WhiteCoat

Unnecessary Medical Testing

MRI scannerThe topic of unnecessary medical testing comes up all the time in the health care reform debate and is a recurrent theme in news headlines.

Study finds that unnecessary tests ordered in 43 percent of checkups – CBS News
$700 billion each year is spent on unnecessary medical tests
– Healthcare Economist
Why doctors order unnecessary tests
– KevinMD (with some excellent insights)
Millions squandered in unnecessary tests ordered in routine doctor visits
– Medical News Today
The Cost Conundrum
– New Yorker article by Atul Gawande
Even this month’s Night Shift column in EP Monthly details a family discussion about unnecessary medical testing and health care reform.

The term “unnecessary testing” is on its way to becoming the new “death panel” of the health care reform debate. But just as the term “death panel” was disingenuous, the term “unnecessary testing” is ambiguous.

What exactly is an “unnecessary test”?

Perhaps an unnecessary test is a stress test that has little predictive value in determining death from heart disease. A study of 25,000 men who underwent stress testing showed that in ten years only 158 men died from heart disease. Stress testing was normal in 40% of the men who died. Is stress testing “unnecessary”?

Perhaps an unnecessary test is one that has a low likelihood of showing a positive result. Spontaneous carotid artery dissections occur less than 1 in 34,000 individuals. Maybe we shouldn’t be performing all those expensive magnetic resonance angiograms on patients who have headaches or neck pain. After all, a vast majority of the tests will be normal.

Personally, I think that the term “unnecessary testing” is a misnomer. To me, the term “unnecessary” means that there is absolutely no likelihood that a test will find or exclude a disease process and that there is absolutely no likelihood the test results will change the patient’s proposed treatment — like performing saliva screening for food particles. A majority of tests aren’t really “unnecessary,” they just don’t show abnormalities very often.

Everyone is quick to criticize the necessity of a negative test after it has been performed. What about a prospective look at the testing?

A more appropriate term for testing considered by some to be “wasteful” should be “low-yield testing.” Sure a vast majority of “low yield” tests will be normal, but if you perform enough low yield tests, you will eventually find something wrong. The outside chance that patients may have an uncommon disease picked up by an “unnecessary test” is one of the biggest reasons why low yield testing is performed.

Failure to perform low yield testing serves as the basis for many medical malpractice lawsuits. Regardless of how rare the disease is, a common question raised by malpractice plaintiff attorneys is “What would it have hurt to just do the test?” That question is followed by some iteration of the statement that “if only that horribly negligent doctor had just ordered the simple test on this patient, Little Johnny wouldn’t be an orphan.” During closing arguments, some attorneys can even channel voices from beyond to prove their point.

If we all agree that “unnecessary testing” is such a bad thing, what tests are we all going to agree that doctors should stop ordering? Give me a list of unnecessary tests that I should no longer perform and I’ll follow it. No more wasteful MRIs for back pain? Sign me up. No more  CT scans for the patient with chronic abdominal pain? I’m all for it. PET scans? Outta here.

Maybe we could use percentages instead. If a test has less than a “Y” percent chance of showing an abnormality, then it will be considered “unnecessary” and will not be performed. Now go ahead and define “Y”.

We’ll save millions … no … BILLIONS of dollars.

But here’s the catch … if we stop performing all of the “unnecessary testing”, then there will be an increase in the number of patients whose medical problems will go undiagnosed. So don’t blame me if things go wrong.

If I stop ordering things on your list of “unnecessary tests,” then you can’t hold me responsible if you have a bad outcome because you didn’t get the “unnecessary” test. You can’t complain to the hospital administrators that the mean doctor didn’t order the seventeenth CT scan for you chronic abdominal pain. You give up your right to sue because the doctor missed a heart attack for failing to perform the “unnecessary test” that had less than a 1% chance of catching your heart disease. Sucks that you happened to be in that “less than 1%” category, but “unnecessary” is “unnecessary.”

Many people want extensive testing done to diagnose their problems, but few want to dole out the cash for others to have that same testing. Adding to the problem is that doctors have no incentive to stop performing low yield testing, yet can incur extensive liability if a rare disease is missed.

