Clinical waste comes from unnecessary care, defensive medicine, and excessive paperwork

“Unnecessary spending will continue until we have a reliable system of medical justice that protects reasonable decisions – like prescribing aspirin instead of a CAT scan for a headache.”

“Said Dr. Alan Sager, a co-author of the Boston University study, ‘[W]e need to demand that health care gets reshaped in ways that encourage and persuade doctors to take charge of spending money more carefully [and] … weed out clinical waste.’ Sager also noted that ‘waste comes from unnecessary care, defensive medicine, excessive paperwork born of mistrust between insurers and doctors, as well as theft and fraud.’”

A study suggests that unless defensive medicine is reigned in, health care costs will continue to spiral. After all, a CT scan for a headache is much easier to defend in court than clinical suspicion (via Common Good).

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  • Curious JD

    Your last paragraph is typical nonsense. Especially considering that “defensive medicine” has been debunked by studies which examine it both pre and post the enactment of insurer profit protection, I’d say that it won’t matter. And considering that medical inflation has skyrocketed in all states as well, regardless of litigation.

    However, one part of your article did point the way of the future:

    “Last week, General Motors’ Chief Executive Rick Wagoner urged renewed efforts to control spiraling health-care expenses. The automaker spent $5.2 billion in 2004 to cover 1.1 million U.S. employees, retirees and dependents.

    “Failing to address the health-care crisis would be the worst kind of procrastination, the kind that places our children and grandchildren at risk and threatens the health and global competitiveness of our nation’s economy,” Wagoner said.”

    When GM and the like come out and start publicizing their numbers, it’s because the PR pump is being primed to get them some government assistance. Physician’s continued embrace of Bush is going to cost them when he nationalizes these pension plans and you start getting reimbursed from the taxpayer’s dime even more than you already do.

    National health care may not seem like a good idea to the Administration when it’s just some poor people who can’t get treatment, but when its big donors speak, it will listen.

  • Anonymous

    I think the majority of Curious JD’s posts cite “studies” or “evidence” of his claims. Today it was, the cost of defensive medicine “has been debunked by studies which examine it both pre and post the enactment of insurer profit protection”.

    Has he ever cited any of these studies on any of his previous comments? I’m just wondering.

    How about,

    http://papers.ssrn.com/sol3/papers.cfm?abstract_id=225513

    Probably the most infalliable and improtant research on the entire subject for which the two Stanford based authors won an American Economics Association award. Sounds sort of unbiased and yet they concluded defensive medicine raises cost.

    In fact just a casual search couldn’t find any studies that said defensive medicine didn’t raise costs. I’m sure they’re out here, just stored in the backroom of the headquarters of some malpractice lawyer trade association.

  • Curious JD

    I invite you to check out Dick Cheney’s favorite site, Factcheck.org, particularly this article:

    http://www.factcheck.org/article.aspx?DocID=133

    which discusses the Stanford studies and Bush’s claims based on those and points out the ample evidence to the contrary from private studies as well as government studies.

    I’m pretty sure that you won’t find Cheney, the Journal of Heatth Economics, or the CBO and GAO at ATLA’s headquarters. Perhaps you should have used Google.

  • Anonymous

    Here’s what the factcheck page does. They cite an HHS study and the Kessler & McClellan study (which clearly had some validity with well respected economists, if not the economists in the CBO, for the awards it won).

    Then it tries to refute the Kessler & McClellan by quoting CBO and GAO authorities who read the paper and found faults in its methods.

    What it cannot provide is unbiased reports that found conclusively that defensive medicine did not raise costs. It cites three reports, all of which found some increase in cost, and which admit, this is a quote, “it is impossible in the final analysis to draw any conclusions about the overall extent or cost of defensive medicine.”

    What does that leave us with? Studies that found strong evidence for a rise in cost associated with defensive medicine and three which were inconclusive or foud smaller rises in costs and none which found no rise in cost concerning defensive medicine. I’d make a bet that the rise in cost is somewhere in between. Not as low as the OTA study and not as high as HHS study.

    Look all statistics have their counterparts. But the fact that you CANNOT cite legit studies that absolutley refute the rise in cost based on the practice of defensive medicine says something.

