discussion b

Running head: McVeigh– Defensive Medicine Essay 1

1

It has been said that the fear of medical liability drives healthcare providers, particularly

physicians, to unnecessarily order diagnostic tests and to perform treatments and procedures

that may not be necessary, simply to ensure that nothing is left undone. Is this in fact the case?

Defend position on this premise using literature.

Langley McVeigh, MHA, FACHE

May 23, 2017

McVeigh - Defensive Medicine 2

Yes, defensive medicine is practiced in the United States. However, it is important to

understand: (1) what impact it has on healthcare expenditures (2) to what degree does it occur

(prevalence) and (3) if so, what can be done to prevent it?

As an emergency services administrator for a Level 1 trauma center, experience has led

me to understand the dynamic influencing physicians in their clinical decision making process.

Ideally, this process should be void of non-clinical bias or influence. However, this is not the

case in many circumstances. Physicians are considering risk and liability when ordering tests

and procedures. This risk management, or risk mis-management, phenomenon is called

defensive medicine. By definition, these occurrences are medical practices intended to

exonerate practitioners from liability with limited or without medical benefit to the patient

(Sethi et al, 2012). Physicians have been directed by health policy to provide value based care,

but defensive medicine practice works against this care model.

There have been studies conducted measuring physician attitudes towards tort reform

and defensive medicine practices. While studies show physicians, especially high risk medical

specialists, regularly practicing defensive medicine, the cost implications are unclear.

Furthermore, proposed reforms to the medical tort system must be investigated. Some have

proposed to completely do away with the medical tort litigation and insurance system,

replacing it with a system similar to workman’s compensation models. While it may be a reflex

mechanism to use cost as a metric to measure results of defensive medicine practices, patient

outcomes and quality of life implications must also be measured. The patient is the one who is

being subjected to additional and unwarranted procedures.

McVeigh - Defensive Medicince 3

According to a survey of 2000 orthopedic surgeons in 2010 (Sethi et al, 2012), of the

1214 respondents, 96% admitted to have practiced defensive medicine by ordering labs,

imaging studies, specialist referrals, and inpatient admissions. Many surgeons confided this was

done to avoid malpractice claims. These prescriptions offered little no benefit to patient

outcomes, and contrary to the current posture of value based practice in our health care

system. This additional intervention is costly, at an inconvenience to the patient, and may carry

additional health risk. As a reflex, one may think of the additional testing or care as a good thing

because of the abundance of caution, but carries additional implications for the health care

system in that now risks from these procedures must also be managed.

A similar survey was conducted of neurosurgeons in 2011 (Nahed, Babu, Smith, & Heary,

2012). 76% of members of the American Association of Neurological Surgeons responded to the

survey. Of these respondents, 64% considered malpractice premium costs as a “major or

extreme” burden, consequently influencing 45% of the respondents to eliminate high risk

procedures from their medical practice because of this concern. The study broke down

defensive medicine practice into distinct categories: imaging studies – 72%; lab tests – 67%;

specialist consultation referrals – 66%; and prescribing medication – 64%. These practices were

done solely to avoid a perceived legal risk at a financial cost to the system and at an expense of

patients’ health. This study concluded with two alarming advices: this phenomenon (1)

increases costs; and (2) limits access to care of high risk procedures. Cost and access (& quality)

issues are plaguing our health care system, begging for reform. So not only are we seeing

physicians ordering additional procedures, but we also have physicians avoiding procedures

that may be beneficial for patients because they carry significant risk. Defensive medicine is

McVeigh - Defensive Medicine 4

usually perceived as practices that add additional interventions. Fact is, access to valuable, but

risky, interventions are being limited too. Physicians are thinking twice in prescribing or

operating on procedures that carry a risk of future litigation. Defensive medicine may be

hindering clinical outcomes.