So Mr. Obama, Congressional Counselors at Law, esteemed colleagues, and distinguished guests, here’s how to solve the problem of “unnecessary medical testing”:

  1. Stop throwing around the phrase “unnecessary testing” until you define the term. If you continue to use this term ambiguously, you’re being intentionally disingenuous and your arguments about how such testing is ruining our health care system are suspect.
  2. Don’t retrospectively wag your finger at me and tell me I shouldn’t have ordered that normal test. Grow some gonads and give us prospective examples of “unnecessary tests” that doctors should never be ordering. I’m waiting to be enlightened.
  3. Make it very clear to the public that a reduction in “unnecessary testing” will invariably reduce the number of tests performed, but it will also invariably increase the number of deaths and bad outcomes from failure to diagnose uncommon diseases or uncommon presentations of common diseases. Are we going to swallow the “red pill or the blue pill“?
  4. Fix the medical malpractice system so that doctors aren’t threatened with professional sanctions or financial ruin if they don’t perform “unnecessary testing” or you will never achieve your goal. When doctors are faced with a decision between protecting oneself from being sued for millions of dollars and advancing a government goal to reduce health care spending, lawsuit protection will win every single time.

Now … when we’re done debating this, do we get to talk about other “unnecessary” government expenditures?

51 Responses to “Unnecessary Medical Testing”

  1. LL says:

    This may be because I watched House last night, but the first 3/4 of that show, every week, is “unnecessary testing.” People don’t have a problem with it cuz, TA-DA! In the end, House comes up with some stunning and rare disease that his patient is suffering from, always after discarding a half dozen false diagnoses. American viewers would not be happy with a House show where he says, “No, we’re not testing for this, that, and the other. We’re just gonna cross our fingers and hope we get it right.”

    Wonder what would happen if THAT started popping up in each episode.

  2. Sam Bergman, MD says:

    What about the fact that all tests have some degree of false positives. What do you do about those results? Do you start chasing all of those down with even more tests, which themselves will have false positives? Pretty soon it’s like a chain letter/ponzi scheme that eventually implodes. At what point do you start using medical judgement, and why not use it right from the start? What about spending a little time explaining why a test is not needed, and more often in my experience that it is needed, or why it’s actually bad – additional radiation exposure, pain, infection if a needle or worse is involve, not to mention the the time, expense, and nuisance involved.

    I know, busy ER’s and offices often don’t allow enough time for adequate communication. It’s another reason we often do too many tests as we don’t have time and/or inclination to get good histories from patients – who often don’t know or can’t explain anyway. Better communication and taking a little extra time with patients and families is your best defense, and it’s pre-emptive, against malpractice, not getting every possible test.

    I’m not opposed to doing tests and I agree there are often tests you want to do “just to be sure” and occaisionally oddballs and long shots that might be worth pursuing, but the Dr. House model is not the way to go. I can’t stand the show and the character’s style. I wouldn’t want him involved in my care or that of any of my family, no matter how brilliant he is. The show gives the wrong message about what medical care and caring should be like.

    As much as I hate insurance companies and their trying to make medical judgements and restrict testing, the medical profession helped in providing insurance with the opportunity to act as they do. We have to do a much better job of educating our patients, the media, society in general, and politicians, not to mention ourselves, about what good, appropriate health/medical care really is.

  3. Nunya says:

    Can’t duplicate testing be considered unnecessary? Haven’t you often discussed that tests that were done by another hospital or the PCP are reordered at the current hospital?

  4. Doc99 says:

    An old carpenter’s expression comes to mind: “Measure twice, Cut once. You’ll save a lot of wood.”

  5. Matt says:

    Does it matter how we define it? Call it “unnecessary testing”, “defensive medicine”, whatever. It’s a lobbying term. It means whatever the speaker wants it to mean and it’s effectively unquantifiable by anyone.

    It’s no different than this phrase:

    “Failure to perform low yield testing serves as the basis for many medical malpractice lawsuits.”

