Doctors are worried about malpractice. Did the practice of medicine actually change or did the perception of how they practice change. Self-reported surveys are, in general, not good research. They are only useful if no alternative exists.

I'm genuinely curious as to how this adds to the discussion. What is interesting to me is why even though malpractice is certainly a risk of practicing medicine, doctors estimate their chance of being sued and their chance of losing to be so much higher than actuality. Every doctor is steeped in science as a virtue of their training, but they are tuled by emotion when it comes to this issue.

Anesthesiologists reduced actual malpractice, lowered their payouts, and lowered their premiums. I'd like to see what the comment is regarding this method of dealing with malpractice. (I apologize that I don't know how to format the link to make it fit the comment box.)

http://online.wsj.com/article_email/0,,SB111931728319164845-IRjfoNolaR4oJ2nZYKIaaaDm5,00.html

Telling me you have been sued tells me nothing. For example, virtually every woman I know has been called back or had a biopsy. Does that mean every one of them had breast cancer? No. Another example, I've been to the ER 4 times for chest pain in my life. In each case, I believed it was not cardiac. In each case, I was right. Those near and dear to me who insisted that I go were not practicing "defensive medicine". Is the protocol for chest pain wrong? Should I not go the next time?

Were you successfully sued? Were you in error? Have you never been surprised by the result of a biopsy or callback? Have you ever missed a cancer and not been sued? (I'm not suggesting malpractice just maybe you go back and look at the film and to yourself say, I can see it now, but it didn't look like a cancer then.) Have you ever had a second read that differed from your read? Without the answers to these questions in a study, the question of what is too much is fairly meaningless.

very true, and i'm amazed that radiologists still bother to read mammo's considering the low reimbursement. i think undiagnosed breast cancer was the number 2 reason docs were sued last year.

Inital caveat. I am an electrical engineer in the automotive industry, and thus know little about medicine or health care. Although I have an interest in understanding it's problems.

Here is an idea which you might reject out of hand, but may be worth considering.

Defensive medicine seems to be practised for a couple reasons. While it is understandable that a resident may order an excessive series of tests, an experianced physician shouldn't need to. Except that there is an increasing fear of litigation. I'm certain that this fear has some basis in reality. More than likely the problems and costs of litigation are regularly pointed out by the physicians management, partners, or staff.

We all make mistakes on occasion. Even though I think the medical profession has a far lower incidence of mistakes, often the stakes are significantly higher. But mistakes do occur. One of the methods used to reduce the cost of a mistake to a company, as litigation could drive a company out of business, is a program called workmans compensation. I think you have probably heard of it.

Would a similar program, call it patients compensation, relieve the stress on physicians? That is, I suspect that a program that guarantees a certain level of payment to a patient if a mistake is made, but in exchange the patient waives his right to sue, may appease both the patients and physicians.

Of course, in my ignorance, there may already be a program like this out there.

Any thoughts?

-Flex

Anesthesiologists reduced actual malpractice, lowered their payouts, and lowered their premiums. I'd like to see what the comment is regarding this method of dealing with malpractice.


This has been discussed here many times before.

The most important reason is that anesthesia just had to change one single discrete thing to be able to reap huge patient safety benefits (their anesthesia machines).

To do the same thing more broadly in medicine, the entire system has to be changed. The way hospitals are designed. The way everyday medical tools and gadgets are designed. Early warning systems for complications. The way medications are administered. The way doctors exchange information with each other and other members of the team.

It is almost mindbogglingly huge. It also involves so many things outside the control of doctors: other hospital workers (and their educations/training), hospital CEOs, medical gadget manufacturers. It will require phenomenal workforce changes, both in number and training requirements.

Basically the sort of change that is impossible to make happen, except at a glacial pace. But don't worry, in the mean time, there will always be doctors to blame for every conceivable systemic error (and even complete non-errors). Just make sure the supply of hired guns doesn't run out. (We will unfortunately never have to worry about that happening with lawyers).

very true, and i'm amazed that radiologists still bother to read mammo's considering the low reimbursement. i think undiagnosed breast cancer was the number 2 reason docs were sued last year.


Thankfully my radiology group quit reading mammograms 5 years ago. Most radiologists would love to quit reading them but can't due to contracts with hospitals, managed care, etc. More and more are finding ways to opt out though.