    And like I said before, plenty of well respected unbiased economists outside of the government found no fault in the methodology of the Kessler & McClellan study…which means what we have here is a difference of opinion and the CBO and GAO could easily be wrong.

  • Curious JD

    There are no “conclusive studies” of anything in this arena, for the reason that no one can accurately define “defensive medicine.” Do you know a physician who will publicly admit to ordering a test that wasn’t medically necessary? Not if he billed for it, you don’t.

    What’s more, the Office of Technology report and the Harvard report PREDATE the Kessler study. And surely you’re not arguing that the Journal of Health Economics is some sort of partisan rag. If anything, though the CBO study is the most accurate as it’s the broadest. And why is an economist outside the government any more or less biased? Can you say that Kessler and Co. are more or less biased than the economists at Harvard or the Journal of Health Economics?

    And the fact remains that at best this is a tiny percentage of health care expenditures. So again, the proposed solution has no relation to the problem. You appear to say that because they cannot prove it’s NOT increasing costs, that is somehow evidence that further harming those already injured is necessary.

    That makes no sense. Which is not surprising.

  • Anonymous

    What I always found fishy about the Kessler & McClellan study was that it was NEVER published by a scholarly journal. It just won that award. Thus, it was not peer reviewed, as far as I can tell. But maybe someone can correct me.

  • Anonymous

    Usually, I must admit that Curious JD makes very eloquent and pointed comments, however the post above of his suffers for several flaws. We’ll go through.

    From Curious JD: “Do you know a physician who will publicly admit to ordering a test that wasn’t medically necessary?”

    Not publicly but there are several anonymous survey studies down to help determine if defensive medicine is actually practiced, and they’ve had pretty good response rates. I mean, these surveys are just common knowledge.
    Here’s a British one:

    http://www.ingentaconnect.com/content/rcgp/bjgp/2000/00000050/00000456/art00010

    From Curious JD: ” If anything, though the CBO study is the most accurate as it’s the broadest.”

    The CBO ‘study’ was a basic review of the literature and a recrunching of the numbers. It’s flawed to call it the most accurate because it brought no new information to the table. They just reinterpreted the data. But, the trouble with that is that some think tank can come back and do the same, and whose interpretation is more valid? Only by adding new information and data can a ‘study’ add to the debate.

    From Curious JD: “What’s more, the Office of Technology report and the Harvard report PREDATE the Kessler study. And surely you’re not arguing that the Journal of Health Economics is some sort of partisan rag.”

    I never said that at all. I have no doubt that these published reports are valid. What you’re missing is two points: a) all of these studies were either inconclusive or actually found an INCREASE in cost associated with defensive medicine (however small) and b) these studies are no more biased than Kessler & McClellan.

    From Curious JD: “You appear to say that because they cannot prove it’s NOT increasing costs, that is somehow evidence that further harming those already injured is necessary.”

    It might be my fault, I might be explaining myself poorly. What I have said, is that we only see evidence that defensive medicine is increasing costs, its only a matter of HOW MUCH. What you’ve responded with is a subjective opinion that somehow capping malpractice claims is “harming those already injured”. Good job, counselor.
    Before that, you stop just a thread short of all but admiting that defensive medicine increases health care costs by saying, “and the fact remains that at best this is a tiny percentage of health care expenditures.”
    So here’s the problem. You’ve all but admitted that there is a statistically validated problem concerning defensive medicine increasing health care costs (however small it may be). But, you say you don’t want to do anything about it, because the solution to the increasing cost due to defensive medicine problem is to cap claims. Yet, you cannot provide unbiased evidence that malpractice caps hurt injured patients. It’s a simple problem of logic. You can prove A but you cannot prove that the solution to A, we’ll call it B, does more harm than A itself.

