Palin, have a tort, Obama

[Emma]

"Defensive medicine" adds to the cost of healthcare, but it's difficult to determine what is 'defensive' and what is (now) accepted practice.

In my own humble opinion, it's driven more by demanding patients than any other factor. The general attitude I see is "find it and fix it!". They simply don't accept that sometimes we can't 'fix' everything wrong with 'em.

There is this attitude that they can abuse their bodies, be non-compliant with treatment plans and do whatever the hell they want because in the end, medicine can fix whatever ails them. Personal responsibility has completely flown out the window. It's not their fault they're in the shape they're in; it's medicine's fault for not repairing the damage they've done to themselves over the years.

This is a relatively new phenomenon, IMO. When I started out back in the early 80's, this attitude was rare. I'm not sure what caused such a shift. Perhaps it was TV, where everyone gets all better in an hour's time, or a perverted interpretation of 'patients' rights', or (my own personal pet peeve) hospitals' focus on 'customer satisfaction' and employing the likes of Press Ganey to dictate our practice.
---------
FactCheck.org: President Uses Dubious Statistics on Costs of Malpractice Lawsuits
----------

JAMA -- Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment, June 1, 2005, Studdert et al. 293 (21): 2609

[This is a study aimed at high-risk specialties (emergency medicine, general surgery, neurosurgery, obstetrics/gynecology, orthopedic surgery, and radiology) in a high-risk area.]

Technology plays a key role in defensive medicine, and in malpractice liability generally.34 Specialists reported using technology to pacify demanding patients, bolster their own self-confidence, or create a trail of evidence that they had confirmed or excluded particular disease entities. For example, assurance behavior in our study often involved cancer diagnoses in younger patients who had consulted obstetrician/gynecologists or orthopedists. Advances in diagnostic and therapeutic technologies make early detection of cancer both feasible and beneficial, and increase the likelihood that a missed diagnosis will be ruled negligent and assessed substantial damages.

Defensive use of technology is self-reinforcing. The more physicians order tests or perform diagnostic procedures with low predictive values or provide aggressive treatment for low-risk conditions, the more likely such practices are to become the legal standard of care.
-------

Defensive medicine may reduce or improve quality, depending on the circumstances.36 Most assurance behaviors described, such as additional diagnostic testing, were not harmful to patients and perhaps even offered marginal benefits. Referral of difficult cases to more specialized physicians or better equipped hospitals may be quality-enhancing.

On the other hand, unnecessary invasive procedures create significant risks of patient harm. Many specialist physicians in our study described performing biopsies or referring patients for a biopsy for defensive reasons. Because breast cancer was the most common clinical circumstance in which this occurred, female patients appear to bear a considerable portion of incremental risk from defensive medicine. False-positive results associated with low-yield diagnostic testing may also have detrimental effects on quality, particularly when ambiguous findings produce emotional distress and necessitate additional invasive or hazardous procedures.

Defensive medicine takes a toll on interpersonal quality of care and the patient-physician relationship. Some physicians may spend additional time with patients and provide more complete information about treatment risks and alternatives because of malpractice risk, but others may react with suspicion, confrontation, and abandonment. Our study suggests that certain types of patients commonly prompt specialist physicians to behave defensively, especially those who are seen as demanding, emotional, or unpredictable. Safety campaigns that urge patients to Speak Up37 should take these effects into account.

Two contrasting behavioral responses were evident. Specialists who perceived or anticipated adversarial relationships with patients often indulged their demands for expensive but unnecessary diagnostic studies. However, specialists also reported refusing to care for patients with prior complications (especially if they had expressed dissatisfaction with a previous physician), noncompliant patients, workers’ compensation cases, and obese persons. Both behavioral responses entail considerable time and energy spent predicting patients’ possible litigiousness, especially for new patients, reflecting a level of suspicion that itself is arguably detrimental to quality.38

Study Limitations

Our study has several limitations. First, measurement and self-identification of defensive medicine are difficult because distinctions between inappropriate and appropriate care are not clear in many clinical situations.39 Moreover, it can be difficult to disentangle liability-related motivators from other factors that influence clinical decision making, such as physicians’ general desire to meet patients’ expectations, preserve trust, and avoid conflict.2, 4, 40 To the extent that physicians unconsciously practice defensively, our results will underestimate defensive medicine; to the extent that physicians attribute liability motivations to decisions driven primarily by other considerations, our findings will be exaggerated.

Second, physician self-reports of defensive medicine may be biased toward giving a socially desirable response or achieving political goals. This may lead respondents to overstate the frequency of forms of defensive medicine that seem wasteful but not harmful, while causing them to understate the frequency of potentially dangerous practices. Third, our findings are derived from 6 physician specialties in a single state with a highly stressed liability insurance system, and may not be generalizable to other locations or malpractice climates.