I agree. and lawyers who state this is in the best interest of patients do not say that actually patient pay for this.

Flex,

Lawyers only get a certain number of strikes just because they want them, usually 3-6, and even those can't be based on certain factors such as race. And both sides (the fact that the defense has very good lawyers is often forgotten) get those strikes.

The rest have to be "for cause" and the judge does get to make that determination.

We can talk all day about a "no-fault" system, and how great the legal systems of every other country are perceived to be. However, until you give the victims of malpractice the social safety net those countries give, then the comparison to their legal systems is inept. What's more, no insurers are backing this, so nothing is going to happen. Without insurer money, doctors appear to have little legislative strength.

This thread, and the one with 37 replies above illustrate the real problem very well. All we hear is how it is all the lawyer's fault, or the greedy victims, etc. Yet no one looks at the real roots - patient communication. No one talks about actually studying and looking at the root causes of malpractice.

And when someone points out that the anesthesiologists did exactly that, to great success, it's only explained why that's wrong and how it could never work in this area or that area of medicine etc. etc. Even with the most restrictive caps proposed, there are no guarantees premiums will fall - because the cost of medical care will continue to rise meaning economic damages will continue to rise. But if you actually reduce the amount of malpractice, you might have a chance to lower premiums. What have you got to lose? What you're doing now isn't working.

But a rigorous self examination isn't near as much fun or as easy as blaming it all on someone else.

Anonymous, I see no further point in replying to you. You make claims that you have no basis to make because you don't even ask obvious questions. You're a true believer in whatever you're told, as long as it ends in "lawyers are bad." Below will be the last reply to one of your painfully misinformed rants, so enjoy the last word.

The only reason we're having this discussion is because insurers are gouging you on your rates. That's it. We didn't have this discussion in the 90s because they weren't raising rates because there was plenty to be made on the float. After 9/11, it became an issue again because they started to lose money so they jacked your rates.

All the tort reform in the world isn't going to lower those rates as the insurers have told you, isn't going to improve your reimbursement rates, isn't going to reduce the amount of malpractice, isn't going to improve your patient relationships, etc. On its best day, all tort reform will do is put a few more dollars in the pockets of insurance cos. and make it harder for people without economic damages to bring claims, further adding to the ranks of those on the public dole for health care. And pushing us further toward universal health care.

Good luck.

"Legislative strength is not determined by money. Legislative strength is determined by commitment. (Although money helps."

-- How...quaint. And naive. Are we living in the same country? Millions protested the Iraqi war, showing great commitment. Unfortunately Halliburton's bottom line-- and that of the various oil companies-- was more important. Get your head out of the sand, please.


"Our goal should be fairly simple; affordable, or free, high quality health care for all citizens"

-- Define "affordable." I disagree on principle with the notion that health care should be free. People who provide services deserve to be allowed to avail themselves of the traditional payor-provider relationship insofar as possible. Here's my personal "best possible system," which I feel melds the best aspects of both socialized and privatized systems, and is the fairest possible system I can conceive of for both patients AND providers:


Ideally, there should be a system which operates via a sliding deductible scale based upon income brackets. People should still have insurance, but it should be more akin to catastrophic coverage-- because, really, that's what most middle-class folks are worried about (I know my folks are); they worry that if they're in an accident and have to stay at the hospital for a month or so, that they'll have to sell their house in order to pay the bills. Obviously, for the unfortunate few who undergo such a tragedy, this is not reasonable (nor do I believe it to be sensible). You didn't ask, but here's how I feel it should work:


$15-20K Income = $150-250 deductible
$55-65K Income = $1000-1300 deductible (it's not proportional to the previous case due to sustenance costs which more greatly affect those in lower income brackets)