    How many is “many”? Hell, how many med mal lawsuits are there overall? No one knows, so how can you draw any conclusions from it. It’s like saying “MANY doctors commit medicaid/medicare fraud.” OK, if you say so – what does that tell me about the problem or the viability of a solution? Nothing. It sounds good though, so it’s effective as a lobbying phrase.

    Welcome to politics. Meanwhile, the public option which will morph into single payer is back on the table while we discuss the meaning of lobbying phrases.

  6. Ron says:

    Whitecoat makes a number of excellent points, not the least of which is that “unnecessary testing” is a rhetorical phrase. But there are tests that don’t make sense to do, and a test that makes sense in the ED context may not elsewhere.

    Asymptomatic disease is rare, so when one tests for a condition that is asymptomatic, most of the resulting positive tests will be false positives. The cost of following up false positives, economic, physician and patient time, complications, can outweigh the value of finding that one needle in a haystack.

    Testing asymptomatic women for ovarian cancer is a good example; in a recent large-scale trial of screening, over 900 women had to undergo surgery secondary to positive screening tests, in order to learn that fewer than 90 of them had a malignancy.

    In the ED, of course, tests are less commonly ordered to rule in (or out) conditions that are currently symptom free.

    There is no test that is always necessary or always unnecessary. It is more useful to think about whether a test is necessary (or better, helpful) for a particular patient in a particular context.

    To move to a more useful way of thinking about testing, one should ask (a) would I treat this patient any differently if the outcome of the test is positive compared to if it is negative? (b) does the likelihood of detecting the disease if it is present outweigh the costs this patient will have to bear if the test comes back positive, but the patient doesn’t have the disease? (c) do the results of my history and physical suggest that this patient has substantially elevated risk for the condition the test addresses? and (d) could I get the same information the test will provide without additional risk to the patient by waiting 24 hours and observing what transpires?

    If the answer to any of questions (a) through (c) is “no” or the answer to (d) is “yes”, then we might want to consider that test for THAT patient “unnecessary.”

  7. matt says:

    It never occurs to anyone the problem isn’t the tests its that the tests are expensive, often requiring labor that hasn’t been automated. The company located on the floor below me, is a biotech company they do blood tests. Their tests require only a drop of blood, and they can test it for 400 markers. The drop of blood goes on a chip, a few minutes later they have the results. They charge a lot for their service. But that is because their tech is currently patented.

    In japan they have MRI machines that cost 1/10 of the GE monsters we have in the US.

    The future looks like this, you come into your doctors office, and before ever meeting with your doctor, you get a finger prick, give a urine sample, then when you go into the room the table you lay down on will scan you in higher resolution and detail then anything we have now. All of this will be done and interpreted by computers. It will be absurdly cheap by today’s standards.

    These tests seem like a big deal today, but testing will get cheaper, and the thought of not scanning anyone who comes to a clinic will be considered barbaric. The thought that the doctor doesn’t have your genome data will be considered absurd. The idea that the computer doesn’t have a record of every blood test and can’t chart changes in every bio-marker will be considered unthinkable.

    We are in a period with lots of new technology. Much of them are dead ends, they are outdated so fast they don’t have time to get any cheaper, and the new thing is always more expensive. However, this is a temporary situation. More technologies, that are going to be continually useful are becoming mature, things like blood tests on a chip. In 5 years sequencing your genome will cost $100. The technology will only get cheaper, because its not a dead end. It’s mature technology, that will be around forever. I challenge you to find a device that serves basically the same functions it did when it was invented that isn’t dramatically less expensive today.

    More information is always better. In the short run it can cause problems because we have less of sense of what normal variation is and end up treating things that don’t need it. In the long run with lots of customers and data mining those bugs are worked out.

    The way to make health care cheaper is not by collecting less data from patients. Its from making the collection much cheaper. Lots of ways to encourage this.

    • DUH says:

      Umm, actually no, you’re wrong. While the high costs of many ‘unnecessary’ tests is a factor it is the false positive risk(by definition 5% of a large enough panel of tests will be technically abnormal) and the losing the forest for the trees phenomenon that is the problem. An abnormal test demands a follow-up of some kind. It may be as simple as explaining why that result is probably irrelevant. But then that is time spent and time has cost. That is time that is now not available for another patient of for a more clinically relevant point with the patient in front of you.

