Survey Tracks Effects of Defensive Medicine in Massachusetts

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

The physicians’ group says such defensive practices, conservatively estimated to cost a minimum of $1.4 billion, 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 is also the first of its kind to link such data directly with Medicare cost data and is believed to be one of the largest of its kind, with nearly 900 physicians completing the survey.

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. Lead researchers were Dr. Manish Sethi of the Department of Orthopedic Surgery of Massachusetts General Hospital and a member of the medical society’s board of trustees and its Committee on Professional Liability; and Dr. Robert Aseltine Jr. of the Institute for Public Health Research at the UConn Health Center in Farmington.

“This survey clearly shows that the fear of medical liability is a serious burden on health care,” Sethi said. “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.”

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 showed that 83{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the physicians surveyed reported practicing defensive medicine and that an average of 18{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 28{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of tests, procedures, referrals, and consultations and 13{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} 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 2005-06. 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 said 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{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} 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 that the actual cost of defensive medicine in Massachusetts is significantly higher than the survey quantified.

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.

Dr. Alan Woodward, vice chair of the MMS Committee on Professional Liability and a past president of the organization, said that “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. 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 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.

The survey found that 38{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of responding physicians reported they reduced the number of high-risk services they performed, with orthopedic surgeons (55{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), obstetrician/gynecologists (54{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), and general surgeons (48{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) reporting the highest frequencies. Additionally, 28{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of physicians in the sample reported reducing the number of high-risk patients they saw, with obstetrician/gynecologists (44{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) and surgical specialists (37{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 42{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}) much more likely to reduce their number of high-risk patients.

Woodward said that safety issues arising from defensive medical procedures may include unnecessary radiation exposure, severe allergic reactions to contrast dye, and complications from cesarean sections.

Reduced access to care because of the fear of liability has been supported by separate studies undertaken by the medical society. In its annual Physician Workforce Study over the last five years, the MMS has found that an average of 44{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} to 48{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of physicians in the state reported that they are altering or limiting their practices because of the fear of being sued.

The most recent workforce study in 2008 found that more than half of physicians in seven specialties (six of which were surveyed in the defensive medicine study) said they have altered or limited their practice because of the fear of being sued: neurosurgery (76{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), urology (75{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), emergency medicine (66{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), obstetrics/ gynecology (57{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), family medicine (53{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), general surgery (51{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}), and orthopedics (51{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}).

“This survey further demonstrates the negative impact of the current dysfunctional liability system on health care and the need for fundamental reform,” Woodward said, adding that lawsuits through the current system, with their adversarial nature, overhead inefficiencies, and years of litigation, should be used only as a last resort.

The best approach, he argued, is for fundamental transformation to a new model, such as the one proposed by the Joint Commission on the Accreditation of Healthcare Organizations, which urges investing in a baseline culture of safety at every health care enterprise, full disclosure to patients about adverse events, sincere apology for avoidable injuries with an offer for timely and fair compensation, and mediation and arbitration to resolve disputes.

Woodward said that kind of reform will improve patient safety, compensate more patients more equitably and efficiently, foster open communication and transparency, build trust, and reduce the practice of defensive medicine.

The report on the Investigation of Defensive Medicine in Massachusetts may be found at www.massmed.org/ defensivemedicine.