$85-90K Income = $1600-2300 deductible
$120K Income = $4000-4500 deductible


I feel that this would be a fair system for several reasons: first, it would allow primary care physicians to finally have fee-for-service again, benefitting their bottom lines and allowing them to give the sort of care that all patients desire, rather than having to rush through patients assembly-line style in order to keep their practices solvent; secondly, those who are earning $60K per annum can certainly afford to pay $1200 for their medical costs (realistically, the only time costs would ever get to that point would be the rare procedure or expensive diagnostic test, which would be needed perhaps once or twice per year if that). I say that they can afford it because these largely comfortable middle-class people don't hesitate in the slightest to shell out $400 for a battery of tests for their dog at the vet, or $800 for a new TV set, or $150 on a dinner out each week, or $350 for their plumber, or $1000 when the coils blow on their car. Yet these same people, by and large, want to be able to go to their primary care physician and hand over the insurance card and a $10-15 co-pay. That is injustice right there, I'm sorry; it cannot be philosophically defended. A person's health is presumably more important than entertainment, or cuisine, or even their pet's health, yet they have no qualms in denying a physician, who is among the most skilled and dedicated of professionals, his due compensation. The sense of entitlement in this country is shocking, and that definitely contributes to this sentiment among the populace; also, however, I do not believe that the majority of people understand how primary care (and ER and other) docs are being squeezed at the moment-- if they did, I do believe that many of them would be more amenable to such plans, or at least with throwing some extra cash or a check their doctor's way after a visit.


It would also benefit insurance companies, as their payouts would decrease, if only due to the fact that they would no longer have to reimburse primary care physicians except in the most exceptional of cases where the cost of care ran over the pre-set deductible. Since the incidence of more expensive procedures such as surgery should remain relatively constant, insurance companies will be able to generate larger profit margins if they keep their premiums steady. However, what would most likely have to ensue is 1) sufficient education of the consumer/employee as to the reasons for the new cost structure, and 2) at least a slight reduction in premiums to account for the company's decreased financial liability for all sorts of primary care. I do honestly believe that most people would be accepting of such a system so long as they are comforted by the knowledge that their medical costs will never go beyond their reasonable means. For instances of extended hospitalization etc. (where costs would go quite far beyond the deductible, not merely a couple of thousand dollars), perhaps a system could be worked out where for every $X in costs incurred, the patient has to pay a certain amount. So, say, for every $10K in costs incurred above the deductible (but only once cost has gone above $10K beyond the deductible), the patient may have to chip in another $1000 or so (this would, ideally, also be tied to income bracket in my opinion, so the less fortunate pay less and the more well-off pay more).


Also, those who legitimately cannot afford to pay even for primary care service-- either because their income falls below the $15K level or they are currently unemployed-- should not be denied care despite their inability to pay. I feel that if all of the above policies (conceived in haste, but that's the general idea) were implemented, most, if not all, physicians would not have any problem with treating the occasional non-paying patient. Hell, in many cases, they do so now, and actually LOSE money on the transaction with the insurance company. The problem with the current system is that, since everybody is covered by these ludicrous plans, the physicians cannot recoup the costs anywhere else; in the proposed plan, they'd be able to recoup these costs from the people who can actually afford to pay.


I believe education is the key to this plan, and I've begun it in my own way by speaking to my family about the realities of the current system. My family's combined income is around $60-65K before taxes, and my mother is one of the aforementioned folks who will glady (well, not gladly, but she's done it) drop $600-1000 on my dog at the vet when he's sick, but still hands over a $10 co-pay at the doctor's office. Now, it's not because she's greedy, or feels entitled-- it's because she just doesn't know any better; I'd wager most people don't. I've already told my mother and father that it wouldn't kill them to throw another $20-30 (in addition to the $10 co-pay and the pittance the insurance co. reimburses the doctor) to the doctor when they have to see him once every 2-3 months. We're not going to starve. But medical professionals who've worked so hard for so long and are dedicated, caring (for the most part), and knowledgeable (and saddled with debt in many cases) deserve their due. I'm sorry.


Just my two cents.


