Study: Doctors order tests out of fear of lawsuits

By MARILYNN MARCHIONE, AP Medical Writer Marilynn Marchione, Ap Medical Writer – Wed Feb 16, 6:56 pm ET
SAN DIEGO – CT scans, MRIs and other pricey imaging tests are often more for the doctor's benefit than the patient's, new research confirms.

Roughly one-fifth of tests that bone and joint specialists order are because a doctor fears being sued, not because the patient needs them, a first-of-its-kind study in Pennsylvania suggests.

The study comes a day after President Barack Obama began a push to overhaul state medical malpractice laws as a way to reduce unnecessary tests that drive up health care costs.

"This study is a glimpse behind the curtain of what's happening in a doctor's mind," said its leader, Dr. John Flynn of Children's Hospital of Philadelphia. If doctors sense you might second-guess them or cause trouble, "you could potentially be risking more tests being done."

Results were reported Wednesday at an American Academy of Orthopedic Surgeons conference in California.

Patients expect the highest level of care and think this means the most advanced technology, Flynn said. Many patients feel better when a doctor orders lots of tests — until they get the bill.

Besides hurting your wallet and adding to health care costs, unnecessary tests can expose people to radiation that accumulates over a lifetime and can raise the risk of cancer. Ordinary X-rays are rarely a concern, but an MRI, or magnetic resonance imaging scan, can cost $1,000 or more. And super-sharp X-rays called CT scans involve relatively large radiation doses.

Yet doctors often order tests they don't really think a patient needs because they fear being sued if the diagnosis was wrong or they miss detecting a problem.

Previous studies of how often this happens have relied on doctor surveys. This is the first one to enlist doctors in advance to track their decisions over time.

It involved 72 orthopedic surgeons throughout Pennsylvania who tracked tests they ordered on 2,068 patients, mostly adults, in ordinary office visits, emergency rooms and other settings. Doctors checked a box saying a test was either required for clinical care or done "for defensive reasons."

Defensive imaging accounted for 20 percent of total tests — 11 percent of X-rays, 38 percent of MRIs, 33 percent of CT scans, 57 percent of bone scans and 53 percent of ultrasounds.

Defensive medicine also accounted for 35 percent of costs, nearly all of it from MRIs.

One example: a torn meniscus, a knee cartilage injury that is a leading reason for knee surgery. Studies have shown that a doctor's judgment based on symptoms and an exam is even better than an MRI to diagnose the condition. Yet patients hardly ever go to surgery without having the imaging test, Flynn said.

Surprisingly, the study found that newer doctors were less likely to be defensive.

"That's counterintuitive," Flynn said. "You would expect when you're new in practice, not as trustful of your clinical judgment, you'd order more."

Doctors who have been sued in the last five years were more likely to order tests defensively, said Robert Miller, a Temple University medical student who helped lead the study and presented the results at the conference. The authors said similar studies are needed on defensive imaging in other specialties.

Dr. Lawrence Wells, a Philadelphia surgeon who participated in the study, said doctors learn to develop "a radar" for problem patients.

"It's disheartening" to be sued, he said. "Someone's accusing you of a bad outcome or a wrong," and that can affect how a doctor behaves the next time he sees a similar case.

Patients need to trust their doctor's judgment on what is needed, Wells said.

On Tuesday, Obama made a budget proposal that includes money to help states rewrite malpractice laws. Possible measures include caps on awards. The administration also has proposed health courts where specially trained judges rather than juries would decide such cases.

Questions to ask about a medical test:

_Is it truly needed? How will it change my care?

_Have you or another doctor done this test on me before?

_Does the test involve much radiation and is there an alternative that does not?

_How many images are needed?

_Do you have a financial stake in the machines that will be used?

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http://news.yahoo.com/s/ap/20110216/...ts_malpractice

"Patients need to trust their doctor's judgment on what is needed"

Except there's huge variance in what doctors say is needed, some of it legit disagreement about treatment, but the biggest driver is the doctor is recommending treatment he sells, like any good salesmen, what brings him the most income.

I always laugh when I hear UCA medicine is moving towards "evidence based" medicine. But they're moving away from what? :lol

This is old news. This is a practice done for a long time to help prevent malpractice suits. One reason why our medical system costs so much, but no... You don't believe what I said years ago, until you read a study that says so.

we needed a study for this?

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Originally Posted by Wild Cobra

This is old news. This is a practice done for a long time to help prevent malpractice suits. One reason why our medical system costs so much, but no... You don't believe what I said years ago, until you read a study that says so.

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:rolleyes

Nice try.

You have long advocated tort reform as some magic bullet, as if limiting the ultimate amount of liability will prevent this, and I didn't, and don't buy that.

