Op-ed: Wasted medical dollars

The following op-ed was published on April 23rd, 2008 in the USA Today.

A recent analysis by PricewaterhouseCoopers concluded that more than half the dollars in our $2.2 trillion health care system are wasted.

Medical errors, inefficient use of information technology and poorly managed chronic diseases were all cited as factors. Dwarfing these reasons is a phenomenon in which doctors order tests to avoid the threat of a malpractice lawsuit. This is known as “defensive medicine.”

At $210 billion annually, defensive medicine is one of the largest contributors to wasteful spending, and it can manifest in many forms: unnecessary CT scans, MRIs, cardiac testing and hospital admissions. A 2005 survey in the Journal of the American Medical Association found that 93% of doctors reported practicing defensive medicine.

When you consider that rampant testing is a major driver of escalating health care dollars, addressing defensive medicine should be a primary goal of cost containment.

Testing to protect the doctor

Why do doctors order these unnecessary tests? The simple reason is that every physician wants to avoid being sued. Win or lose, the ordeal of a malpractice trial is a devastating experience. The American Academy of Family Physicians, citing a study that interviewed doctors who had fought medical liability cases, said 90% “suffered significant mental effects from the lawsuits” and, disturbingly, 10% contemplated suicide.

In an optimal system, every case tried should involve clear medical malpractice “” wrong-site surgery or performing an incorrect procedure, for instance. But the reality is far from that. Poor medical outcomes occasionally occur despite textbook medical care.

A landmark study from The New England Journal of Medicine analyzed more than 1,400 malpractice claims and found that in almost 40% of cases, no medical error was involved. Facing such an unpredictable malpractice climate, a physician’s instinct is to increase testing. When facing jurors and trying to explain a medical catastrophe, who wants to tell them why a specific test wasn’t ordered?

In my experience, patients don’t seem to mind the extra testing, and they often equate defensive medicine with “more thorough” care. After all, if one test is good, wouldn’t more be better?

More harm than good

Not necessarily. Every test has the risk of a “false positive,” which is a positive test in the absence of disease. Doctors generally act on every abnormal result, so a simple X-ray finding could lead to further tests, such as an advanced imaging scan or biopsy. When you consider that a CT scan can expose patients to radiation equivalent to several hundred X-rays, and a biopsy might have serious complications such as bleeding or infection,there comes a point where increasing the frequency and degree of diagnostic studies could lead to harm.

This is what studies have found. Pioneering work by researchers at the Dartmouth Atlas Project concluded that higher intensity medical services have led to worse outcomes, higher costs and an increased number of medical errors.

How do we tackle this problem?

Whenever a test is performed, there has to be a willing patient. Know that more tests might not always be better medicine. Before undergoing a scan or procedure, understand why it is being ordered. This includes a thorough discussion of the risks as well as a sense of what the physician is looking for. Patients tend to decline tests of questionable benefit when appropriately informed of possible complications. Don’t be afraid to ask questions.

For physicians, remove the incentives to order defensive tests. Specifically, the malpractice system needs to do a better job to not try doctors who experience poor medical outcomes despite practicing the appropriate standard of care. Although the majority of physicians win malpractice cases, remember that the trial itself is emotionally scarring and that the statistics do not reflect the vast number of cases settled out of court.

Until the system is perceived as being fairer, physicians will do all they can to avoid being sued. That involves ordering unnecessary tests, which is a shame, because those billions of dollars can be put to much better use.

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  • Medicine and Man

    As you mentioned that a majority of malpractice cases are settled out of court, it will be interesting (and enlightening) to see in how many such settlements do doctors (or their insurance company) pay the patient to avoid legal hassles and cost.

    Although many malpractice cases are won by doctors, this out of court settlement could very well be a major factor in filing frivolous lawsuits.

  • Anonymous

    I must agree. I can’t even begin to tell you how many well-trained physicians that I work with are ordering up extra tests to be “extra sure.” And these are the quality guys and gals, those who are the experts of their fields and with a decade’s worth of experience. It’s scary to imagine the testing expenses of the newer physicians, who are often not as sure of their decisions as the experience ones. Malpractice cases must be contained and should be the focus for reform.

  • Jennifer

    It’s the system…it is very EASY for consumers to slap a lawsuit against healthcare practitioners, particularly physicians. As a consumer of healthcare, I have heard of some pretty frivolous lawsuits against physicians—one that sticks out in my mind is a man who needed to have his gallbladder removed due to gallstones.

    He got a referral from his family practice physician to a surgeon and anesthesiologist. The doctors do all the workups needed pre-surgery, and the guy unfortunately dies on the operating table due to a large bloodclot that apparently dislodged elsewhere from his body.

    The survivors not only sued the anesthesiologist and surgeon, but also went after the family practice doctor for recommending the surgeon/anesthesiologist.

    I live in KY…we don’t have a major amount of physicians here because it is so easy to sue them.

