-

The extent and existence of "defensive medicine" -- excessive medical care to defend a physician against malpractice claims -- is a perennial subject of both policy and academic debate.  For example, malpractice liability and associated defensive medicine are among the most-cited reasons for escalating health-care spending in the United States.

In this colloquium, Dr. Brian Chen will present results from his research investigating the extent of defensive medicine in Taiwan. He studies the impact of a series of court rulings in Taiwan that increased physicians’ liability risks, and a subsequent amendment to the law that reversed the courts’ rulings, on physicians’ test-ordering behavior and propensity to perform Caesarean sections.  He finds that physicians faced with higher malpractice pressure increased laboratory tests as expected, but unexpectedly reduced Caesarean sections.  (The reduction in Caesarean deliveries may be due to the fact that liability risks were more closely aligned with physicians’ standard of care after the court rulings.) After the law was amended to negate the court decisions, physicians reversed their previous behavior by reducing laboratory tests and increasing Caesarean deliveries.

This pattern of behavior is highly suggestive of the existence of defensive medicine among physicians in Taiwan. In other words, by studying physicians' response to legal changes in Taiwan, we find that greater malpractice liability may, under certain circumstances, prompt physicians to perform more services without necessarily improving patient health.

Dr. Brian Chen recently completed his Ph.D. in Business Administration in the Business and Public Policy Group at the Haas School of Business, University of California at Berkeley. He received a Juris Doctor from Stanford Law School in 1997, and graduated summa cum laude from Harvard College in 1992.

Philippines Conference Room

Shorenstein APARC
Stanford University
Encina Hall, Room E-301
Stanford, CA 94305-6055

(650) 736-0771 (650) 723-6530
0
2011 AHPP/CEAS Visiting Scholar
IMG_5703.JPG JD, PhD

Dr. Brian Chen is currently a visiting scholar with the Asia Health Policy Program and Center for East Asian Studies at Stanford University. He was recently Shorenstein Asia-Pacific Research Center's 2009-2010 postdoctoral fellow in Comparative Health Policy. As a visiting scholar, Dr. Chen will conduct collaborative research about health of the elderly and chronic disease in China.

As an applied economist, Chen’s research focuses on the impact of incentives in health care organizations on provider and patient behavior. For his dissertation, Chen empirically examined how vertical integration and prohibition against self-referrals affected physician prescribing behavior. His job market paper was selected for presentation at the American Law and Economics Association’s Annual Meeting, the Academy of Management, the Canadian Law and Economics Association, the Conference on Empirical Legal Studies, and the First Annual Conference on Empirical Health Law and Policy at Georgetown Law Center in 2009.  The paper was also nominated for best paper based on a dissertation at the Academy of Management.

Chen comes to the Shorenstein Asia-Pacific Research Center not only with a multidisciplinary law and economics background, but also with an international perspective from having lived and worked in Taiwan, Japan, and France. He has a particularly intimate knowledge of the Taiwanese health care system from his experience as an assistant to the hospital administrator at a medical college in Taiwan.

During his past residence as a postdoctoral fellow with the Asia Health Policy Program, Chen conducted empirical research on cost containment policies in Taiwan and Japan and how those policies impacted provider behavior. His work also contributed to the program’s research activities on comparative health systems and health service delivery in the Asia-Pacific, a theme that encompasses the historical evolution of health policies; the role of the private sector and public-private partnerships; payment incentives and their impact on patients and providers; organizational innovation, contracting, and soft budget constraints; and chronic disease management and service coordination for aging populations.

Dr. Brian Chen recently completed his Ph.D. in Business Administration in the Business and Public Policy Group at the Haas School of Business, University of California at Berkeley. He received a Juris Doctor from Stanford Law School in 1997, and graduated summa cum laude from Harvard College in 1992.

Brian Chen Shorenstein-Spogli Fellow in Comparative Health Policy Speaker
Seminars
News Type
News
Date
Paragraphs

On May 10-11, 2010 the Program on Arab Reform and Democracy at CDDRL held its inaugural international conference. In line with the Arab Reform Program’s vision, the conference featured internationally renowned scholars, activists, and practitioners from the Arab world, Europe, and the United States.

