present, however, may not be representative of premiums and 
claims experiences at all centers. The insurance industry requires comprehensive 
national data as a basis for setting premiums. 
ALTERNTI 
THREE  APPROACHES TO INSURING CENTR PROVIERS 
BEING PURUE. 
Coverage under a risk-purchase group policy 
Establishment of a risk-retention group to self-insure 
Exanded coverage under the Federal Tort Claims Act (flCA) 
COVEGE UNER A RISK-PURCHE GROUP POUCY: 
Centers would band together to obta coerage at reduce rates from 
commercial inurers.

The National Association of Community Health Centers (NACHC) established a risk-
purchase group, open to all centers nationally. This group has encountered several 
difficulties: No carriers will provide obstetrical coverage, premium reductions have 
been smaller than expected, and participation has required an increase in 
administrative work for the centers. Partially as a result of these limitations, few 
centers have participated. 
The Virginia Primary Care Association also established a risk-purchase group for the 
17 centers in that state in 1984. The Virginia group reports that its insurance carrier 
8 percent group premium discount, which saved the participating centers 
granted a 10.
$15 412 in 1991. 
ESTABLISHMNT OF A RISK-RENTON GROUP TO SELF-INSUR: 
Centers would self-inure by developing a capita  out of which succful 
clai. agait 
liabilty  the centers and their provders would be 
pad. 
Two self-insurance proposals have been introduced during the 101st Congress. 
One bil would establish a federally capitalized and administered risk retention group 
for the community and migrant health centers (S. 815, introduced by Senator Hank 
Brown (R-CO)). This pool would be capitalized at $80 milion through the transfer of 
funds from the centers' Federal grant appropriations. Each center s contribution to  the capital pool would be based upon its risk exposure 
(including the numbers of
patients served , and tyes of care provided). 
, tyes of providers
The Public Health Servce would be required to review the pool at least once every 
two years. If claims payments were lower than expected, the excess funds would be 
returned to the centers as a supplement to their annual grant awards. If claims 
payments were high, and inadequate funds remained to cover potential claims 
additional sums would be transferred to the pool from the centers' grant
appropriations. 
Afer five years, three independent evaluations of the fund and the centers' claims 
history would be made. If claims continued to be as low as anticipated, then the 
amount of capital in the fund would be reduced, and the excess sum would be 
returned to the centers as part of their grant appropriation. 
A second bil calls upon the centers to form an independent national risk-retention 
group to provide professional liabilty coverage (S. 489; H.R. 1004, introduced by 
Senator Orrn Hatch and Representative Nancy Johnson)P Funds would be 
appropriated to establish this risk-retention group. If independent insurance experts 
determined that the operation of the group would result in an increase in the amount 
of funds available for use by the centers, then the Department of Health and Human 
Servces would capitalize the group. 
Advocates of self insurance argue that, by holding centers responsible for their 
, this approach gives centers a financial incentive to maintain the 
malpractice claims
quality of their care. Further, it is anticipated that self-insurance would result in a 
substantial cost savings to the centers.

Centers have long claimed that a self-insurance program is not feasible because they 
cannot afford to capitalize the pool, and have been prohibited from using Federal 
grant funds for capitalization purposes. 
CLS 
EXPANED COVERAGE UNER TH FEDERA TORT  ACf: 
ca 
In  medica provders offerig servces at federa fuded 
of litigation,  all 
communty and migrant heath centers would be treated as Federa employees. 
clai 
They would be defended by the Deparent of Justice, and  would be 
paid out of the U.S. Treasury. 
A bil to this effect has been introduced in the House (H.R. 2239, the Federally 
, sponsored by Representative 
Assisted Health Clinics Legal Protection Act of 1991
Ron Wyden (D-OR )). 
Supporters contend that tort reform represents a return to the original program policy, 
under which a large percentage of center providers were federally employed National  Health Servce Corps members, and thereby covered by the Federal Tort Claims Act. 
They further argue that, if the numbers and amounts of 
claims are as low as 
anticipated, tort reform would create a significant cost savings, not merely a cost shift. 
Federal tort reform is the preferred option of the National Association of Community
I4 and has been supported by the Children 
Health Centers
 s Defense Fund and the
Institute of Medicine. 
Others have described tort reform as a poor strategy for both risk management and 
quality assurance. By shifting liabilty away from the centers, the measure would 
remove the centers' economic incentive to ensure quality of care. It is also argued 
that the data presently available are inadequate to demonstrate the need fore-or 
economy of--this proposed reform in tort liabilty coverage. 
The Deparment of Justice maintains that the Federal Government cannot accept 
liabilty for the actions of individuals who are not Federal employees and therefore are
16 There are further concerns that this
not subject to direct Federal supervision.

