Item 13 Defensive Medicine

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Item 13Defensive Medicine
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Defensive Medicine

• The over-utilization by physicians of certain
  diagnostic tests or procedures (or reduction of
  services) primarily to reduce their exposure to
  malpractice liability
• United States General Accounting Office, Medical
  Malpractice Implications of Rising Premiums on
  Access to Health Care, GAO-03-836, August 2003

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Malpractice and Defensive Medicine - Summary

• Physicians reported that they practice defensive
  medicine to varying extents.
• Some specific clinical studies suggest that tort
  reform could reduce defensive medicine resulting
  in medical expenditure savings.
• However, findings are inconclusive and limited,
  and costs have not been reliably measured outside
  specific studies.

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Do Doctors Practice Defensive Medicine?February
1996
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1996 Study

• Analyzed the effects of malpractice liability
  reforms using data on all elderly Medicare
  beneficiaries treated for serious heart disease
  in 1984, 1987, and 1990.
• Findings reforms led to 5-9 reductions in
  medical expenditures without significant impact
  on patient health (i.e., reduced defensive
  medical practices).
• Kessler, Daniel P. and McClellan, Mark B., Do
  Doctors Practice Defensive Medicine?, National
  Bureau of Economic Research Working Paper No.
  W5466, February 1996

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Medical Liability, Managed Care, and Defensive
MedicineFebruary 2000
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2000 Study

• Analyzed populations of elderly Medicare patients
  treated for two types of heart ailments from
  1984-94.
• Studied the direct effects of liability reforms
  and managed care, and how they interact, on
  hospital expenditures for these patients.
• Kessler, Daniel P. and McClellan, Mark B.,
  Medical Liability, Managed Care, and Defensive
  Medicine, Stanford Law School, John M. Olin
  Program in Law and Economics Working Paper No.
  191, February 2000

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2000 Study - Findings

• Malpractice reforms reduced hospital expenditures
  about 7 in areas with both low and high levels
  of managed care enrollment, without impacting
  patient health.
• Managed care and liability reforms are
  substitutes for each other the reduction in
  defensive practices through reforms is smaller in
  areas with high managed care usage.
• Kessler, Daniel P. and McClellan, Mark B.,
  Medical Liability, Managed Care, and Defensive
  Medicine, Stanford Law School, John M. Olin
  Program in Law and Economics Working Paper No.
  191, February 2000

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The Effect of Malpractice Liability on the
Delivery of Health CareAugust 2004
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Issue Addressed

• Do increases in malpractice liability change the
  way medicine is practiced by increasing the use
  of certain procedures?
• Baicker, Katherine and Chandra, Amitabh, The
  Effect of Malpractice Liability on the Delivery
  of Healthcare, National Bureau of Economic
  Research Working Paper No. 10709, August 2004

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Approach

• Study analyzed several different treatments as
  well as overall Medicare expenditures
• Study used annual state-specific data to analyze
  effect of malpractice liability on the practice
  of medicine
• Baicker, Katherine and Chandra, Amitabh, The
  Effect of Malpractice Liability on the Delivery
  of Healthcare, National Bureau of Economic
  Research Working Paper No. 10709, August 2004

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Findings

• For the most part, there is little evidence of
  change in treatment patterns in response to
  increases in premiums.
• The results . . . show small and insignificant
  effects for most of the treatments studied.
• Little increase in overall expenditures for the
  Medicare population
• Baicker, Katherine and Chandra, Amitabh, The
  Effect of Malpractice Liability on the Delivery
  of Healthcare, National Bureau of Economic
  Research Working Paper No. 10709, August 2004

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Findings

• The use of mammography seems somewhat more
  sensitive to malpractice costs than the other
  procedures tested.
• Mammography rates increase significantly with the
  average size of payments.
• Baicker, Katherine and Chandra, Amitabh, The
  Effect of Malpractice Liability on the Delivery
  of Healthcare, National Bureau of Economic
  Research Working Paper No. 10709, August 2004

