More evidence is emerging about the rather minimal impact medical malpractice has on medical costs.
The majority of lawsuits are dropped with no payment made to the plaintiff.
Meanwhile, the lobbyists are reaching for their lances as they prepare to charge the Tennessee med mal windmill.
I’m continually puzzled about the kerfuffle surrounding medical malpractice. Yes, it has caused physicians to practice more defensively, but the impact on costs has been minimal. Meanwhile, the amount of mis- and dis-information out there in the media is just stunning.
Fortunately, some are beginning to realize that the med mal ‘crisis’ is largely manufactured, and appears to be an insurance industry creation.
Here’s hoping that this stinky red herring is tossed in the trash so we can engage on real problems in health care.
As we’ve discussed before, malpractice insurance is a big deal for certain high risk specialities like OB/GYN’s, neurosurgeons, and orthopedic surgeons. It’s basically a non-issue for psychiatrists and perhaps a small issue for PCP’s. By far the bigger cost, however, is defensive medicine. For example, C-Section births accounted for only 5% of all deliveries in the U.S. in the 1970’s but are now close to 30% of deliveries. The main reason is the fear of lawsuits. A number of the early suits related to children born with cerebral palsy, yet the incidence of cerebral palsy has not changed much over the years despite the dramatic increase in the number of C-Sections. Many malpractice suits relate to a failure to diagnose a problem. This is why many PCP’s may send a patient complaining of a headache for an expensive MRI to rule out the 1 in 10,000 chance that it might be brain cancer. While malpractice premiums only account for 1% of total healthcare costs, I suspect that defensive medicine could easily account for another 5% or even more. In a $2 trillion plus healthcare system, that’s not nothing.
What you are forgetting is doctors’ fear of lawsuits and the resulting changes in practice. Nobody wants to be sued. Even a dropped lawsuit results in loss of money ande time, not to mention anxiety.
In order to avoid being sued, doctors a) order a bunch of unnecessary tests to rule out a tiniest chance of missing something. b) don’t bother informing you of risks and lack of evidence of other tests and just order them.
Consider something like PSA for example. There is no evidence that it saves lives. There is some evidence of overdiagnosis -i.e. diagnose of “cancers” that would have never presented a threat if remained undetected. The guidelines recommend discussing pros and cons and letting an individual make a choice. But because there was a legal precedent of a doctor being successfully sued in spite of such a discussion, most doctor don’t bother informing you.
Not only unnecessary tests cost money, they also have false positives. False positives lead to more expensive and riskier tests. Overdiagnosis increases the incidence of cancers i.e. the number of people treated with at least surgery and radiation.
Incidentally Orac from Respectful Insolence has a very informative post with a very detailed description of why early detection is not always a good thing. You may want to read it – while not exactly on topic of defensive testing, it’ll give you an idea why more testing is not only doesn’t save money, but is very likely to result in its loss.
I don’t know if C-sections is really the best example to use. Don’t doctors get paid more for a C-section than for a vaginal birth? Just looking through the web, one study showed that over 26% of deliveries covered by private insurance were by C-section while only 15% of indigent women delivered through that method. Based on the reams of evidence that providers do tend to perform more profitable procedures over less profitable ones, you could easily make a case for that being a major contributing factor. Not to mention it might not be a threat of law suits per se, but more the sense of control and the “I learned how to do it, I’m going to do it” effect that comes from C-sections. There’s probably a lot more going into that decision than just law suits.
Joe – it is a political issue, nothing more. Trial lawyers traditionally give more to democratic candidates than republicans and as such, republican legislators do everything they can to put them out of business.
BC – please, spare us the unsubstantiated tripe that defensive medicine caused by fear of lawsuit accounts for five percent of healthcare costs. If there is any substantiation for your “suspicions,” then please share it. Because, as a practical matter, I “suspect” that at least 5% of healthcare costs result from doctors ordering tests and procedures that are provided by entities with which they are affiliated, or are owned be friends, or by people who send them on fancy trips…. And, in a $2 trillion plus healthcare system, that’s not nothing.
It is obvious that atheist has never practiced medicine. If you have ever practiced medicine. So much of what is done today is just to cover against lawsuits and rule out all suspicion. Until you can walk a mile in teh physicians shoes you have no right to comment on what you think atheist.
DEAR JOE,
AS THE MEDICAL DIRECTOR,CEO AND STILL PRACTICING PHYSICIAN IN 5 OCUUPATIONAL CLINICS IN SOUTH FLORIDA, I STILL FEEL THE FINACIAL PRESSURE OF MALPRACTICE LIABILITY AS A SIGNIFICANT ECONOMIC FACTOR IN THE DELIVERY OF HEALTHCARE. MALPRACTISE COVERAGE FOR A STAFF PHYSICIAN WITH NO SUITS FOR 20 YEARS REMAINS MORE THAN 10% OF HIS GROSS INCOME AND 20% FOR THOSE WITH ANY MALPRACTICE HISTORY. PLUS HAS ANYONE EVER DONE A GOOD STUDY ON THE TRUE IMPACT OF PRACTICING DEFENSIVE MEDICINE, ASKING THE TREATING ER OR REALLY ANY PHYSICIAN “IF THERE WAS NO MALPRACTICE LIABILITY, WOULD YOU HAVE ORDERED THAT TEST” OR IF THERE IS, NO GOOD EVIDENCED-BASED DATA ON A PROCEDURE, THIS TRANSLATES INTO THERE IS A HIGH RISK OF MEDICAL LIABILITY IF IT FAILS-THUS HALTING THE WAIVE OF UNPROVEN PAIN-RELIEVING AND OTHER COSTLY INEFFECTIVE PROCEDURES AND PRODUCTS IN MEDICINE.