    I think the current state of malpractice is just a mess, and needs to reformed…and I agree that it only should be possible in cases of obviously gross negligence such as your example of wrong surgery sites and such.

  • http://advocateyourself.blogspot.com Cheryl

    Speaking as an orthopedic patient that was injured by a doctor who suffered no detrimental effect (advocateyourself.blogspot.com) and speaking as a caregiver for an elderly dad who has been blatantly abused and mistreated by hospitalists, I think the whole idea of “defensive medicine” is a joke.

    With all due respect, any doctor who loses his professional judgment and stops treating the patient as an individual (but instead makes all of his medical decisions based on a obsessive fear of being sued) should get out of clinical practice. Period. Return to medical research. Get a job at McDonalds. Anything but working with patients. Unnecessary fear and being over cautious makes you more than a dopey physician – it makes you a dangerous physician bc you are no longer really practicing medicine.

    If the physician puts his or her fear of being sued over the best interests of the patient then the physician should certainly refer the patient out.

    Grow up doctors. You allow attorneys to effect your practice of medicine and now you are on the verge of letting Obama Care take over your practices . . . all bc you are perceived as weaker than you really are.

    Good grief.

  • Rusty

    Cheryl provides some really strong, bitter opinions. There actually are physicians who are leaving the field or retiring early because of the fear of frivolous lawsuits. If every physician who practiced medicine with a fear of lawsuits were to leave as Cheryl has suggested I guarantee there would be no one left. Then what are you going to do, sue the nurses?

    Defensive practice can be found in all industries. Look at all the disclaimers warning us that the coffee is hot or the knife is sharp or taking to much of this drug is bad for you. Why should the medical field be any different? Regardless of whether you think it is valid or not people in the medical field, hospitals, nurses, not just doctors practice defensive medicine.

  • Cheryl

    An overcautious doc is as dangerous as an overcautious car driver. If tge doc is overcautious then he or she has lost his or her professional judgment and yes in such a case of a useless doc i would rather be treated by a nurse.

    Too many state medical societies protect the bad docs & even good docs protect bad ones bc ama intimidates docs from testifying agn bad docs.

    If u are overcautious, not trusting ur pt & ordering dopey tests then u are not really practicing medicine. You are doing ur pts a disservice. Shame on u

  • Rusty

    It’s interesting that Cheryl uses the driving analogy to criticize “overcautious” physicians because aren’t we all told that we shoud drive defensively?

    In regards to trusting patients, that all sounds good and fine but not all patients are reliable when it comes to their ability to tell the doctor what they are feeling or experiencing.

    This argument can go around in circles forever. Being too cautious is just as bad as not being cautious enough. Where does one draw the line to determine who gets sued? How does one determine the right level of cautiousness?

  • http://www.grandslamnewyork.com David Cohen

    The question is, in removing defensive testing to cut costs are we actually leaving patients at risk? I hear over and over again of emergency room doctors who find themselves at the wrong end of a lawsuit because in their hurry they neglected to perform defensive testing in favor of a clear cut diagnosis-even if that diagnosis was a wrong one. Medical error has to be considered, but we have to be careful how much medical error our financial concerns are causing rather than preventing. A few extra tests probably aren’t going to hurt you. Missing a life threatening condition can have slightly longer lasting consequences.

  • Deb

    As someone who was misdiagnosed, had an unnecessary surgery, and was subsequently provided treatment based on a standard of practice that made me sicker, I can say that my experience has been one of disillusionment in how medicine is practiced.

    Practicing medicine is truly an art but the push by HMO/short office visits, evidence-based research/one-size-fits-all treatment, & pharmaceutical companies and attorneys trying to make maney have left practitioners relying way too much on tests and less on developing a relationship with and listening to their patients. I can forgive a physician who has made a mistake with my care, admits the mistake and learns from it. It’s harder to forgive when the physician hasn’t listened to me, comes across as arrogant, and refuses to acknowledge their limitations. I want a solid patient-doctor relationship with my physician and I’m willing to put forth the effort to make this happen but I expect the same from my doctor. I think many docs struggle on how to do this with their patients. The research I’ve seen has found that malpractice suits are much fewer when the patient has had an effective relationship with their doctor.

  • vernia

    What if I make the statement, The individual is the central value in terms of whom all consequences are to be judged.” what might this entail on our parts?

  • http://www.doconomics.com/blog Chris Gregory

    In Texas, we supposedly fixed the med-mal defensive medicine problem when we enacted tort reform in 2003. However, the problem in Texas is that we are some of the biggest wasters and overutilizers – and some docs still try to justify overutilization by citing med-mal threats. In Texas, waste is epidemic in areas like Dallas and McAllen – because the docs can do what they want. In Dallas, the annual cost to treat a Type 2 diabetic is around $7,000 a year, while in Fort Worth, just 30 miles away, the annual cost is around $1,700 – because Fort Worth is a primary care centric system. We’ve still got too many docs gaming the system.