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Limitations

• We have by no means captured the universe of
  treatments that patients receive that may respond
  to changes in malpractice costs.
• Baicker, Katherine and Chandra, Amitabh, The
  Effect of Malpractice Liability on the Delivery
  of Healthcare, National Bureau of Economic
  Research Working Paper No. 10709, August 2004

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Congressional Budget Office ReportJanuary 8, 2004
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Malpractice and Defensive Medicine

• If malpractice is defined too broadly or is not
  clearly defined, or if awards tend to be too
  high, doctors may carry out excessive tests and
  procedures to be able to cite as evidence that
  they were not negligent, or inefficiently
  restrict their practices, or retire.
• Congressional Budget Office Economic and Budget
  Issue Brief, Limiting Tort Liability for Medical
  Malpractice, January 8, 2004

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Malpractice and Defensive Medicine

• Therefore, a possible effect of limiting tort
  liability may be to reduce the extent to which
  physicians practice defensive medicine.
• Congressional Budget Office Economic and Budget
  Issue Brief, Limiting Tort Liability for Medical
  Malpractice, January 8, 2004

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Malpractice and Defensive Medicine

• Conversely, if doctors face less than the full
  costs of their negligence. . . they may have too
  little incentive to avoid risky practices.
• Moreover, some so-called defensive medicine may
  be motivated less by liability concerns than by
  the income it generates for physicians or by the
  positive (albeit small) benefits to patients.
• Congressional Budget Office Economic and Budget
  Issue Brief, Limiting Tort Liability for Medical
  Malpractice, January 8, 2004

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CBO Conclusion

• Because of these divergent possibilities, it is
  unclear whether controlling malpractice by means
  of liability will affect defensive medicine in an
  efficient manner.
• The evidence for indirect effects on efficiency
  . . . through changes in defensive medicine is at
  best ambiguous.
• Congressional Budget Office Economic and Budget
  Issue Brief, Limiting Tort Liability for Medical
  Malpractice, January 8, 2004

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Basis for Conclusion Existing Studies

• Based on existing studies and its own research,
  savings from reducing defensive medicine would
  be very small.
• These existing studies were limited in scope
  (e.g., to one state, to a narrow part of
  population, to only a few ailments).
• Congressional Budget Office Economic and Budget
  Issue Brief, Limiting Tort Liability for Medical
  Malpractice, January 8, 2004

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Basis for Conclusion - CBO Research

• CBOs own research was broader than earlier
  studies, and found no evidence that restrictions
  on tort liability reduce medical spending.
• CBO found no statistically significant
  difference in per capita health care spending
  between states with and without limits on
  malpractice torts.
• Congressional Budget Office Economic and Budget
  Issue Brief, Limiting Tort Liability for Medical
  Malpractice, January 8, 2004

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General Accounting Office ReportAugust 2003
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GAO Study Scope

• Surveyed various providers and their
  representatives in the AMA, AHA, etc. in nine
  states (five problem states and four without
  reported problems no New England states)
• Reviewed available empirical studies
• United States General Accounting Office, Medical
  Malpractice Implications of Rising Premiums on
  Access to Health Care, GAO-03-836, August 2003

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GAO Study Findings

• In response to rising premiums and fear of
  litigation, physicians do practice defensive
  medicine which could raise healthcare costs.
• The overall prevalence and costs of such
  practices have not been reliably measured.
• United States General Accounting Office, Medical
  Malpractice Implications of Rising Premiums on
  Access to Health Care, GAO-03-836, August 2003

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GAO Study Findings

• Must exercise caution in interpreting the results
  of the surveys/studies
• Low response rates
• Imprecise measurements on the extent of defensive
  medicine practices
• Research is limited to very specific clinical
  situations
• Some defensive medicine is practiced to increase
  revenue
• United States General Accounting Office, Medical
  Malpractice Implications of Rising Premiums on
  Access to Health Care, GAO-03-836, August 2003

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GAO Study Conclusions

• Although available research suggests that
  defensive medicine may be practiced in specific
  clinical situations, the findings are limited and
  cannot be generalized to estimate the prevalence
  and costs of defensive medicine.
• United States General Accounting Office, Medical
  Malpractice Implications of Rising Premiums on
  Access to Health Care, GAO-03-836, August 2003

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