Conclusions

Higher levels of defensive medicine are part of the social costs of instability in the malpractice system. The most frequent form of defensive medicine, ordering costly imaging studies, seems merely wasteful, but other defensive behaviors may reduce access to care and even pose risks of physical harm. Because both obstetrics and breast cancer detection are high-liability fields, women’s health may be particularly affected. Efforts to reduce defensive medicine should concentrate on educating patients and physicians regarding appropriate care in the clinical situations that most commonly prompt defensive medicine, developing and disseminating clinical guidelines that target common defensive practices, and reducing the financial and psychological vulnerability of individual physicians in high-risk specialties to shocks to the liability system.

 

[Sinatra]

"Defensive medicine" adds to the cost of healthcare, but it's difficult to determine what is 'defensive' and what is (now) accepted practice.

In my own humble opinion, it's driven more by demanding patients than any other factor. The general attitude I see is "find it and fix it!". They simply don't accept that sometimes we can't 'fix' everything wrong with 'em.

There is this attitude that they can abuse their bodies, be non-compliant with treatment plans and do whatever the hell they want because in the end, medicine can fix whatever ails them. Personal responsibility has completely flown out the window. It's not their fault they're in the shape they're in; it's medicine's fault for not repairing the damage they've done to themselves over the years.

This is a relatively new phenomenon, IMO. When I started out back in the early 80's, this attitude was rare. I'm not sure what caused such a shift. Perhaps it was TV, where everyone gets all better in an hour's time, or a perverted interpretation of 'patients' rights', or (my own personal pet peeve) hospitals' focus on 'customer satisfaction' and employing the likes of Press Ganey to dictate our practice.
---------
FactCheck.org: President Uses Dubious Statistics on Costs of Malpractice Lawsuits
----------

JAMA -- Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment, June 1, 2005, Studdert et al. 293 (21): 2609

[This is a study aimed at high-risk specialties (emergency medicine, general surgery, neurosurgery, obstetrics/gynecology, orthopedic surgery, and radiology) in a high-risk area.]

Technology plays a key role in defensive medicine, and in malpractice liability generally.34 Specialists reported using technology to pacify demanding patients, bolster their own self-confidence, or create a trail of evidence that they had confirmed or excluded particular disease entities. For example, assurance behavior in our study often involved cancer diagnoses in younger patients who had consulted obstetrician/gynecologists or orthopedists. Advances in diagnostic and therapeutic technologies make early detection of cancer both feasible and beneficial, and increase the likelihood that a missed diagnosis will be ruled negligent and assessed substantial damages.

Defensive use of technology is self-reinforcing. The more physicians order tests or perform diagnostic procedures with low predictive values or provide aggressive treatment for low-risk conditions, the more likely such practices are to become the legal standard of care.
-------

Defensive medicine may reduce or improve quality, depending on the circumstances.36 Most assurance behaviors described, such as additional diagnostic testing, were not harmful to patients and perhaps even offered marginal benefits. Referral of difficult cases to more specialized physicians or better equipped hospitals may be quality-enhancing.

On the other hand, unnecessary invasive procedures create significant risks of patient harm. Many specialist physicians in our study described performing biopsies or referring patients for a biopsy for defensive reasons. Because breast cancer was the most common clinical circumstance in which this occurred, female patients appear to bear a considerable portion of incremental risk from defensive medicine. False-positive results associated with low-yield diagnostic testing may also have detrimental effects on quality, particularly when ambiguous findings produce emotional distress and necessitate additional invasive or hazardous procedures.

Defensive medicine takes a toll on interpersonal quality of care and the patient-physician relationship. Some physicians may spend additional time with patients and provide more complete information about treatment risks and alternatives because of malpractice risk, but others may react with suspicion, confrontation, and abandonment. Our study suggests that certain types of patients commonly prompt specialist physicians to behave defensively, especially those who are seen as demanding, emotional, or unpredictable. Safety campaigns that urge patients to Speak Up37 should take these effects into account.

Two contrasting behavioral responses were evident. Specialists who perceived or anticipated adversarial relationships with patients often indulged their demands for expensive but unnecessary diagnostic studies. However, specialists also reported refusing to care for patients with prior complications (especially if they had expressed dissatisfaction with a previous physician), noncompliant patients, workers’ compensation cases, and obese persons. Both behavioral responses entail considerable time and energy spent predicting patients’ possible litigiousness, especially for new patients, reflecting a level of suspicion that itself is arguably detrimental to quality.38

Study Limitations

Our study has several limitations. First, measurement and self-identification of defensive medicine are difficult because distinctions between inappropriate and appropriate care are not clear in many clinical situations.39 Moreover, it can be difficult to disentangle liability-related motivators from other factors that influence clinical decision making, such as physicians’ general desire to meet patients’ expectations, preserve trust, and avoid conflict.2, 4, 40 To the extent that physicians unconsciously practice defensively, our results will underestimate defensive medicine; to the extent that physicians attribute liability motivations to decisions driven primarily by other considerations, our findings will be exaggerated.

