The results of a first-of-its kind survey of Massachusetts physicians about the practice of “defensive medicine” — tests, imaging, hospitalizations, referrals and consultations ordered by physicians out of the fear of being sued — should capture the attention of everyone concerned about health care and its costs in the Commonwealth.
Conducted and sponsored by the Massachusetts Medical Society, the Investigation of Defensive Medicine in Massachusetts has shown that the practice is widespread, adds billions of dollars to health care costs, reduces access to care, and may be unsafe for patients.
The study, which conservatively estimates a portion of these defensive practices to cost a minimum of $1.4 billion annually in the state, is the first to specifically quantify defensive practices across a wide spectrum and among a number of specialties and the first to link such data directly with Medicare cost data.
The findings are consistent with a smaller 2002 study by Common Good, a non-profit, non-partisan legal reform coalition, that reported nearly all physicians and hospital administrators feel that unnecessary or excessive care is often or sometimes provided because of the fear of litigation.
The survey found that 83 percent of physicians reported practicing defensive medicine and that an average of 18-28 percent of tests, procedures, referrals and consultations and 13 percent of hospitalizations were ordered for defensive reasons.
But that’s only part of the story. The survey included physicians in just eight specialties, accounting for only 46 percent of the physicians in the state. The cost estimates don’t include defensive practices ordered by physicians in other specialties and do not include observation admissions to hospitals, specialty referrals and consultations, or unnecessary prescriptions. Thus, the real cost is likely several billion dollars.
The implications of defensive medicine, however, go far beyond costs. Defensive medicine restrains access to care, as physicians decline to perform high-risk procedures and avoid caring for high-risk patients. According to the survey, 38 percent of physicians have reduced the number of high-risk services they performed and 28 percent have reduced the number of high-risk patients they serve. This confirms the results from previous studies: Over a five-year period, medical society workforce surveys have consistently seen an average of 44-48 percent of physicians say they alter or limit services out of the fear of being sued.
Defensive medicine also raises safety issues: patients exposed to unneeded imaging tests face the risks of radiation exposure, and many surgical procedures like Caesarean sections have increased because of liability concerns.
The conclusions are clear: defensive medicine is expensive, reduces access, and poses unnecessary risks for patients. But because the fear of litigation is so pervasive, the practice remains a widespread. The potentially dire economic, personal, and professional consequences that may result from a lawsuit are simply too great for physicians to leave to chance.
The Commonwealth has become the model for the nation with its health care reform. Yet the irony is that as we continue to struggle with exploding expense – which most experts agree is the single biggest threat to the success of health care reform – we continue to spend billions on defensive medicine.
Reducing and even (in the best of all possible worlds) eliminating the practice of defensive medicine would significantly curtail our overuse of resources and unnecessary spending. Such a goal should be high on everyone’s list of health care priorities.
This goal will only be achieved, however, with a much-needed, long overdue reform of the medical liability system. Physicians practice defensive medicine because they don’t trust the system, regarded by many to be dysfunctional for both patients and physicians, and one that breeds secrecy and mistrust and impedes safety efforts.
A fundamental transformation is needed. One model, such as the one proposed by The Joint Commission, enhances patient safety; encourages open communication, full disclosure and transparency; offers sincere apology for avoidable injuries with timely and fair compensation, and resolves disputes with mediation and arbitration. Lawsuits should be a last resort. This model is efficient, timely, equitable, and encourages evidence-based medicine rather than defensive medicine.
Results of this survey should provide a strong impetus for legislative, business, and health care industry initiatives for fundamental liability reform. The physicians of the Commonwealth are sending a strong message. Government and health care industry leaders must ask: Are we willing to listen and begin a dialogue for reform? Or are we content with continued dysfunction, eroding trust, and soaring costs?
Alan C. Woodward, M.D., is a past president of the Massachusetts Medical Society and Vice Chair of its Committee on Professional Liability.
Thank you Dr. Woodward for your discussion of defensive medicine. I agree that defensive medicine practices represent a substantial portion of our our-of-control healthcare costs and that we must work to reform this system that engenders a culture of fear. As a first year medical student, I admit that our current system fraught with high malpractice premiums and stories of physicians faced with litigation is something I fear, particularly as I face the decision of which field of medicine to enter. I have always wanted to work in women’s health, but have seen many OB/GYNs quit the OB part of their practice due to high malpractice costs.
I think it is important however, to recognize that the motivation behind our legal system may be in the right place as it seeks to hold physicians accountable for their practices to ultimately provide safe, high-quality healthcare to patients. If we are to reform the legal system, we must begin to investigate and implement alterative mechanisms for achieving this end. Your mention of the One Model proposed by The Joint Commission sounds especially promising, particularly for its emphasis on open communication, full disclosure and transparency. I would like to add that we must also work towards an ideological shift that begins with acceptance from both the medical community and the public at large, that physicians are only human and as much as we seek to minimize mistakes, they are to some degree inevitable. Only through the honest humility to recognize and admit our fallibility as physicians can we move forward towards the next step of preventing future medical error in the provision of safe, high-quality healthcare to our patients.
Reform in this area of health care is absolutely essential. As stated above, defensive medicine is costing billions of dollars and, in many cases, causing unnecessary harm to both patients and health care providers. Unfortunately, American culture must undergo great change in order to acknowledge this. Most immediately, it may be beneficial to look to systemic improvements that could aid in the minimization of human error. Computerized medical records could help to achieve this as would standardization of resources and their locations in health care settings. Force functions could also help immensely by inhibiting certain mechanically mediated errors such as incorrect medicine administration or dosage.
Addressing systemic error will only bring us so far before we must achieve a cultural reform in which both medical professionals and the public accept the fact that human error is inevitable. By reducing the blame, shame, and personal responsibility associated with error, the medical community can encourage dialogue and strategic initiatives among health care professionals to minimize its occurrence. If the American people see these efforts, perhaps, they will begin to treat health care professionals with more compassion when error unavoidably takes place.