Tuesday, August 28, 2012

The Medical Overtreatment Problem

It’s just as well that Tara Parker-Pope does not speculate about the cause of the problem. Sometimes it is sufficient to describe the problem and allow us to reflect on the cause.

The medical profession, Parker-Pope reports, has developed an unfortunate tendency to overtreat patients. Often, unnecessary treatment and tests make patients worse than they would have been otherwise.

In her words:

When it comes to medical care, many patients and doctors believe more is better.

But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.

A few weeks ago Dr. Sanjay Gupta wrote an article—dutifully reported here—in which he attributed overtreatment to the fear of lawsuits.

You cannot get sued for ordering too many tests or too many hospitalizations.

A physician can inoculate himself against lawsuits by ordering tests that patients, mostly, do not have to pay for and overtreament becomes endemic to the system.

Parker-Pope gives me the impression that there is more to it than the fear of lawsuits.

She explains:

Some complained that when they switch doctors they are required to undergo duplicate blood work, scans or other tests that their previous doctor had only recently ordered. Others told of being caught in a unending maze of testing and specialists who seem to forget the patient’s original complaint. I heard from doctors and nurses, too — health professionals frustrated by a system that encourages these excesses.

Or, consider the experience of Kara Riehman:

Sometimes the toll of too much medicine is brief, but emotional. Kara Riehman, 43, of Atlanta was vacationing in California when she lost a struggle with an ironing board in her hotel room and ended up with a black eye.

As the bruising peaked around 10 days, she called her doctor to make sure everything looked normal. But instead of seeing her, the doctor, through a conversation with the nurse, ordered a CT scan. She had no symptoms other than a bruised eye, but the doctor never spoke with her or examined her. The scan came back with an ambiguous finding, and the nurse told her it could be a tumor. She was then given an M.R.I. and for two weeks while she waited for the results, she worried she had brain cancer. The nurse called to tell her the M.R.I. was fine.

“It was really terrible,” she said. “It was only two weeks, but there is a lot of cancer in my family. I never actually talked to my doctor through this whole thing.”

The total cost to her insurance company was about $7,000. “It did change how I think about interacting with the medical system,” Ms. Riehman said. “It made me much more of a questioning consumer.”

One does not, as a non-physician, want to start second-guessing physicians. In this case the physician might reasonably have wanted to be cautious. And yet, the physician did not examine her or speak with her throughout her ordeal.

Most of Parker-Pope’s examples are anecdotal, and yet, the research suggests that the problem is pervasive.

From reading her story, one must conclude that physicians themselves bear some responsibility for the problem.

Beyond the fear of malpractice lawsuits, physicians often have a vested interest in prescribing extra care or extra tests or additional follow-up visits. All of them generate income for someone.

Thanks to trial lawyers and patient advocates we have all been taught that every American deserves the best medical care. The more the better.

And every American has been inculcated with the notion that physicians are venal and error-prone, to the point where we need armies of lawyers to protect us against their predatory impulses.

In this culture the practice of medicine has become an adversarial procedure. If it is acceptable for the lawyers to rip off the system, why shouldn’t physicians do the same? If people are dying because of physician error why wouldn’t physicians overtreat and overprescribe… not because they think that it is the best way to help their patients, but because they believe it is the best way to protect themselves against lawsuits and to enrich themselves.

Some will read these stories and conclude that we need malpractice reform. They will note that since Obamacare scrupulously protects the vested interest of trial lawyers it will never succeed in correcting this problem.

Others will examine the facts and decide to double down. They will conclude that we need more regulation, more government control and more trial lawyers policing the system.


JP said...

Medical malpractice is a dying industry for lawyers.

So is personal injury, for that matter.

Whatever's happening in the medical system, it's not because lawyers are able to scam the system.

For whatever reason, the sun is setting on the golden age of trial lawyers.

Stuart Schneiderman said...

Thanks for the information. Where can we go to read up on this... and, if it's not the lawyers, how does one explain the overtreatment problem?

JP said...

It's probably hard to find a non-biased source.

Law publications will stress how little medical malpractice contributes to health care costs, whereas medical publications will point their fingers at attorneys.

The overtreatment problem could, in part, be a lagging response to the golden age of trial lawyers when the John Edwardses of the world really made some money.

There has been significant tort reform. There have also been limits on damages.

Also, you will find pockets of plaintiff-friendly courts who still award lottery-type winnings because the jury pool likes to give money to it's friends.

Law's just hard to pin down from a systemic approach since each jurisdiction is different.

Stuart Schneiderman said...

Thank you for the clarification. I suppose that we would have to look at the incidence of overtreatment in states that have enacted malpractice reform and its incidence in states that have not.

Gupta, of course, was responding to the lawyers by showing that the practice of defensive medicine has many costly consequences, beyond the cost of malpractice insurance.

Sam L. said...

"And every American has been inculcated with the notion that physicians are venal and error-prone, to the point where we need armies of lawyers to protect us against their predatory impulses." That's what Obama told us, including unneeded amputations.

Dennis said...

Of course the ABA would present a study that says the high cost of medical care is not the legal profession's fault. As there is increasing realization that litigation, especially nuisance suits, are raising the cost of almost everything in this country we are going to see more of this kind of legal justification.
If this was not about the money then lawyers would do malpractice litigation as "pro bono" and the jury awards would go to those who have been wronged instead of their own pockets.
There are good lawyers who take their responsibilities to the public seriously and then there are those who use the legal system to extort the rest of us. It does seem that "Due Process" has become the money due in the process. One can almost envision a conveyor belt winding its way through the court house with a large number of hands reaching out and taking their share of the money due in that process.
I have gotten to know a number of lawyers, judges and doctors and the honest ones will tell you that litigation DOES cause doctors to practice CYA medicine to the detriment of everyone involved.

Anonymous said...

Litigation doesn't affect the cost of healthcare much at all. A 2010 Harvard Study placed the costs at $55.6 billion, or 2.4% of healthcare spending. Studies, including one from the Bush White House, came to about the same conclusion.

States that have passed malpractice reform, like California and Texas, have shown NO decrease in costs. In fact, costs in those states are rising faster than the national average.

The number one reason doctors order extra tests is that they don't know what exactly is going on. An expensive MRI, for example, is more accurate than a physical exam. COnsidering all the information a doctor has to know, getting an MRI becomes rote, and you teach that to the next generation of doctors.

Doctors want to pay lower malpractice insurance rates, and malpractice reform does address that (somewhat). But let's not fool ourselves into thinking that malpractice fears have much to do with the rising cost of healthcare.

Stuart Schneiderman said...

I'm wondering what you make of Sanjay Gupta's argument, to the effect that physicians order far more tests than they need to because they fear lawsuits, and that these tests sometimes produce false positives that provoke unnecessary treatments.

Are you saying that physicians do not overtreat their patients at all?

I would like to see a reference to the situations in California and Texas... all told these states are governed by very different principles, so I am curious about the comparison.

Thanks for contributing to the discussion.

Dennis said...

It would be interesting to remove the costs of treating illegal aliens and their families in both of these states. Both of which have a huge population of illegals. It would seem that using California and Texas as an example has problems of its own They may be governed by different principles, but they essentially have the same problems. One that increasingly adds to the costs of services in more and more states.
Add to that 23 million people without jobs who still use emergency rooms and require medical care and we begin to see that health care costs are going to rise.