Second, physician self-reports of defensive medicine may be biased toward giving a socially desirable response or achieving political goals. This may lead respondents to overstate the frequency of forms of defensive medicine that seem wasteful but not harmful, while causing them to understate the frequency of potentially dangerous practices. Third, our findings are derived from 6 physician specialties in a single state with a highly stressed liability insurance system, and may not be generalizable to other locations or malpractice climates.

Conclusions

Higher levels of defensive medicine are part of the social costs of instability in the malpractice system. The most frequent form of defensive medicine, ordering costly imaging studies, seems merely wasteful, but other defensive behaviors may reduce access to care and even pose risks of physical harm. Because both obstetrics and breast cancer detection are high-liability fields, women’s health may be particularly affected. Efforts to reduce defensive medicine should concentrate on educating patients and physicians regarding appropriate care in the clinical situations that most commonly prompt defensive medicine, developing and disseminating clinical guidelines that target common defensive practices, and reducing the financial and psychological vulnerability of individual physicians in high-risk specialties to shocks to the liability system.

_____________

Sounds like we need Tort Reform.

Hopefully some Democrats will finally have the courage to address this need...

 

[Emma]

Sounds like we need Tort Reform.

Hopefully some Democrats will finally have the courage to address this need...

I don't think tort reform is a federal issue (see my post somewhere above on this thread), and I don't believe it's going to solve the problem.

 

[DiveCon]

Sounds like we need Tort Reform.

Hopefully some Democrats will finally have the courage to address this need...

I don't think tort reform is a federal issue (see my post somewhere above on this thread), and I don't believe it's going to solve the problem.

you are right, its a states issue, but that doesnt mean it isnt needed

 

[KittenKoder]

Wait, people still think that insurance companies control the prices that doctors charge? Fine, show us how this is. If it was because of what insurance companies charge then logic dictates that it would be cheaper to go without insurance, so prove that insurance companies control what the medical providers charge.

 

[DiveCon]

Wait, people still think that insurance companies control the prices that doctors charge? Fine, show us how this is. If it was because of what insurance companies charge then logic dictates that it would be cheaper to go without insurance, so prove that insurance companies control what the medical providers charge.

it costs the insurance companies more than it does for pay for your own
they pick up the costs of cash AND medicare/medicaid

 

[KittenKoder]

Wait, people still think that insurance companies control the prices that doctors charge? Fine, show us how this is. If it was because of what insurance companies charge then logic dictates that it would be cheaper to go without insurance, so prove that insurance companies control what the medical providers charge.

it costs the insurance companies more than it does for pay for your own
they pick up the costs of cash AND medicare/medicaid

I know that, I just don't get how people can think that the ones who pay the costs are somehow the ones who control the costs as well, it's not logical or even possible. If they truly did that then other countries would have picked up all our good doctors by now.

 

[DiveCon]

Wait, people still think that insurance companies control the prices that doctors charge? Fine, show us how this is. If it was because of what insurance companies charge then logic dictates that it would be cheaper to go without insurance, so prove that insurance companies control what the medical providers charge.

it costs the insurance companies more than it does for pay for your own
they pick up the costs of cash AND medicare/medicaid

I know that, I just don't get how people can think that the ones who pay the costs are somehow the ones who control the costs as well, it's not logical or even possible. If they truly did that then other countries would have picked up all our good doctors by now.

yup

 

[Emma]

Wait, people still think that insurance companies control the prices that doctors charge? Fine, show us how this is. If it was because of what insurance companies charge then logic dictates that it would be cheaper to go without insurance, so prove that insurance companies control what the medical providers charge.

They do. Insurance carriers negotiate with providers fee schedules for services. Providers agree to accept the payments set by the insurance carriers.

As an example:

What is a "negotiated rate" and when does it apply?

First of all, negotiated rates are only applicable with PPO (Preferred Provider Organizations) plans and only when you are using in-network providers (doctors and hospitals). The negotiated rate is essentially the basis for the entire PPO model of health care insurance. With a PPO health plan in California, the health carrier contracts with doctors, hospitals and other medical providers to accept lower reimbursements when PPO members use their services. The trade-off to the provider is that many more people will choose these providers for their services. It's essentially a large group discount. This negotiated rate is usually 30-60% lower than a person would pay if you did not have PPO coverage. The negotiated discount tends to be larger for facility care (such as hospital care) and lowest for medication costs (pharmacy claims).

http://www.calhealth.net/california_health_insurance_negotiated_rates.htm

 

[Emma]

Medicare Rates to Be Posted - washingtonpost.com

 

[Emma]

In simplest terms, it works like this: Doctors and hospitals determine "list" prices for procedures, but hardly anyone pays those fees (unless they're uninsured). Rather, they pay their portion of a rate negotiated by their provider and insurer. If the insurer is Medicare, Uncle Sam sets the rate.