Over the two days, conference participants engaged in multidisciplinary debates addressing hard politics as well as soft politics, and analyzing political reform from different angles, with panels on the economy, state systems, the media, civil society, political opposition, youth politics, and the role of international actors. Problems facing political reform in the Arab world today were discussed and scrutinized, as were possible paths forward. The conference debates unearthed the need for a deep understanding of the problems facing political reform in region that is driven by an analysis of long-term and often ignored issues that are at the core of political developments. The debates also highlighted that problems and prospects for reform are different in each Arab country because each country has its own unique set of issues and because within each country different ethnic groups, classes, and locales have different takes on and stakes in political developments. The conference closed with a speech by Dr. Saad Eddin Ibrahim.

All News button
1

On May 10-11, 2010 the Program on Good Governance and Political Reform in the Arab World at CDDRL held its international inaugural conference. In line with the Arab Reform Program's vision, the conference featured internationally renowned scholars, activists, and practitioners from the Arab world, Europe and the United States. Over the two days, conference participants engaged in multidisciplinary debates addressing hard politics as well as soft politics, and analyzing political reform from different angles, with panels on the economy, state systems, the media, civil society, political opposition, youth politics, and the role of international actors. Problems facing political reform in the Arab world today were discussed and scrutinized, as were possible paths forward. The conference debates unearthed the need for a deep understanding of the problems facing political reform in the region that is driven by an analysis of long-term and often ignored issues that are at the core of political developments. The debates also highlighted that problems and prospects for reform are different in each Arab country because each country has its own unique set of issues and because within each country different ethnic groups, classes, and locales have different takes on and stakes in political developments. The conference closed with a speech by Dr. Saad Eddin Ibrahim.

Bechtel Conference Center

Conferences

Discourse on American public diplomacy has been traditionally focused on use of the broadcast media by the US government, such as Voice of America, to reach out to audiences in the Middle East and other regions. For example, much has been written about initiatives such as Radio Sawa and Al-Hurra television, and their struggles to gain credibility among Arab audiences.

News Type
News
Date
Paragraphs
In a recently published book (One Alliance, Two Lenses: U.S.-Korea Relations in a New Era) based on analysis of newly collected data from major American and Korean newspapers, Gi-Wook Shin, director of the Asia-Pacific Research Center, argues that U.S.-ROK relations, linked to the issue of national identity for Koreans, are largely treated as a matter of policy for Americans -- a difference stemming from each nation's relative power and role in the international system.
All News button
1
News Type
News
Date
Paragraphs

On February 17, 2010 the Program on Good Governance and Political Reform in the Arab World at CDDRL held its inaugural seminar with Prof. Philippe C. Schmitter, Professor Emeritus, European University Institute, Florence and Visiting Scholar at CDDRL and Dr. Sean Yom, Hewlett Postdoctoral Fellow at CDDRL.

The seminar was titled Exploring the missing link between liberalization and democratization in the Middle East. The seminar aimed to start a public discussion on one of the routine assumptions of students of democratization, which is that there is a close, causal relationship between liberalization and democratization. The former is said to drive those who concede it toward convoking credible elections and, eventually, tolerating ruler accountability to citizens. The link between those processes of regime transformation is alleged to be the mobilization of civil society. It has been argued that the weakness or absence of this linkage is one (among many) of the conditions which make the polities of the Middle East and North Africa resistant to democratization.

In his response to this argument, Philippe Schmitter began by saying that in the work that he started on Southern Europe and Latin America, there was a distinction between democratization and liberalization. Once an autocratic regime enters a process of liberalization, it faces unexpected consequences. Thus, the most vulnerable time for a regime is when it starts to reform itself. Some of the consequences of this process are the resurrection of civil society, more freedom of expression and movement, the release of political prisoners and the freer operation of political parties. Such consequences are what liberalization means.

Schmitter argued that all autocratic regimes have tried this process, and that this process is normally triggered by divisions within the regimes or succession struggles, where regimes feel the need to open up. The kind of liberalization that takes place depends on the type of autocracy present. But the objective of liberalization, Schmitter said, is to coopt and produce a large social basis for autocracy, for example, through cultivating political parties that agree not to be too oppositional.

Schmitter added that many autocracies are under pressure from external regimes. Most of the countries in the Middle East have some kind of agreement with the EU for example, which carries clauses on issues like the rule of law. Another factor is that liberalization is selective in its inclusion, focusing on the urban middle class. It is thus "voluntary", conceded from above by the regime, and not based on any form of mobilization from below. In other words, Schmitter argued that regimes choose to liberalize and are not forced to do so. Thus, regimes are limited in their scope of liberalization (elections for example are not always genuinely free). He then presented a scale of measures of autocracy liberalization, saying that the most difficult measure in the Middle East is that of releasing political prisoners, while the easiest measure is concessions on the level of human rights.