Nota Bene: This is not to say that such a plan is perfect-- no plan is. One legitimate criticism of it would be that people would say "why should I pay twice for my medical care-- once to my insurance co. and once to the physician?" My short answer to that would be: People did that for decades. Catastrophic coverage was the dominant paradigm for health insurance up until the early-mid 90's. What, precisely, about human nature, the concept of service provider/consumer/payment for services rendered, or the expertise of doctors has changed in that time which now entitles you to essentially "free" care on the backs of physicians who are making less and less after having dedicated, in many cases, nearly a decade in post-graduate schooling to their profession? Answer: Nothing has changed except people's biases and expectations, which is why they have to be re-educated on such matters. When the catastrophic coverage model was dominant, self-reported customer satisfaction with the medical system was actually at an all-time high, especially as compared with today. But my above system is by no means perfect; then again, is our current system perfect? Hardly. Can anyone propose a flawless system? Doubtful, but I'd be quite open to hearing about it if you can. What I've outlined above is simply the fairest system I can conceive of for all involved parties (patients and practitioners); I feel it strikes an appropriate balance where there currently is none. Obviously all notions of "fairness" are inherently subjective, and so I clearly leave myself open to charges of bias and/or skewed notions of propriety. But I would argue we all do to one extent or another.


If poorer people realized that they could get quality primary care when they needed it (and there was accordingly less reticence on the part of GP's to treat them, as they would be reimbursed at an acceptable rate, and could be thorough in their evaluations and diagnoses) they would likely avail themselves of that option, which would obviate the need for a lot of the more costly procedures and care which are needed when poor folks let their medical conditions get too far out of hand. This strikes me as fair and sensible.



Well, there you have it.

-- CJM

That wasn't Curious JD's post, it was mine ("CJM", not "CJD"), though I can see why you'd get the two mixed up. :P


Btw, interestingly, the examples you cite regarding the efficacy of grassroots movements were all many decades ago. The government stopped listening to the people years ago, except when it concerns whatever voting bloc they're trying to sway. If that weren't the case, then issues that have broad social support (as evidenced by nationwide polls)-- such as putting an end to illegal immigration, preventing outsourcing, reining in our military expenditures, decreasing aid to Israel etc. (all of which show >65% support in nationwide polls)-- would have been addressed long ago.


As for whether or not such a plan as I proposed would be practicable, well, I hold that it would be. Obviously, the indigent currently account for a disproportionate amount of our health care expenditures, but there are two point to be made here:

1) We're still subsidizing those costs anyway via Medicaid and other "free" statewide insurance programs. So the costs, whatever they may be, will be there regardless.

2) The second point was mentioned in the last paragraph of my previous post. Costs would come down because poor people would be able to see their physician more regularly, which would prevent their health problems from getting out of hand, which costs much more money down the road. This would lead to substantial savings, and would constitute the first step in implementing a sound preventive medicine system in this country (the other steps would be greater public education as regards health issues).

Believe me, however, when I tell you that unless a way is found to infuse actual CASH into the system again (i.e., 100% of costs + profit for a given service), the system will be in danger of insolvency for many years to come. Socialized medicine is not the answer, as it is ultimately unsustainable (financially). It is also fraught with ethical dilemmas (as are all proxy-payor systems, really, including our own), such as the needs of the patient differing from the needs of the payor (i.e., best possible care vs. cost containment). When you compel people to pay a reasonable percentage of their medical costs out of pocket each year (IF they avail themselves of the services, that is), you align the interests of the payor and patient again, because they will again be one and the same person for a substantial percentage of services rendered. No person would be left wanting for care under such a plan, since once the deductibles are reached for any given year, catastrophic coverage would take over and foot the bill for the rest of the year. This is the best possible compromise I can see.


My $.02 :)

-- CJM

CJM said
That wasn't Curious JD's post, it was mine ("CJM", not "CJD"), though I can see why you'd get the two mixed up. :P

Doh! I apologise. It's entirely my fault for failing to read closely.

The examples you cite which require reform are valid, but reforms rarely happen from external pressure. The civil rights reforms occurred once we elected people dedicated to making those reforms. Popular reforms which aren't attempting to get people into positions of power to enact them are doomed to fail.

If you strongly support a reform, you need to identify candidates which agree with you and vote for them. Regardless of party afiliation. Of course, it's getting pretty difficult to identify any candidates position.
If you feel strongly enough about something, run for office yourself.

Thanks for the ideas, I will be discussing them with friends and co-workers. This comment thread seems to be pretty well played out, but maybe we'll run across each other in the blogsphere again sometime.

Cheers,

-Flex

I'm 13 years old and i want to know if i can get Brast Cancer. My Great Grandmother had it and my dad had liver cancer. Could I get Cancer at all?