How much is the does the medical liability system cost the nation? According to an

assessment conducted in 2008 (Mello, Chandra, Gawande, and Studder, 2010), only $55.6

billion annually or 2.4% of total health care expenditures were attributed to medical liability. In

absolute dollars, this may not seem like a minimal amount, however, the actual percentage is

not as high as some political voices have expressed in the health care debate. The authors of

this study concluded that measures to reduce these costs have minimal impact on overall

health spending and recommended efforts placed on reforming financing and reimbursement

methods to curb the overuse of ineffective procedures. A continuation of a move away from a

fee-for-service system should help. If payments are bundled into outcomes-based-best-

practices, additional utilization should be curbed. This still does not address the psychological

and financial stresses physicians face by risk of litigation in the current medical tort system.

Another study published around the same time (Thomas, Ziller, and Thayer, 2010)

concluded from their analyses of the Congressional Budget Office’s reporting on medical

specialty practices that the impact of defensive medicine on health care costs are little. Savings

estimations predict that a 10% decrease in malpractice premiums would result less than 1% in

total health care costs. While the phenomenon exists, the significance of impact is

questionable. The authors of this study opined physician’s perception of medical liability and

management of risk was more of a concern rather than the actually statistics illustrating cost.

McVeigh - Defensive Medicine 5

Tort reform intends on lowering expenditures by controlling the cost of malpractice

insurance (insurance covering indemnity payments of claims plus legal costs). Reforms changing

the current medical tort systems could have an indirect affect on healthcare spending by

removing the incentive to providers to order additional tests, medications or procedures to

avoid litigation. If physicians do not have pressure to manage legal risk in practicing medicine,

they would be free to practice as they are trained to as clinicians.

The question then arises: what is going to prevent physicians from being reckless or

malicious? If the pressure of litigation is stressing some physicians to dot I’s and cross T’s, how

should the system continue to encourage and support physicians to always do right by their

patients if there are changes to the risk management dynamic? Also, what about patients that

are harmed by some practices. How can these victims be fairly compensated for their losses?

There is a definite need for additional applied research studies and policy discussions to explore

strategies to manage risk and ensure quality and accountability of physicians.

The professional goal or objective of a physician is to heal patients and not cause harm.

Technology and human practice have flaws and are not perfect. These imperfections can cause

mistakes or even deliberate harm. The medical tort system may have been well intended on

holding physicians accountable of their practices. However, the system has shown to influence

them into exposing patients to additional risk, limiting access to complex or risky care

interventions, and in the lease additional financial costs or logistical inconvenience to the

patients. The health care delivery system must always strive to do better and solve problems

that need resolving. We must explore reforms of our medical tort system, not necessarily for

the financial cost implications, but also for quality considerations.

McVeigh - Defensive Medicine 6

Medical liability drives physicians to practice defensive medicine. These practices add

cost, add medical risk, and limit access. The delivery system must always consider the Iron

Triangle of Health Care - cost, access and quality in deciding the future of health care delivery.

Defensive medicine practices must be addressed in this pursuit.

Quddus - DHA Admission Essay 7

References

Mello, M. M., Chandra, A., Gawande, A. A., & Studdert, D. M. (2010). National costs of the

medical liability system. Health Affairs, 29(9), 1569-1576.

https://doi.org/10.1377/hlthaff.2009.0807

Nahed, B. V., Babu, M. A., Smith, T. R., & Heary, R. F. (2012). Malpractice liability and defensive

medicine: A national survey of neurosurgons. PLoS ONE, 7(6), 1-7.

https://doi.org/10.1371/journal.pone.0039237

Sathiyakumar, V., Jahangir, A. A., Obremsky, O. T., Lee, Y. M., Apfeld, J. C., & Sethi, M. K. (2013).

The prevalence and costs of defensive medicine among orthogpaedic trauma surgeons:

A national survey. Journal of Orthopedic Trauma, 27(10).

https://doi.org/10.1097/BOT.0b013e31828b7ab4

Sethi, M. K., Obremskey, W. T., Natividad, H., Mir, H. R., & Jahangir, A. A. (2012). Incidence and

costs of defensive medicine among orthopedic surgeons inthe united states: A national

survey study. American Journal of Orthopedics, 41(2), 69-73.

Thomas, J. W., Ziller, E. C., & Thayer, D. A. (2010). Low costs of defensive medicine, small

savings from tort reform. Health Affairs, 29(9), 1578-1584.

https://doi.org/10.1377/hlthaff.2010.0146