Physicians are practicing more defensive medicine

A new survey of physicians, nurses, and hospital administrators suggests that malpractice concerns are leading to the practice of more and more defensive medicine. Large numbers of medical doctors report that they order more tests, refer more patients, prescribe more medication, and suggest biopsies more often than is necessary because of concerns about malpractice.

Large majorities of physicians, nurses, and hospital administrators say they believe that defensive medicine leads to provision of unnecessary or excessive care. Most doctors say fear of liability discourages open discussions of ways to reduce medical errors and is a primary reason why hospitals do not share the results of inquiries into patient injury cases. Large majorities of doctors and hospital administrators do not trust the current justice system to achieve reasonable results, and large majorities of doctors, nurses, and hospital administrators favor replacing the current lay court system with special medical courts staffed by medical experts.

Those are some of the results of a nationwide Harris Interactive survey of 300 practicing physicians, 100 hospital administrators, and 100 nurses in March 2002. The survey was conducted for Common Good, an organization that advocates reform of the civil justice system, including malpractice reform.

The survey found that, because of the fear of liability, 79% of physicians say they order more tests than are medically needed, 74% of physicians say they refer patients more often than they would if based only on their professional judgment, 51% of physicians suggest invasive procedures such as biopsies more often than they would if based only on their professional judgment, and 41% of physicians prescribe medications more often than they believe is medically necessary.

Overall, 94% of physicians, 66% of nurses, and 84% of hospital administrators say they believe unnecessary or excessive care is provided because of the fear of malpractice. The survey also found that 43% of medical doctors now practicing say they have considered leaving medicine because of the malpractice liability system. Furthermore, most physicians (59%), but only minorities of nurses (22%) and hospital administrators (25%), say they believe fear of liability discourages medical professionals from thinking of and discussing ways to reduce medical errors.

Only small minorities of physicians (17%) and hospital administrators (28%) — but almost half (48%) of nurses — say they feel they can trust the justice system to achieve reasonable results. As a result, very large majorities of doctors (94%), nurses (75%), and hospital administrators (81%) favor medical courts "presided over by independent medical professionals and other experts."

Most appeals deal with coverage, not necessity

The majority of preservice appeals to health insurers are disputes over choice of provider or contractual coverage, rather than medical necessity, according to a new study from the Harvard School of Public Health and RAND.

The study, published in the Journal of the American Medical Association, examined appeals during a 30-month period at two major HMOs. [Studdert DM, et al. Enrollee appeals of preservice coverage denials at two health maintenance organizations. JAMA 2003; 289:864-870.]

"Medical necessity disputes proliferate not around lifesaving treatment but in areas of societal uncertainty about the legitimate boundaries of insurance coverage," the study says.

Among the findings: About a third of the appeals (36.6%) centered on the scope of contractually covered benefits. An additional 19.7% involved out-of-network appeals.

Medical necessity disputes (36%) were concentrated on relatively few services and therapies that generally are not considered to be essential, as opposed to life-sustaining therapies. The five most common disputes — surgery for obesity or related conditions, breast alterations, varicose vein removal, bone density and sleep studies, and treatment of scars of benign lesions — accounted for 40% of appeals.

"Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits, may help to avoid a large proportion of disputes in managed care," the researchers concluded.

Bill to help hospitals fund immigrant care

In what is likely to be welcome news for hospitals burdened with the cost of caring for undocumented aliens, federal legislation has been introduced that would reimburse providers for the cost of emergency care for these people.

A bill introduced by Sen. Jon Kyl (R-AZ), and a companion bill introduced by Rep. Jim Kolbe (R-AZ), would reimburse hospitals $1.45 billion annually for the costs of adhering to the provisions of the Emergency Medical Treatment and Labor Act.

A coalition of health care providers in Arizona, California, New Mexico, and Texas worked with lawmakers on the legislation.

"We are grateful to Arizona’s congressional delegation for acknowledging that this federal mandate should be backed up with federal funds," says John Rivers, president and CEO of the Arizona Hospital and Healthcare Association.