e forcing function in the development of ADR was the rise in medical malpractice claims. Some surveys showed that such claims doubled during the period 1979-1985; others revealed a slowing in the rate of increase in the mid-1980s to about 29 percent per annum (Yuen 28-29). The impact of medical malpractice claims varied widely by region and by speciality. Since 1976, the hardest hit group was obstetricians and gynecologists followed by many types of surgeons (Yuen 228-29). In 1993, in an area with an especially high incidence of such claims, metropolitan Detroit, the annual malpractice insurance premium paid by an obstetrician was $68,148-$141,144 per annum or more than 15 times the national average for all physicians which nevertheless rose 8.3 a year in that year (Crane 52, 54).
A recent trend is an increase in the exposure of general practitiioners, such as internists, to medical malpractice liability, and the increased exposure of health care institutions to liability under various legal theories, including that of enterprise liability. These trends are related to the "increased specialization of health care providers which some argue has resulted in the depersonalization of the health care industry and a lack of communication between physicians and patients" (Yuen 12). This has been accompanied by the growth through mergers and otherwise of giant health care providing organizations known as health maintenance organizations (HMOS). Joseph says that "as horizontal and vertical integration expands within the health care system, so, too, will enterprise liability" (90). In the corporate practice of medicine, a premium is placed on standardization of treatment and the lowering of costs. One result is that the ge
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