Tort costs don't directly factor into health care cost growth, but defensive medicine is always something I have admitted to taking place.

It is one of the reasons, but not *the* reason for medical cost inflation.

Lots of moral hazard in the medical field.

Doctors wanna make money. Most people won't challenge any expense anyways since they don't feel the pinch (because insurance covers and they're just paying a small copay, if that). Unless it's a major procedure, the insurance pays because they already negotiated to pay just a portion of what the doctor wants.

I'm always kind of skeptical when the doc orders a test for a device he has right there in his office. Ultimately, what are you gonna do? He's the doc. I have felt uncomfortable in the past though with stuff like that.

Sorry RG, but

DUH!

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Originally Posted by ElNono

I'm always kind of skeptical when the doc orders a test for a device he has right there in his office. Ultimately, what are you gonna do? He's the doc. I have felt uncomfortable in the past though with stuff like that.

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+1

I was referred by regular doc to an allergist a while back.....went to the allergy doc a who ordered me to take a test right there in his office........and later found out it wasn't covered on my insurance.

Got a bill for $60 for a 5-10 minute test. I tried to tell insurance that he ordered me to take it, but they argued it wasn't necessary.

live and learn to ask "how much will this cost me" as much as possible I guess.

(We've been asked not to post AP content here. Dunno if AP has bothered Kori Ellis and timvp lately, but they have in the past.)

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Originally Posted by 101A

So the U.S.'s PUBLIC per capita expenditure on healthcare is THIRD in the world? What are you liberals so upset about?

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GF - wtf does this have to do with who pays for the coverage; this is about the billing, not payment side.

Also, it ain't the libs pushing for tort reform; they're the ones in bed with the trial lawyers, remember?

You need to direct your anger better.

Also, the article misses a major contributor to the unnecessary tests; who owns the radiology labs. Often the same docs ordering the tests.

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Originally Posted by DarrinS

Sorry RG, but

DUH!

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No need to be sorry. That was my reaction.

It is good to get actual data on the subject though, even if it was really obvious to anyone with some common sense.

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Originally Posted by Winehole23

(We've been asked not to post AP content here. Dunno if AP has bothered Kori Ellis and timvp lately, but they have in the past.)

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HMM. That is what I remember.

Easy enough to find reuters or other mention of it. Yahoo news uses AP a lot though.

I like yahoo as an aggregator for news. Much better structure and depth than google.

There seem to be three distinct issues here:

1. Tort Reform

2. Tests ordered to be performed on doctor-owned equipment

3. Varying concepts of what constitutes 'good medicine"

Tort reform in not the sole answer to increased health care costs, but, if done properly and fairly, could certainly contribute to lessening the rate of health care cost inflation.

It is not enough to say "Well, tort reform was done in this-and-such a place and hasn't had a material effect on health care costs."

Certainly, tort reform (which should be different than disallowance of any suit for damages in any case at all) is a necessary but insufficient condition for significantly lowering health care costs.

"could certainly contribute to lessening the rate of health care cost inflation."

bullshit. Tort reform in TX has had no effect on doctors' insurance rates or on lessening health care costs.

Tests ordered by doctors on equipment that they own or have a financial interest in are,in my mind, ALWAYS suspect.

I just had an annual physical the other day and noticed a sign in the waiting room that said "we now offer such-and-such a test in our own offices. I knew then that I would be given that test, and sure enough, I was.

I have refused certain tests three times in the past three years because it has been clear to me that they were unnecessary. It pisses me off when they try it. In each case that I refused, though, it was because I had had a similar or identical test to the one being ordered in the recent past, and knew that those tests results were available, and that whatever condition was being tested could not possibly have changed within the time frame of the last test and whatever one they wanted to do.

This one is clearly a case of docs wanting to recover their costs ASAP, I think.

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Originally Posted by boutons_deux

"could certainly contribute to lessening the rate of health care cost inflation."

bullshit. Tort reform in TX has had no effect on doctors' insurance rates or on lessening health care costs.

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Damn, b-d. This is EXACTLY why I made the point I did about "it is not enough to say "tort reform was tried in this and such a place and health care costs didn't come down materially".

Your argument is logically fallacious. To say that a single attempt in a particular place failed to produce optimal results as an example of a failed premise that 'properly done tort reform will be an integral part of any comprehensive health care cost reduction is just flat out nonsensical.

If tort reform was properly construed to prohibit frivolous lawsuits, while simultaneously allowing serious and well-founded suits to proceed to fruition with proper financial recompense, that could certainly help keep down medical insurance for doctor's, which could keep down doctor's fees.

