In Utah, traditional tort reforms such as caps on noneconomic damages, limits on attorney contingency fees, and the collateral source rule have been in place for several years. Although these reforms have successfully added some predictability to an otherwise arbitrary liability system, they have not eliminated the existing system's inherent flaws. Consequently, Utah physicians have a great interest in examining entirely new methods of compensation for patient injuries.

With the Utah Medical Association taking the lead, a broad-based Utah coalition was formed to develop and test a new system. The coalition, the Utah Alliance for Health Care, comprises medical, hospital, business, labor, and other consumer organizations. The Alliance has agreed that the new system will operate from a group of hospitals and integrated managed care entities across the state that will be designated as project sites.

We call our plan EPIC, which stands for Experiment in Patient Injury Compensation. Under EPIC, an injured patient would not have to prove negligence to receive compensation. Instead, an injury would be compensable if the harm was an avoidable consequence of the medical care the patient received. The patient would file a claim with a claims adjuster established at the site, who would determine whether the injury was compensable and would propose an award that is based on predetermined policies. A patient who is dissatisfied with the adjuster's decision could appeal to a medical panel and ultimately to an administrative agency within the Utah Department of Commerce.

If the claim is approved, benefits would be available immediately. Payments would cover expenses incurred for treatment or rehabilitation of any iatrogenic injury that meets the compensation standard. Payments would provide compensation for lost wages, loss of enjoyment of life, and pain and suffering. However, unlike in the current system, payments would not be open-ended but rather would be limited to those not covered by other sources of insurance. Schedules and caps on pain and suffering awards would also be established, and punitive damages would be eliminated.

In addition to its no-fault component, EPIC would use an enterprise liability model for adjudicating payments for injuries by making the project sites responsible for payment. The site would resolve all claims for injuries that occurred within the site or in a participating physician's office. Apportionment of the payment between the hospital and the physician would occur behind the scenes. Both hospitals and physicians would continue to carry liability insurance.

Because hospitals and other entities will be responsible for resolving disputes, methods for injury detection and prevention should improve. As the payment entities, the project sites will have incentives to develop system-wide quality-assurance programs. These approaches will probably be more effective than existing methods because the sites will be able to identify risks and study patient injury from an epidemiologic perspective. These approaches will also coincide with the "continuous quality improvement" programs that have been undertaken by many health plans and hospitals.

Before this plan is implemented, data on the current system must be gathered. Using the research method with which patient injury and compensation were studied in New York a few years ago [2-4], we will determine the comparable rates for patients in Utah. Once collected, this information will be used to measure the success or failure of EPIC.

We believe that EPIC will be a dramatic improvement over the existing system. The current system spends $0.60 of every premium dollar on administrative costs, primarily for attorney fees, and it often requires several years to resolve disputes. In contrast, EPIC will compensate injured persons more quickly and fairly. By removing the burden of proving fault, EPIC will be more efficient and less time-consuming for patients and providers.

A frequent criticism of no-fault plans is that they will be too expensive. We believe, however, that sufficient limits are in place to ensure that this will not happen. It is important to remember that because the plan's projected overhead is 30% of the total budget rather than 60%, nearly twice as much money will be available to pay patient claims than is currently available under the fault-based system.

Finally, as the College recognizes in its position paper, plans such as EPIC will be a boost for physicians because they will relieve physicians of the tremendous burden the current liability system imposes. Because the threat of litigation and its personal nature will be removed, the physician-patient relationship should improve. As the feelings of mistrust that have crept into our relationships with patients fade, so should the incentives to practice defensive medicine. Thus, health system costs should be reduced.

Completion of the Utah project will take several years, and the plan faces many obstacles. However, devising a strategy to restructure the tort system is an important and worthwhile task. Like the College, we recognize that traditional notions of liability increasingly do not fit a health system that is characterized by integration of professionals and institutions and by decision making that is influenced by clinical, organizational, and economic factors.

Although not every alternative will work in all states, we are confident that what we learn in Utah will help others across the United States develop their own solutions. Our plan will provide a solid foundation for substantial change in the liability system.