pital Care (Washington, D.C.: GAO/PEMD-907, December 1989).

95. Institute of Medicine, Quality Assurance, 226.

96. U.S. Department of Health and Human Services, Food and Drug Administration, Second Annual Adverse Drug/Biologic Reaction Report, 1986 (Washington, D.C., 1987).

97. Lynn Payer, Medicine and Culture. Varieties of Treatment in the United States, England, West Germany and France (New York: Henry Holt and Co., 1988 9-10) and Donald M. Berwick, "Health Services Research and Quality of Care. Assignment for the 1990s. Medical Care 27 (8) (August 1989): 764.

98. David Eddy, "Quality of Medical Evidence," Health Affairs (Spring 1988): 21-23.

99. Ibid.

100. Institute of Medicine, Quality Assurance, 224.

101. Ibid., 244.

102. Ibid., 144.

103. A recent survey of the findings of these various quality assurance mechanisms is provided in the Institute of Medicine, Quality Assurance, 230249.

104. This summary is drawn from Paul Weiler and Troyen Brennan, "Medical Malpractice" in Pepper Commission, A Call for Action, Supplement to the Final Report (Washington, D.C.: Government Printing Office, 1990). [Hereinafter cited as Weiler and Brennan, "Medical Malpractice."]

105. Harvard Medical Practice Study to the State of New York, Patients, Doctors, and Lawyers: Medical Injury, Malpractice Litigation, and Patient Compensation in New York (Boston, 1990).

106. Patricia Danzon, "Medical Practice Liability," in Liability-Perspectives and Policy, ed. Robert E. Litan and Clifford Winston (Washington, D.C.: The Brookings Institution, April 1988), 105.

107. Patricia M. Danzon, Medical Malpractice, Theory, Evidence, and Public Policy (Cambridge, Mass.: Harvard University Press, 1985).

108. General Accounting Office, Medical Malpractice: Framework for Action (Washington, DC.: GAO/ HRD 87-33, 1987) 2.

109. U.S. House Committee on Ways and Means, Medical Malpractice, 101st Cong., 2d Sess., 1990, WMCP: 101-26, Chapter 4.

110. Weiler and Brennan, "Medical Malpractice," and Dana Hughes, Sara Rosenbaum, David Smith and Cynthia Fader, "Obstetrical Care for Low-Income Women: The Effects of Medical Malpractice on Community Health Centers," in Institute of Medicine, Medical Professional Liability and the Delivery of Obstetrical Care, Vol. 2 (Washington, D.C.: National Academy Press, 1989), 59-78.

111. Institute of Medicine, Medical Professional Liability and the Delivery of Obstetrical Care, Vol. 1 (Washington, D.C.: National Academy Press, 1989).

112. Frank A. Sloan and Randall R. Bovjberg, "Medical Malpractice: Crises, Response and Effects," Research Bulletin (Washington, D.C.: Health Insurance Association of America, 1989): 25.

113. U.S. Congress, Senate Special Committee on Aging, The Rural Health Care Challenge, 100th Cong., 2d Sess., 1988, S.Rpt. 100-145, 51-53. [Hereinafter cited as Senate Aging Committee, Rural Health Care Challenge.] President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Securing Access to Health Care: The Ethical Implications of Differences in Availability of Health Services Vol. 1 (Washington, D.C., 1983): 83-84. [Hereinafter cited as President's Ethics Commission Report.]

114. Designation as an HMSA is based on the ratio of residents to primary care providers and other factors indicating underservice. U.S. Public Health Service, Health Resources and Services Administration, Bureau of Health Care Delivery and Assistance, The Bureau of Health Care Delivery and Assistance's Unique Role in Primary Care (Rockville, Md., December 1988). [Hereinafter cited as PHS, Bureau of Health Care Delivery and Assistance's Unique Role.]

115. David A Kindig and Homoz Movassaghi, "The Adequacy of Physician Supply in Small Rural Counties," Health Affairs 8 (2) (Summer 1989): 66.