Thursday, August 2, 2012

Really Affordable Medical Care

Everyone wants to make medical care more available and more affordable.

Many people believe that Shakespeare had the solution to an important aspect of the affordability problem: “The first thing we do, let’s kill all the lawyers.”

Not literally, of course. But still, Shakespeare was prescient beyond even his imagination.

It should go without saying, but during the public debate about Obamacare, few mainstream media outlets addressed the issue of malpractice reform. Since trial lawyers are an integral part of the Democratic party, one understands that the hyper-partisan media would have ignored their influence on the cost of medical care.

Now, however, that the Supreme Court has ruled in favor of Obamacare, reputable professionals are now addressing the malpractice issue.

Among them, Dr. Sanjay Gupta, of CNN. Writing in The New York Times, Gupta explains the different aspects of the problem.

First, American physicians prescribe a “staggering number of tests and procedures” when compared with other nations.

Second: they do so because they need to protect themselves against “potential lawsuits.”

Third: the more physicians prescribe tests, the more they increase risk to the patient. In and of themselves, procedures expose patients to risk.

Fourth, when procedures yield “false postives” physicians prescribe treatments that are unnecessary or even harmful.

This means that the mania about malpractice is not only increasing the cost of American medicine but is indirectly making people sick.

In Gupta’s words:

But a reasonable estimate is that medical mistakes now kill around 200,000 Americans every year. That would make them one of the leading causes of death in the United States. Why have these mistakes been so hard to prevent?

Here’s one theory. It is a given that American doctors perform a staggering number of tests and procedures, far more than in other industrialized nations, and far more than we used to. Since 1996, the percentage of doctor visits leading to at least five drugs’ being prescribed has nearly tripled, and the number of M.R.I. scans quadrupled.

Certainly many procedures, tests and prescriptions are based on legitimate need. But many are not. In a recent anonymous survey, orthopedic surgeons said 24 percent of the tests they ordered were medically unnecessary. This kind of treatment is a form of defensive medicine, meant less to protect the patient than to protect the doctor or hospital against potential lawsuits.

Herein lies a stunning irony. Defensive medicine is rooted in the goal of avoiding mistakes. But each additional procedure or test, no matter how cautiously performed, injects a fresh possibility of error. CT and M.R.I. scans can lead to false positives and unnecessary operations, which carry the risk of complications like infections and bleeding. The more medications patients are prescribed, the more likely they are to accidentally overdose or suffer an allergic reaction. Even routine operations like gallbladder removals require anesthesia, which can increase the risk of heart attack and stroke.


JP said...

The problem is that the 200,000 preventable deaths a year mean that there are 200,000 cases of malpractice where the doctors (or other indivuals) who caused such deaths need to be violently sued for malpractice.

George Boggs said...

Regarding CNNs Flatulent Head:

"Since 1996, the percentage of doctor visits leading to at least five drugs’ being prescribed has nearly tripled..."

Before that statement has any meaning, we need to know the base rate. Has 0.00001% increased to 0.00003%, or has 10% increased to 30%?

And I'm not sure whether, in either case, it's necessarily bad, or simply a reflection of more highly targeted pharmaceuticals.

"...and the number of M.R.I. scans quadrupled."

The MRI wasn't even approved by the FDA until 1984. Was its adoption faster than that of X-ray technology? Or skin grafting? Or bypass surgery?

I hold no brief for lawyers, but it seems to me that attributing the diffusion of advanced treatments is neither necessarily bad nor the fault of the tort bar.

I do think, though, that medical malpractice should be handled by administrative courts and not jackpot juries.

Stuart Schneiderman said...

I think your point well taken, though I am assuming that for CNN and the Times to run a story that makes the trial lawyers look bad, the reality is probably worse than they are saying.

To me the important point is not just that doctors order more tests-- 24% for an orthopedist-- than anywhere else in the world, but that these tests can produce illness all by themselves. And they can produce false results that lead to expensive treatments.

In other words, it's not just about the extra tests; there's a ripple effect throughout the health system.

As you say, there has to be a better way to deal with malpractice.

Nick said...

My uncle is a psychiatrist who voted for Obama. A large chunk of is income is consumed by malpractice insurance and he hates it. I remember during the health care debate he kept saying, "Go after the trial lawyers! Go after the trial lawyers! Why aren't they going after the trial lawyers?! They're the problem!" Why he thought Democrats would do so is understandable - I think people were expecting them to actually solve problems after we fired the Republicans in 2008. Boy, have they failed.

@inpatientmed said...

I didn't read the linked article, but will still posit that your interpretation is a little off. I don't see any medical professional's or organization really pushing to hold trial lawyers accountable. If fact, I think the opposite is true.

As you are probably aware many medical governing bodies are proposing guidelines to limit medical testing in certain circumstances. The example is The ACP's Choose Wisely program. In it they make recommendations to physicians to stop ordering tests in situations where they aren't necessarily indicated. For instance, don't perform ECG's on healthy patients, don't order stress tests on patients w/ atypical chest pain, stop ordering CT's of the chest in patients w/ low pre-test probability of having PE's.

It is a laudable goal, but misses the point of why these tests get ordered in the first place. That is to protect physicians from litigation from that one patients that has a bad outcome.

Your point regarding the ripple effect of such testing is thought provoking and undoubtedly true, but I see no evidence that anyone is really taking tort reform seriously. Instead, a glorified public service announcement is being paid for be physician organizations that makes physicians look stupid, naive and greedy.

It is infuriating.

JP said...

Medical malpractice from the point of view of the attorney is a very judge/jury based issue.

For instance, I'm in a no-cash region. That means that you aren't going to win a trial in this county against a doctor. Ever. Plus, they just passed tort reform.

Compare with a place like Philadelphia, which is like an ATM dispenser.

They just need to fix the payments for doctors who kill people (meaning fixed payout per death) and then ban the doctors who do the killing from practicing medicine ever again. They can go to law school instead.

Problem solved.

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