qotd: Higher spending is associated with fewer malpractice claims

BMJ
November 4, 2015
Physician spending and subsequent risk of malpractice claims:
observational study
By Anupam B Jena, Lena Schoemaker, Jay Bhattacharya, Seth A Seabury

Conclusions

Despite evidence that the majority of US physicians report practicing
defensive medicine, no evidence exists on the broader question of
whether greater resource use by physicians is associated with fewer
malpractice claims. Our findings suggest that greater resource use,
whether it reflects defensive medicine or not, is associated with fewer
malpractice claims.

Discussion

Despite evidence that many physicians practice defensive medicine to
reduce the risk of malpractice claims, no evidence exists on the broader
question of whether a greater use of resources by physicians is
associated with a reduced risk of such claims. We investigated the
association between average resource use by physicians and subsequent
malpractice claims. In six of seven specialties, we found that greater
resource use was associated with statistically significantly lower
subsequent rates of alleged malpractice incidents. For example,
internists in the highest fifth of patient risk adjusted resource use
were less than half as likely to face a future malpractice claim
compared with those in the lowest fifth. Among obstetricians, those with
higher caesarean rates — a procedure sometimes considered to be
defensively motivated — had lower subsequent rates of alleged
malpractice. These relations held even when we adjusted for patient
characteristics and accounted for time invariant physician
characteristics such as patient mix, clinical skills, or communication
skills.

http://www.bmj.com/content/351/bmj.h5516-0.full.pdf+html

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Comment by Don McCanne

Much has been written about the high costs of defensive medicine -
excessive health care services that are delivered merely to protect
against the potential of malpractice lawsuits. This study tends to
reinforce the belief that there is a solid basis for defensive medicine
since higher spending on health care is associated with fewer
malpractice claims. But does this additional care represent defensive
medicine, or does it represent beneficial health care services that
prevent adverse outcomes?

Although physicians admit that they practice defensive medicine, do they
really do so strictly because of fear of lawsuits? Or do they do so
because there is a real possibility that the patient may experience a
significant adverse outcome because of the physician's failure to detect
or manage a serious medical condition? Invariably the latter concern
plays at least some role in the medical decisions made.

Imaging is probably the most common procedure that is thought all too
often to represent defensive medicine, especially when you consider how
many results are normal. But if the physician is 100 percent certain
that the imaging procedure will not demonstrate any pathology, then she
would not order it since she could not be sued for a condition that does
not exist. Imaging is ordered only when there is a real possibility of
an abnormal finding, even if the odds are low.

When physicians order low yield tests they often think of them as
defensive medicine. But as physicians back off on low yield testing, the
incidence of missed pathology increases, as does the risk of a
malpractice suit. Thus the test that picks up significant pathology is a
beneficial health care service and really should not be categorized as
defensive medicine only because it also has that benefit. The same
reasoning applies to a test that provides the benefit of reassurance
that the potential pathology is not demonstrated.

With concerns about the very high costs of health care, many recommend
that we do something to reduce all of this unnecessary defensive
medicine. The problem with that is, for the reasons mentioned, not much
of health care falls into the category of pure defensive medicine that
is of absolutely no clinical value. Therefore there is not much savings
to recover. You can talk about flat of the curve medicine or low yield
medicine, but as soon as you start eliminating care, you sacrifice the
health and well being of a few of your patients, not to mention that you
deprive many others of the reassurance they would have from a negative test.

Another point is that so called defensive medicine is a very small
percentage of the $3 trillion we are spending on health care, and we can
afford that. After all, much of it is still beneficial.

If we really want to reduce waste, we should eliminate the profound
administrative excesses of our dysfunctional, fragmented, multi-payer
system, by adopting a single payer national health program. We would
recover hundreds of billions of dollars that way. That is in contrast to
this study that shows that spending more on patients is associated with
a lower incidence of lawsuits. Whether we label that defensive medicine
or beneficial health care services, we are not going to find much
savings there.