Defensive medicine carries hefty price tag, study finds

A first-of-its-kind survey of physicians by the Massachusetts Medical Society on the practice of "defensive medicine" - tests, procedures, referrals, hospitalizations, or prescriptions ordered by physicians out of fear of being sued - has shown that the practice is widespread and adds billions of dollars to the cost of health care in that state alone.

The physicians' group says such defensive practices, conservatively estimated to cost a minimum of $1.4 billion per year in Massachusetts, also reduce access to care and may be unsafe for patients.

The "Investigation of Defensive Medicine in Massachusetts" is the first study of its kind to specifically quantify defensive practices across a wide spectrum and among a number of specialties. The study also is the first of its kind to link such data directly with Medicare cost data. The survey queried physicians in eight specialties between November 2007 and April 2008: anesthesiology, emergency medicine, family medicine, internal medicine, general surgery, neurosurgery, orthopedics, and obstetrics/gynecology.

The study also is believed to be one of the largest of its kind, with nearly 900 physicians completing the survey, says researcher Manish K. Sethi, MD, of the Department of Orthopedic Surgery of Massa-chusetts General Hospital and a member of the Medical Society's Board of Trustees and its Committee on Professional Liability. The other researcher was Robert H. Aseltine Jr., PhD, of the Institute for Public Health Research at the University of Connecticut Health Center in Farmington.

"This survey clearly shows that the fear of medical liability is a serious burden on health care," Sethi says. "The fear of being sued is driving physicians to defensive medicine and dramatically increasing health care costs. This poses a critical issue, as soaring costs are the biggest threat to the success of Massachusetts health reform efforts."

Sethi says while the survey specifically addressed Massachusetts, he would expect similar results nationwide. Physicians were asked about their use of seven tests and procedures: plain film X-rays, CT scans, magnetic resonance imaging (MRIs), ultrasounds, laboratory testing, specialty referrals, and consultations, and hospital admissions. The results were self-reported by the physicians responding to the survey.

The results showed that 83% of the physicians surveyed reported practicing defensive medicine and that an average of 18% to 28% of tests, procedures, referrals, and consultations, and 13% of hospitalizations were ordered for defensive reasons.

Sethi and Aseltine estimated the costs of the tests to be $281 million for the eight specialties surveyed, based on Medicare reimbursements rates in Massachusetts for 2005-2006. In addition, the cost of unnecessary hospital admissions was estimated to be $1.1 billion, for a combined total estimate of nearly $1.4 billion. The authors point out, however, that the dollar estimates do not include tests and diagnostic procedures ordered by physicians in other specialties, observation admissions to hospitals, specialty referrals and consultations, or unnecessary prescriptions. The eight specialties represented in the survey account for only 46% of the physicians in the state.

Because of those excluded elements and the fact that less that half of the state's doctors were represented in the survey, the researchers said the actual cost of defensive medicine in Massachusetts is significantly higher than the survey quantified.

Aseltine notes that defensive medicine may come in various forms, including the ordering of medically unnecessary laboratory or radiologic tests, prescriptions, specialist referrals, invasive procedures, and hospital admissions. Also included would be the avoidance of high-risk procedures or even the avoidance of high-risk patients, he says.

Alan Woodward, MD, vice chair of the Medical Society's Committee on Professional Liability and a past president of the organization, says physicians practice defensive medicine because they don't trust the medical liability system.

"This survey should provide a strong impetus for legislative, business, and health care industry initiatives promoting fundamental liability reform," he says. "Reducing defensive medicine in Massachusetts could dramatically reduce costs and at the same time improve patient safety, access to care, and quality of care."

Woodward added that defensive medicine is not only costly, but it also reduces patient access to care and may be unsafe for patients. Because of the malpractice environment, many specialists have closed their practices, stopped performing high-risk procedures, or reduced their care of high-risk patients. As a result, many smaller communities have little or no access to medical specialists, he says.

The survey found that 38% of responding physicians reported they reduced the number of high-risk services they performed, with orthopedic surgeons (55%), obstetrician/gynecologists (54%), and general surgeons (48%) reporting the highest frequencies. Additionally, 28% of physicians in the sample reported reducing the number of high-risk patients they saw, with obstetrician/gynecologists (44%) and the surgical specialties (37%-42%) much more likely to reduce their number of high-risk patients.

Woodward notes that safety issues can arise from defensive medicine procedures. For instance, patients exposed to unnecessary imaging tests face the risks of radiation exposure and possible severe allergic reactions to contrast dye.

"In addition, many surgical procedures like cesarean sections have increased as a result of liability concerns," he says.

(Editor's note: For the full results of the report on the Investigation of Defensive Medicine in Massachusetts, go to