He presented the hypothesis is that almost all efforts at democratization are preceded by liberalization. This is triggered by the resurrection of civil society, which itself is triggered when the costs of repression increase quite significantly and a regime is faced with the question of is it "better" to repress or tolerate? Often, in this case, regimes choose to tolerate the self organization of groups that are not tolerated otherwise. But mobilization of such groups, like lawyer groups, may lead to mobilization on the street. Schmitter said that although Arab regimes liberalize, this kind of process does not normally happen in the Middle East. Liberalization occurs then declines without the regimes suffering many consequences. He finished by stating that there seems to be something in the Middle East region that encourages liberalization, but that leads this liberalization to decline.

Sean Yom responded by saying that for the last 10 years, scholars of democratization literature have made ethnocentric assumptions about this issue. He argued that it is almost assumed that democracy is easy, but what actually happens at the end stage of liberalization is complex. He said that if we take a historical view of the Middle East, the literature says that regimes are durable. But countries like Iran, Iraq, Libya and Syria have all witnessed regime termination. The dictators today in the Arab world are merely the winners of the state-building process.  So why is liberalization not followed by democratization for these survivors?

Yom argued that distinctive regimes have distinctive ways through which they liberalize but not democratize. He related the lack of democratization following on from liberalization to two key questions: Why are there no elite splits in the public arena during times of crisis? And why has the middle class not staked any sacrifice to demand more of a democratic and revolutionary change?

He presented two reasons: the first is that many current regimes have well institutionalized methods of dealing with elite splits before they hit the public domain. Hegemonic ruling provide one such mechanism. The National Democratic Party in Egypt, the Neo-Destur of Tunisia, and the Baath parties in Syria and Iraq for example were able to coopt/isolate softline elites well before their conflict became rebellion.  Yom argued that in monarchical autocracies, incumbents have just as well-institutionalized mechanisms of co-optation that revolve around the palace; such networks were developed shortly after colonial rule, and were designed to effectively enshrine a certain distribution of power.

The second reason, Yom argued, lays in the nature of social opposition.  No dictator liberalizes because they want to give up power.  That is, they do not liberalize to achieve democracy; they liberalize in order to survive in the face of burgeoning social unrest.  The problem is that in the MENA context, the so-called "middle-sector"-labor, professionals, intellectuals, and other urban forces-have not staked out sacrifice to their demands for greater freedom, when push comes to shove.  One reason is that they were incorporated into ruling coalitions early on in the state-building process, and that such early coalitional bargains that traded loyalty for prosperity have proven durable even during economic crises in the 1980s and 1990s.  For instance, large-scale employment in the public sector to certain groups is a common side-payment.  Countries like Jordan and Bahrain exploit population cleavages (the Palestinians and the Shiites, respectively, being the key factors), where the regimes operate an optimal mix of loyalty and oppression/coercion.  In these cases, leaders strategically choose to incorporate different constituents into different networks of patronage.

The presentations were followed by a question and answer sessions where additional factors were discussed and others elaborated on, such as the role of Islamists; authoritarian pacts with the West especially in the cases of "countries that are too important to be politically conditioned" as Schmitter put it, or in the case of illegal Western dealings with Middle East states which makes it difficult for the West to present them with reform conditions; the absence of independent middle classes; and the issue of political prisoners, who are the hardest to coopt by any given regime, and hence tend to be kept inside prisons.

Hero Image
Schmitter
All News button
1
News Type
News
Date
Paragraphs

The Pulitzer Prize-winning author of Ghost Wars and The Bin Ladens offered the 2010 Payne Distinguished Lecture on March 4, 2010, at FSI, with a focus on Pakistan. President of the New America Foundation and a staff writer at the New Yorker, Coll formerly served as the managing editor of the Washington Post and has spent more than 20 years studying the geo-politics of Pakistan and the region.

During his talk, Coll chose to address four major issues:

  • Why have Pakistan's Army, Security, and Intelligence Services chosen to support the Taliban and other groups with known terrorist ties?
  • What is the changing nature of Islamist militarism inside Pakistan?
  • Where is the United States headed in its efforts to change Pakistan's behavior and how does Pakistan see its own interests?
  • What is the current status of Pakistan's relationship with India and what are the prospects for Indo-Pakistani reconciliation?

In a riveting and lively discussion with the audience, Coll noted that his key objective was to help create a fuller, more nuanced understanding of an exceedingly complex political, military, and cultural dynamic on the ground in Pakistan.

Hero Image
steve coll
All News button
1
Subscribe to The Americas