Medical Malpractice Liability Reform....

[physasst]

If anyone is interested, and I don't know if anyone even cares...but I am writing a series of articles on Angry Bear about tort reform. Angry Bear is a WSJ Online Top 20 rated blog and is read by many, many economists and policy folks....

 

Angry Bear is mostly PhD economists and policy wonks, and I think they have a healthy respect for PA's....These will all have a decidedly wonkish, economic focus, considering the audience. But I think I have earned their respect.

 

Anyway, here's the link if anyone cares...this is the first of a 3 part series...

 

I will also be posting an article on insurance consolidation....a series on primary care workforce, alternative financing mechanisms, and ACO structure and function....etc.etc.

 

http://www.angrybearblog.com/2011/02/medical-malpractice-reform-truth-in.html

[physasst]

Part Deux of the series....

 

This one was picked up by Business Insider...

 

http://www.businessinsider.com/medical-malpractice-reform-truth-in-advertising-needed-2011-2

 

It would help if I included the second one...

 

http://www.businessinsider.com/medical-malpractice-reform-truth-in-advertising-needed-part-two-of-three-2011-2

[winterallsummer]

Hmm interesting, I also read the article a while back by Atul Gawande about the physicians in south Texas (I live in the Dallas area) who spent a ton of money on testing. The data you worked on for costs and growth is interesting, but here is what I'm wondering: we hope that limiting malpractice suits will decrease unneccesary testing, right? Well, is there any data on if decreasing testing affects patient care?

[physasst]

That was part of my second article. It's hard to say, but the one study noted an increase in C-Sections, and a 6% increase in preventable complications around childbirth with tort reform measures. Nothing big, as Apgar scores were not affected. The problem is, that automatically, you will have some degree of increase in morbidity and mortality. It's inevitable. The thing is, and once you are in practice, you will understand this as well, but the thing is, that defensive medicine testing DOES find things. Everyone here who has been in practice for more than a few years would be able to tell you about a patient that they ordered a test on, thinking it would almost certainly be negative, only to find something unexpected. The question is the rate. If you look at the NBER data that Darius and Seth presented, they found a 0.2% increase in patient mortality would occur with every 10% reduction in medical malpractice liability costs. Now this is simply econometric modeling, and attempting to apply it can be difficult. Questions immediately arise. What patient groups would this occur in? Well checks? Chronic disease? etc. But, if we consider applying this math to the 5% of the population that is responsible for 47% of the total US healthcare spending (theoretically, the sickest 5%), that would equate to an additional 30,000 deaths annually with a 10% reduction in medical malpractice liability costs. Now considering that about 100,000 patients die from iatrogenic causes every year, we could certainly argue whether or not 30,000 is significant. But that is a moral argument, and also hinges on the contingency that physicians would actually change their practice behaviours.

 

Certainly in Texas, they did not. Additionally, Sloan and Shadle did a paper in 2009, examining Medicare expenditures per beneficiary over a long time span in states, looking at both before and after tort reform measures were passed. They expected to find a decrease in expenditures after tort reform measures were enacted, but were never ever to show this.

 

Bottom line is, IF testing is decreased, then yes, theoretically, it will cause an increase in patient mortality and morbidity, but there is not really any evidence to date to show that they will actually change their practice behaviours (at least with direct malpractice reform measures, IE; non economic caps....indirect measures may actually hold more promise, but that's an entirely separate discussion)

[winterallsummer]

So would you say it is more of a moral roadblock stopping it from being enforced? Or are practicioners still basically forced to practice defensively until something is done about malpractice rates? If not tort reform, what would you suggest?

 

I also wonder if data could be pulled for some of the specifically expensive tests, although I'm not sure which these tests would be. Particularly with geriatric patients, since I assume that will be the main upcoming rise of cost. I'm currently working on a research paper for a study I've been on for about a year now, began as a student intern, on the effects of short term exercise on cognition in aging adults. We take their DNA, specifically looking at BDNF and APOE-E genes, as these people are predisposed to Alzheimer's (AD). I don't know how well this will actually materialize in real life, as far as being a useful method of treating AD patients or individuals shown to be genetically predisposed to AD. Even when I worked on a geriatric unit, their treatment involved basically process groups but little physical exercise or cognitive exercise. Fall risks were too much of a concern, although maybe water exercise is more practical..

 

Well, it seems that a few things are going to be inevitable to realistically address growing costs in health care:

1) Decrease cost of physicians - answer is to address things like this, malpractice, and increase the number of midlevel practicioners. Also doesn't help IMO that med school is so overpriced and physicians are (IMO) overpaid.

2) Increase preventetive measures - however I rarely if ever see this being addressed in much any communities.

3) Decrease costs of end of life care and encourage more pallative care - I wrote a paper for school some time back and actually found that in many, many cases, pallative care led to longer survival rates for many patients than very costly end of life care.

4) Decrease unneccesary testing, this seems to me like the most slippery slope to go down.

 

So how soon do you think hospitals will begin addressing malpractice and decreasing testing? I understand it's a pretty heavy topic in research right now but I am curious how many measures are being taken in typical hospitals. Also, curious as to what you think of Atul Gawande's "Checklist Manifesto" if you have read it?

[physasst]

Well let's start with a few things. One hospitals and/or physicians will not address malpractice outside of minimizing it to the greatest degree possible while maximizing profits. Decreasing testing sounds great....which ones? See the problem is, and you will understand this better once you've been through school and in practice, that physicians and providers also care about their patients, and often don't want to miss diagnoses, not out of a fear of litigation, but out of a fear of not treating something that should have been treated on their patient. Additionally, and anyone here will likely echo this, but administrators are very often obsessed with patient satisfaction scores. Hearing "Well ACME hospital wouldn't do the test, cause they said it was 'unnecesary', but I went to another place that found out that I had X (insert scary pathology here)"......While my hospital is good about backing us up to a degree, many hospitals get freaked out over feedback like that.

 

Also, testing is a means of driving revenue, as Gawandes sentinel article about McAllen Texas demonstrated so well. So, for a whole number of reasons, I don't think tort reform will reduce testing, as Sloan and Shadle found.

 

There are a number of things that can be done, and a number of economic mechanisms by which to create, or encourage change, but the first step, without which nothing else can be accomplished, is to change how physicians and hospitals are paid. Fee for service is an anachronism that has to go. It encourages or fosters quantity over quality and volume over value, and is not sustainable...there are a few different types of payment changes that could be done, but my favorite is the Prometheus model....

 

Do a google search on Prometheus and the New England Journal of Medicine....that'll get you started.