move would set a precedent whereby other Federal grant recipients might seek 
Federal coverage for their employees. 
Congressional staffers have suggested that this plan is not in the best interests of 
either community health center providers or patients. Providers would object to being 
defended by assigned Justice Department attorneys, who might lack expertise in 
malpractice issues. Community health center patients who have suffered legitimate 
injury might be intimidated by the prospect of suing the Federal Government for 
damages.  APPENDIX A

MEODOLOY

To gather information for this report, we spoke with representatives of the following 
offces and organizations: Senator Hank Brown (R-CO); Senator Tom Harkin (D-IA);
Senator Orrn Hatch (R-UT); Senator Edward Kennedy (D-MA); Representative 
Barney Frank (D-MA); Representative Nancy Johnson (R-Cf); Representative Ron 
Wyden (D-OR); Minority Counsel, House Energy and Commerce Committee; the 
General Accounting Offce; the U.S. Department of Justice; the Bureau of Health 
Care Delivery and Assistance; the National Association of Community Health Centers; 
the New England Community Health Center Association; the Northwest Regional 
Primary Care Association; the Connecticut Primary Care Association; the Rhode 
Island Primary Care Association; the Utah Primary Care 
Association; the Virginia 
Primary Care Association; the American Insurance Association; and the Children 
Defense Fund. We reviewed published reports and proposed legislation from these 
offices. 
We also reviewed preliminary results of a June 1991 survey of all 330-
grant recipients 
that was conducted as part of the Offce of Inspector General study: "The Perinatal 
Servce Capacity of the Community Health Centers" (OEI-Ol-90-02330). We received 
an 84 percent response rate, representing centers in every HHS region, and in every
state and territory in which the Public Health Servce funds centers, with the 
exceptions of the District of Columbia and the U.S. Virgin Islands. Two OIG 
inspection reports on perinatal services at urban and rural centers are forthcoming in 
winter 1991-92.  APPENDIX 
PRE 
RERTS ON MEICAL MARACfCE  AN 
COMM HETI 
EXERICE 
AT 
The Medical Malpractice Claims Experience of Community and Migrant Health Centers:

A Comparative StUy

National Association of Community and Migrant Health Centers, Washington, D.

February 1986.

Claims of Medical Injury, Filed under the Federal Tort Claims Act against the Indian 
, between FY 1980 and FY 1986 
Health Service and the National Health Service Corps
Health Resources and Servces Administration, Rockvlle, MD, February 1987. 
Rik Financing Alternatives StUy

National Association of Community and Migrant Health Centers, Washington, D.

June 1, 1987.

Obstetrical Care for Low-Income Women: The Effects of Medical Malpractice on 
Community Health Centers  Medical Professional Liabilty and the Delivery of 
" in 
Obstetrcal Care 
Dana Hughes, Sara Rosenbaum, David Smith, and Cynthia Fader 
Institute of Medicine, Washington, D. 
, 1989. 
Report on Malpractice

Rhode Island Health Center Association, March 1989. 
Review of Legal Resolution Mechanisms for Claims against State and Local Public 
Employees

Children s Defense Fund, Washington, D.  , July 1989.

Statement on Statewide Malpractice Insurance Policy 
Virginia Primary Care Association
, 1991. 
Statement on Utah Community Health Center Malpractice Infonnation 
Association for Utah Community Health
, 1991. 
The Malpractice Insurance Question for the Community Health 
Cellers of Connecticut 
Robert S. Burke, available from the Connecticut Primary Care Association, May 1991. 
Medical Malpractice: Data on Claims Needed to Evaluate Health Cellers  I11UrallCe 
(HRD-91-98) 
Alternatives 
S. General Accounting Office, May 1991.  Statement of Thomas Trompeter, Executive Director, Northwest Regional Prmary Care 
Association, before the House Judiciary Subcommittee on Administrative Law and 
Governmental Relations 
July 17, 1991.