Because of this system, patients typically have little idea how much procedures actually cost and how much their insurance is willing to pay until they receive the bill in the mail. Doctors don't have to compete to provide good care cheaply, and both insurance companies and the government are able to exercise considerable market power in negotiating prices.

Health Care's Transparency Problem - Forbes.com

 

[KittenKoder]

In simplest terms, it works like this: Doctors and hospitals determine "list" prices for procedures, but hardly anyone pays those fees (unless they're uninsured). Rather, they pay their portion of a rate negotiated by their provider and insurer. If the insurer is Medicare, Uncle Sam sets the rate.

Because of this system, patients typically have little idea how much procedures actually cost and how much their insurance is willing to pay until they receive the bill in the mail. Doctors don't have to compete to provide good care cheaply, and both insurance companies and the government are able to exercise considerable market power in negotiating prices.

Health Care's Transparency Problem - Forbes.com

Without the insurance companies negotiating lower prices, imagine how much they'd have to charge to stay in business ... really, you are paying for their employees as well as the medical expenses they cover. However, if medical expenses are higher without insurance, like people for government run healthcare admit to, then taking away those people would not lower the price. Instead the price would rise, since there would be no negotiating, the medical professionals and pharmacies would simply charge the amount the government has already dictated, which is higher than insurance companies charge.

What world is this a good idea?

 

[Emma]

In simplest terms, it works like this: Doctors and hospitals determine "list" prices for procedures, but hardly anyone pays those fees (unless they're uninsured). Rather, they pay their portion of a rate negotiated by their provider and insurer. If the insurer is Medicare, Uncle Sam sets the rate.

Because of this system, patients typically have little idea how much procedures actually cost and how much their insurance is willing to pay until they receive the bill in the mail. Doctors don't have to compete to provide good care cheaply, and both insurance companies and the government are able to exercise considerable market power in negotiating prices.

Health Care's Transparency Problem - Forbes.com

Without the insurance companies negotiating lower prices, imagine how much they'd have to charge to stay in business ... really, you are paying for their employees as well as the medical expenses they cover. However, if medical expenses are higher without insurance, like people for government run healthcare admit to, then taking away those people would not lower the price. Instead the price would rise, since there would be no negotiating, the medical professionals and pharmacies would simply charge the amount the government has already dictated, which is higher than insurance companies charge.

What world is this a good idea?

What makes you think there would be no negotiated rates?

 

[DiveCon]

then how come if you pay cash, the price is always lower than it would be if you had insurance or medicare/medicaid?

 

[Emma]

then how come if you pay cash, the price is always lower than it would be if you had insurance or medicare/medicaid?

That's not true.

For example, my Dad's Federal insurance (he never paid ss or payroll taxes, his retirement and insurance is through his federal job so he's not on soc sec or medicare) negotiated a fee with his primary care doc. The office charge for him is considerably lower than what the doc usually charges. Medicare's negotiated rates with providers are even lower than private insurance.

 

[DiveCon]

then how come if you pay cash, the price is always lower than it would be if you had insurance or medicare/medicaid?

That's not true.

For example, my Dad's Federal insurance (he never paid ss or payroll taxes, his retirement and insurance is through his federal job so he's not on soc sec or medicare) negotiated a fee with his primary care doc. The office charge for him is considerably lower than what the doc usually charges. Medicare's negotiated rates with providers are even lower than private insurance.

every doctor i have worked with had lower prices if i paid them directly

 

[Lumpy 1]

Just like me to change the subject!
I believe allot of people are concerned with privacy. The government having access to your medical records as close as a click on a computer. I would certainly feel safe that these records couldn't possibly be hacked in to. I've also heard that in one of the House bills access to your Social Security information is a given and all that goes with that.

 

[Polk]

then how come if you pay cash, the price is always lower than it would be if you had insurance or medicare/medicaid?

No paperwork.

 

[DiveCon]

then how come if you pay cash, the price is always lower than it would be if you had insurance or medicare/medicaid?

No paperwork.

ROFLMAO
no shit
but the price is still LOWER

 

[Emma]

SOME providers will do so. No way in hell you can say "always". And how do you know what rates they've negotiated to charge various insurance carriers, Medicare and Medicaid? (you don't)