Legal, Regulatory, and Claims-Related Factors Associated With U.S. General Surgery Malpractice Premiums, 2013-2023

Background General surgery malpractice premiums vary across states. We examined whether legal, regulatory, and payment measures were associated with premium levels and annual changes. Methods We analyzed 50 states during 2013-2023, expressing monetary measures in 2023 dollars. Between-state regressions evaluated mean premiums; annual models included state- and year-fixed effects. Generalized caps included restrictions on noneconomic recovery in at least one ordinary medical-liability claim category. Policy-change analyses were exploratory. Results Among 550 state-years, each additional mean annual payment report per million residents was associated with 2.32% higher mean premiums across states (95% CI, 1.20%-3.44%; P < .001). The adjusted cap association was −18.53% (95% CI, −37.11% to 5.53%; P = .118); judicial climate and premium regulation were also nonsignificant. Within-state payment-frequency and payment-size associations were nonsignificant. Three states changed generalized cap status; event-time estimates showed pre-change differences (joint P = .016), limiting causal interpretation. Discussion Higher payment frequency was associated with higher average premiums across states, but year-to-year changes in payment frequency within a given state were not detectably associated with that state’s own premium changes. Cap estimates varied depending on how caps were defined and remained statistically uncertain. These ecological findings do not establish causal effects or support specific policy prescriptions.