I come from a family of physicians and others in the medical field, including one OB/GYN and a radiologist, both high-risk specialties. They all tell me that their first concern is for the patient, and any doctor who is thinking about his bottom line before that ought to be in another line of work (though few exercise that option).
My question to them, then, is how does one tell the difference between a procedure or test that is done to prevent a lawsuit and a procedure or test done to prevent a complication or rule out a more serious diagnosis? And they tell me there is no difference, since both achieve the same objective.
And yet, I still read posts here and elsewhere from physicians who say they have done things to prevent lawsuits. So, by implication, if the threat of lawsuit were eliminated, are they saying those procedures and tests would not be performed? Or would they still be performed so that they would rule out serious disease and prevent complications? One would hope the latter, but then the docs would have no argument, would they?
I think much of this article is amateur insurance hype. As mentioned in Paragraph #4 above, Med Mal is manufactured by the insurance industry with the cost paid by thousands under the category of “Health Care” not insurance. How do many of the claims get dropped? Hospitals’/Doctors’ attorneys defending the claim do not work, pro bono; therefore, added cost for frivolous claim. One emotional settlement can be Millions with attorney contingency fees and fees and fees…keep trial lawyers rich under the category -“cost of health care.” What happens when the indigent mother, without health care, delivers a baby? Is there a chance that it will be healthy due to great prenatal care? not likely. So now the indigent mother has a child that is “not perfect” and some lawyer that says, I can get you money to care for the child. Or the case of the Neuro Surgeon that does what he can retore functioning and is not successful, but no errors? You got it, he is nailed by the “if it didn’t turn out right you can sue” lawyers looking for a good contingency case. Cost of Med Mal, try checking it out a little closer.
Tom:
If you want to create a forum where only physicians have the right to comment, set up your own blog or lobby Joe to change his rules to deny non-MDs the right to comment. Where in medical school do they go through the relative free speech rights of physicians and patients?
And, since you sound like a doctor who has been burned by the med/mal system, here’s a tip for you – patients are far less likely to sue doctors who treat them with respect and apologize when they make mistakes, rather than tell them to shut up.
Atheist by all means you can comment all you want that’s fine. I like to read fiction every once in awhile. As Tom stated however, you know nothing about practicing medicine and it gives those of us who do a good laugh to read what you think you know about practicing medicine.
I have no problem with free speech. Yet, people need to know when to exercise their free speech. People should not waste their free speech talking about matters in which they are merely guessing on how things actually work. I personally don’t try and tell other careers how their their job actually is unless I have done their job before (most of the time I haven’t).
And no I have not been involved in med mal. I am still a 4th year student who is being taught. You don’t know how many times I have asked why we are ordering a certain test only to hear the response that we have to rule out of possible diagnosis (even though it is extremely unlikely based on physical exam finding/intuition) because the physician is scared what will happen if he doesn’t. This attitiude is pervasive it is now being taught to the next generation.
So, try to walk a mile in the shoes before you go spouting off uninformed opinions. You are free to say what you want, but unless you want to look ignorant I would exercise restraint if I were you.
“My question to them, then, is how does one tell the difference between a procedure or test that is done to prevent a lawsuit and a procedure or test done to prevent a complication or rule out a more serious diagnosis?”
My answer is to ask the doctor the following question: If the patient were a member of your own family, you were paying the bill out of your own pocket and the probability of a lawsuit if something goes wrong were zero, would you order the test? If the answer is no, ordering it is defensive medicine. If it’s yes, it isn’t.
And my answer to the previous question would be yes for every test. I’m a physician that’s my recommendation take it or leave it. The way the system is now I don’t make decisions on tests. I offer every test I can think of for a problem and let the patient decide. If they don’t want it, I document that they refused the test that I wanted to order. If they want it, so be it. Either way I’m covered. The responsibility is the patients’ not mine.
“My answer is to ask the doctor the following question: If the patient were a member of your own family, you were paying the bill out of your own pocket and the probability of a lawsuit if something goes wrong were zero, would you order the test? If the answer is no, ordering it is defensive medicine. If it’s yes, it isn’t. ”
This might work in case of some defensive tests, although I’d like to hear from doctors if they would answer truthfully to this question. It will not work if a doctor is about to order some test that he himself genuinely believes in even though the evidence says the test is likely to do more harm than good. We all saw recently plenty of articles/TV shows where doctors recommended everyone has test X when there is no evidence test X does any good. It would also not work if your own preferences and risk tolerance isn’t the same as your doctor. In some situations there are disagreements between experts.
In case of screening tests, I usually do my own research and make up my own mind. By research, by the way, I mean check USPSTF recommendations including rationale and summary of evidence, looking up relevant studies, looking up reviews of these studies, etc. I go directly to the source, and ignore journalist summaries. I am pretty thorough and I triple check any information I find.
In case of diagnostic tests if I have real symptoms – I don’t know. I usually try to find out as much as possible about my symptoms before going to a doctor to have an idea which tests might be ordered. I might ask directly if this is a defensive test, I might do what BC suggests, or I might ask what he/she is checking for, and how my probability of having it compares with the test’s risks. I don’t know. In case of particularly worrisome symptoms, I might just agree without questions.
One time many years ago I told “I don’t want it” to a diagnostic test which I felt was defensive. A few years ago I said yes to the same test for similar symptoms (but different circumstances e.g. age, other circumstances). I feel that in both cases it was the right thing to do (it was negative).