The Cost or Benefit from Practicing Defensively: Managed Care 101 in 2010 (Part V)

A survey in Massachusetts on the practice of defensive medicine found that 38% of responding physicians reported they have reduced the number of high-risk services they perform--Orthopedic surgeons by 55%, Ob-Gyn’s by 54%, General Surgeons by 48%. Additionally, 28% of physicians sampled reported they have been reducing the number of high-risk patients they will see, with Ob-Gyn’s, 44% less and the Surgical specialties, 37—42% less.

The contention of this report by the Massachusetts Medical Society is that fundamental change is necessary to mitigate the negative impact of the current dysfunctional liability system on healthcare.

Defensive medicine may come in various forms, including: ordering medically unnecessary laboratory or radiologic tests, prescriptions, referrals to specialists or hospital admissions, and/or the avoidance of high-risk patients or procedures.

Nevertheless, while defensive medicine has been highlighted as a major driver of healthcare costs here and elsewhere, some studies, including a 2004 Congressional Budget Office review, question how much impact reform in this area will have. In addition, the vast majority of people in this country have managed care coverage and that comes with utilization review and management; UR&M is designed to be help control this by looking at tests and procedures practitioners are ordering, making sure that is medially appropriate and reasonable (i.e., medically necessary) and thereby covered. UR&M is a touchy subject, however, among doctors--no one likes criticism, especially when patient demand, fear of litigation, concern over losing the patient to someone who will do the test or procedure, and that a one in a thousand chance the test or procedure might find something unexpected is worth doing it; what I call “mindless medicine.”

Results of the survey:

7 tests and procedures Physicians were asked about their use of seven tests and procedures: plain film X-rays, CT Scans, Magnetic Resonance Imaging (MRIs), ultrasounds, laboratory testing, specialty referrals and consultations, and hospital admissions. The results were self-reported by the physicians responding to the survey.

• 83% of the physicians surveyed reported practicing defensive medicine. (There were 8 specialties represented in the survey, which only account for 46% of the physicians in Massachusetts)

• An average of 18-28% of tests, procedures, referrals and consultations and 13% of hospitalizations were attributed to the practice of defensive medicine.

• The estimated annual costs of defensively-motivated radiological imaging, laboratory testing, and consultations or referrals was $281 million in 2006 dollars for the eight specialties surveyed (based on Medicare reimbursements rates in Massachusetts for 2005-2006).

• In addition, the cost of unnecessary hospital admissions was estimated to be $1.1 billion, for a combined total estimate of nearly $1.4 billion.

It is noteworthy that these estimates of cost do not include tests and diagnostic procedures ordered by physicians in other specialties, observation admissions to hospitals, specialty referrals and consultations, or unnecessary prescriptions.

It is likely that defensive medicine may be motivated less by concerns of liability than by positive (albeit minute) benefit to patients or, insidiously (sort of a conflict of interest), the income it generates. However, even though the savings from reducing defensive medicine might be very small, no one disputes that reform is needed, regardless, to foster trust, improve patient safety, equitably compensate patients who have ben harmed, garner transparency and allow more open communication, healing and patient satisfaction. Garnering those objectives might even reduce defensive medicine.

See “Investigation of Defensive Medicine in Massachusetts, Nov. 2008” [PDF] [Last accessed 11/19/08]

Given the inevitable conflict in views, what are your feelings or comments about the direct AND indirect costs of working as a practitioner in a litigious society?