Community-Based Experience with the Federal Tort Claims Act and Malpractice (Draft) 
David Smith, Donna Denno, Dana Hughes, Bureau of Health Care Delivery and 
Assistance; Sara Rosenbaum, Children s Defense Fund  APPENDIX 
NOTE 
1. The average annual field strength of federally employed corps providers fell from 
Claims of Medical Injury, Filed under the Federal Tort 
696 in 1980 to 412 in 1986. 

Claims Act against the Indian Health Service and the National Health Service Corps, 
1986; Health Resources and Servces Administration 
between FY 1980 and FY 
(HRSA), p. 43. A small percentage of corps providers are stil employed, paid, and 
insured by the Federal government because of special circumstances. These include 
the providers' original employment status , and specific center difficulties in provider 
recruitment. 
2. National Association of Community Health Centers  Mothers, Infants, and 
Community and Migrant Health Centers  1989; p. 9. 
3. General Accounting Office Medical Malpractice: Data on Claims Needed to 
Evaluate Health Centers' Insurance Alternatives 
 (HRD-91-98), May 1991, p. 1. 
4. Survey of Perinatal Services Office of Inspector General, June 1991. 
Significant" responses are a combination of "Moderate" and "Substantial" responses. 
Numbers indicate the percentage of responding Section 330 grantees. Ten urban and 
45 rural centers reported that they have discontinued or omitted obstetrical servces 
for other reasons. 
5. 
Institute of Medicine  Medical Professional Liabilty and the Delivery of Obstetrical 
Care, 1989. 
6. This is the averagAe adjussteds losos ratcio foir aall mtediicoal mnalpra.ct ice carriers for 1990. 
Best s Insurance Management Reports " A.M. Best Company; obtained through the 
American Insurance 
7. Although insurance companies view community health center patients as medically 
high risk, these clients may in fact be less likely than private-practice patients to bring 
suit in case of injury. The 1987 HRSA report notes that "the socio-economic and 
educational levels of patients served by community health centers. . . may constitute 
barriers to awareness that the care provided or the outcome achieved does not meet 
acceptable medical standards. Reduced access to alternative sources of care may also 
mitigate against aggressive redress of injury." Moreover, strict Federal risk-
management and community involvement requirements may promote more positive 
patient-doctor relationships. "The sense of community ownership," one study noted 
has made suits less likely" (Robert S. Burke  The Malpractice Insurance Question for 
the Community Health Centers of Connecticut  1991, p. 20). 
C - formed a risk purchase group in 
8. All 17 centers in Virginia  1984 to obtain insurance 
at reduced rates (see p. 7 of this report). 
9. Tilinghast recommended that the National Association of Community Health 
Centers establish an insurance risk-purchasing group, and that it evaluate the 
feasibilty of establishing an insurance risk-retention group at some future point. 
10. In the remaining 16 percent of cases, either the claim was stil pending or no 
record of the claim could be found. 
11. The authors recommended extension of coverage under the Federal Tort Claims 
Act to all center obstetrical health care providers (not only federally employed 
National Health Servce Corps members). 
12. Senator Hatch's and Senator Kennedy s offces have discussed plans for legislation 
that would build upon the current Hatch and Brown bils. 
13. Representative Nancy Johnson (R-Cf) has introduced a similar bil (H.R. 1565). 
14. Daniel Hawkins, Director of Policy Analysis, NACHC; Letter to Congressman 
Ron Wyden, April 26, 1991. 
15. Sara Rosenbaum, Director, Health Division, Children s Defense Fund; Testimony 
before the U.S. House Small Business Subcommittee on Regulation, Business 
Opportunities, and Energy, October 12, 1989. The Children s Defense Fund has 
conducted a survey of 33 State policies regarding the liabilty of State-employed 
medical providers. Thirty-one of the 33 States cover State-employed medical 
providers under their respective State tort claims acts. 
16. Stuart Gerson, Assistant Attorney General, U.S. Department of Justice, Civil 
Division, Testimony before the U.S. House Judiciary Subcommittee on Administrative 
Law and Governmental Relations, July 17
, 1991. 
C - 2