The 'varying concepts of what constitutes good medicine' goes back to the initial development of HMO's, which were predicated on the belief that 'early diagnosis' of an illness could allow more cost-effective treatment options, rather than waiting until a disease was so far along that huge interventions were necessary to stop the progress of the disease.

Many of the older docs referenced in the article may well be a product of that era of medical thinking.

Quote:

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Originally Posted by EVAY

The 'varying concepts of what constitutes good medicine' goes back to the initial development of HMO's, which were predicated on the belief that 'early diagnosis' of an illness could allow more cost-effective treatment options, rather than waiting until a disease was so far along that huge interventions were necessary to stop the progress of the disease.

Many of the older docs referenced in the article may well be a product of that era of medical thinking.

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Actually HMO's were initially formed to insure specific groups of emploees (LA public ones, I belive). The model was purely financial; the industry picked up the phrase "HMO" for marketing purposes. Apparently, it worked; )

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Originally Posted by EVAY

If tort reform was properly construed to prohibit frivolous lawsuits, while simultaneously allowing serious and well-founded suits to proceed to fruition with proper financial recompense

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Isn't that what judges are for? To throw out baseless claims and adjudicate serious ones?

Tort reform, no matter how "perfectly" construed, will have almost no effect on health care costs because medical malpractice payouts

http://www.kaiseredu.org/Issue-Modul...und-Brief.aspx

President Obama at a recent town hall meeting said he wants to reduce doctors’ insurance premiums, but that, based on his conversations with health care experts, “the evidence at least is that that is a very small, maybe not even a measurable factor in the reason that health care costs are going up.”

http://washingtonindependent.com/555...lth-care-costs

Repug/conservative tort reform is nothing but a huge red herring distracting from the real cause of skyrocketing sick-care costs.

TX got the tort reform the reformers wanted, and sick-care costs haven't changed.

It's impossible to separate which tests are ordered for defensive purposes, or because the doctor get a good slice of the test fee.

Quote:

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Originally Posted by 101A

Actually HMO's were initially formed to insure specific groups of emploees (LA public ones, I belive). The model was purely financial; the industry picked up the phrase "HMO" for marketing purposes. Apparently, it worked; )

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And the current medical thinking at that time was that the 'health maintenance organization' could keep costs from going through the roof for such groups by doing 'preventive, i.e., early diagnostic medicine' to keep the insured group from being hit with catastrophic illnesses that drove up costs for everyone. The belief upon which they were sold to companies and unions was to maintain good health by addressing health issues before they became critical. Therefore, testing for a wide variety of illnesses became commonplace. Now you can't get away from the testing...but it was originally done for industry groups to hold down costs, by keeping healthy employees healthy and productive for longer periods, without being taken out of the workplace for too long with illnesses that could have been prevented if tested for and caught in a timely manner.

I was working in the HR department of a specific company who was sold on this idea on this basis. It looked extremely useful for huge companies that were essentially self-insured.

I remember losing my doctor of long standing at the time because he refused to put up with the paper work of an HMO. Now, when someone loses the ability to use their long-standing doctor the government is being socialistic.
Different interpretations for different providers, I guess.

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Originally Posted by Winehole23

Isn't that what judges are for? To throw out baseless claims and adjudicate serious ones?

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But even getting to the point of arguing whether or not a case should go forward involves legal fees out the wazoo, and adds to already backlogged court proceedings.

Of greater concern, I believe, is in the cases where someone can show genuine harm, but juries get involved in run-away money settlements. These are areas where insurance premiums are impacted so much, seemingly.

Tort reform gets a bad name, I believe, in part because of the perception that if tort reform is enacted, plaintiffs will have no further recourse in the event of wrongdoing. That is not necessarily the case. Tort reform could focus on the size of settlements, and reduce the insurance premiums accordingly. There is no guarantee that premiums would be reduced, but competition among insurance companies could certainly mitigate it somewhat.

Having said all of this, however, it won't really matter, because the ABA lobby will ensure that tort reform has little or no strength. Hence, the reported ineffectiveness of tort reform in Texas. If it doesn't change anything, there is no point. But just because it hasn't changed anything yet doesn't mean that a better constructed reform law couldn't. That was my point to b-d.

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Originally Posted by EVAY

But even getting to the point of arguing whether or not a case should go forward involves legal fees out the wazoo, and adds to already backlogged court proceedings.

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I think that's a point most people don't grasp. We are innocent till proven guilty, but in the meantime, how does a doctor make an income while he's in court. How does he pay a lawyer when he's spending more time in the courtroom than seeing patients. Settling is too often the cheaper way out, even when solidly innocent.