    Also, it is true Kessler & McClellan did not appear in any journal but you can find it in a peer edited collection of works compiled in Japan concerning global economics at

    http://www.amazon.com/exec/obidos/tg/detail/-/0312165269/qid=1109190888/sr=8-1/ref=sr_8_xs_ap_i1_xgl14/103-2234738-0368665?v=glance&s=books&n=507846

    And just to add to the debate, here’s a link to part of the OTA study you like to cite. I love the first line,
    “Although clinical factors are still the most important determinants of physicians’ clinical decisions, research suggests that a number of nonclinical factors influence physicians’ diagnosis and treatment choices, among them malpractice liability concerns”

    - http://www.wws.princeton.edu/cgi-bin/%20byteserv.prl/~ota/disk1/1994/9405/940509.PDF

  • Curious JD

    Anon,

    An anonymous study asking doctors if they practice “defensive medicine”, particularly given the current PR push, is about as worthwhile as asking teenagers if they are using condoms. If you’re not going to point to specific procedures which you say you wouldn’t have done, then it’s basically unverifiable and thus, worthless.

    You’re right – “most accurate” was a poor choice. The truth is neither of us are sufficiently well versed in anything but the results of these studies to adequately criticize them.

    I can’t provide unbiased evidence that caps hurt injured victims of malpractice? That’s so simple to do it’s ridiculous. If a jury awards $500,000 in non-economic damages for a woman who has her breasts removed based on a mistaken interpretation of a report, and the judge has to knock it down to $250,000 because of the law, the person has been harmed. That’s certainly clear.

    I like that last thing you quote, though. I think we can all agree that there are problems with health care, and malpractice may be ONE OF THE “nonclinical” factors affecting it. So why is 90% of the effort focused on an inconclusive or tiny percentage of the problem. We’re taking a sledgehammer to a carpet nail, and ignoring the rest of the house.

    And again, the insurers themselves say it won’t make much of a difference. Why are we not looking at insurance reform legislation? It’s only been 15 years since the last “crisis.” Do physicians have such short memories?

    And, would you not agree that at least a little of physicians’ fear is overblown? At least 80% of physicians have never been sued and never will be. It’s clearly not a career black mark as a large percentage of malpractice payments come from doctors who have made a payment before and are still practicing. And in many of the AMA’s “crisis” states, doctors are in fact not leaving as is claimed, and payouts on med mal are flat or increasing with general med inflation, and claims are static or rising with the population increases.

    It’s almost like the shark attack scare off the coast of Florida a few years ago, when it turned out there were fewer attacks that year than the year before.

    But on another point, do you have any thoughts on my GM comment?

  • Anonymous

    If you have a patient with a tiny brain bleed, aspirin is going to be so helpful.

    CAT scans are pretty safe, and there aren’t a whole lot of perfectly innocent so-called “incidentalomas” in someone’s head that would prompt dangerous/fruitless-yet-expensive follow-up .

    The only objection to checking out unusually severe and/or or chronic headaches can be the cost of the scan itself.

    That one reason I really hope scanning centers so vociferously objected to on memdical blogs stay in business. Patients need a way to do a free-market end run around doctors who think it’s cheaper to let the tiny percentage of positives suffer long delays in diagnosis.

    P.S. Why can’t CAT scans be cheaper?

    I’ve had a bad feeling that much of the objection to commercial scanning centers is that they might drive down the current reimbursement rates or patient supply for radiologists and hospitals with equipment monopolys.

  • Desertfox

    Per capita health care costs in the U.S. are close to DOUBLE those in advanced western countries with universal health care. There are few areas in which U.S. Health care is rated superior. The Stanford study puts 5 – 9% of the cost in heart disease on defensive medicine. No studies on other diseases have resulted in any statistically significant results at all.

    However, for a moment lets assume against evidence that the midpoint of the Stanford study, 7%, of the entire cost of our healthcare is related to the medical negligence system. That still leaves 86% of the doublinf of our costs and those of other western countries to be attributable to other causes.

    The constant focus on this portion appears to have more to do with depriving a group of significant Democratic Party donor with funds than with addressing the major causes of our inefficiency.

  • Anonymous

    How about, since many think that the tort systems is so integral to doctors doing their job correctly, when the governmment confiscates the healthcare system of this country, we have socialized malpractice insurance as well. Since the government will be telling us how to practice medicine then, they may as well take responsibility for it. Sure, the government will put in some sort of immunity for themselves, so lawsuit pickins will be a little thin… oh, wait I forgot- limiting the income potential of lawyers is strictly verboten in this country.
    Just remember, John Edwards never benefitted any individual or society as a whole as much as the worst doctor he ever sued has.
    Olddoc.