      When I get pages and pages and pages of records from a patient’s former doctor it is highly unlikely that I will ever read all of it. If I get a half dozen pages of clinically relevant info, I will.

  8. Max Kennerly says:

    Didn’t Obama put $1B towards comparative effectiveness research, which would give us a clear indication about just how helpful particular tests / procedures were?

    http://www.hhs.gov/recovery/programs/cer/index.html

    What more than that should he do?

    • throckmorton says:

      Max:

      I have been a strong advocate of evidence based medicine of which comparative effectiveness is a major part. It is however useless if an attorney can say “you should have done the other more expensive test”. We have many tests that are very effective and only have a false negative rate of less than 0.01%. The problem is that they will miss something eventually given enough volume. The result of missing that one thing is presently enough for a suit. What we need is to look at the evidence based medicine and decide what standard we will use and make sure that it is held up in court. Otherwise, all the data in the world wont help you in a lawsuit and this is what eventually trickles down to be the “medical-legal standard” that is practiced.

      • Matt says:

        ” Otherwise, all the data in the world wont help you in a lawsuit and this is what eventually trickles down to be the “medical-legal standard” that is practiced.”

        This “medical-legal standard” stuff would have more merit if physicians actually studied cases and reviewed the medical records and then reached conclusions. As opposed to reading a newspaper article or some tort reformers press release and then stopping there and deciding to change your life and practice based on a 500 word article about a 6 week trial which may or may not have been held up on appeal. It is more accurately titled “medical perceptions based on physicians’ reactions to limited information and scare tactics standard”.

      • throckmorton says:

        Matt:

        Cerebal palsy is a classic example. We have all the medical evidence that shows most of the injuries that cause cerebal palsy occur prior to the onset of labor but who do the attorneys find to be at fault? The ob docs. What do the attorneys argue? That there should have been a more rapid c-section. So here in the US we have a C-section rate that is second to none. Here we have medical legal effects driving how medicine is practiced. Would physicians reading more of the cases change anything. I would argue that the more of the cases they read, the more they would practice defensive medicine.

      • Matt says:

        “We have all the medical evidence that shows most of the injuries that cause cerebal palsy occur prior to the onset of labor but who do the attorneys find to be at fault? The ob docs”

        I think your statement here says volumes. I agree, and I think most attorneys would agree with you that “most” of the injuries do occur prior. I don’t know of anyone who argues otherwise. But what you can’t say, and I doubt you would say, is that it is impossible for actions of the physician during labor to result in CP.

        Now, you have no idea how many CP lawsuits there are. You have no idea how many CP cases there are overall. For all you know it may be far less than you’d ever expect. You probably know that the verdicts/settlements are high, but with a life care plan for CP, that’s not surprising. But you are claiming that despite the fact you have no idea what the percentage of CP suits v. CP cases is, you have changed your actions. Your analysis is not based on any accurate assessment of your risk.

        “So here in the US we have a C-section rate that is second to none.”

        Here in the US we do lots of things differently than other countries, for lots of reasons. Convenience, for example. Simply saying that doesn’t tell me if it’s a net positive or negative.

        ” would argue that the more of the cases they read, the more they would practice defensive medicine.”

        Maybe it would, maybe it wouldn’t. You don’t know, but you’re sure you don’t want to find out. It might be that you’d be shocked at the actions of others in your profession and wonder how they got out of medical school. Or you might decide that 90% of these claims were bs. Who knows at this point, because you’re content to rely on lobbyist press releases and newspaper articles in reaching your conclusion.

      • throckmorton says:

        Matt:

        Would you like to stay in the argument or would you like to compare the merits of who got in and out of medical school vs who got in and out of law school. The issue at hand is whether or not lawsuits have affected how medicine is practiced. I argue that it does. There are many factors that come in to play in the practice of medicine, surrounding all of them is the ever present issue of malpractice. I dont have to rely of lobbists or the press. I mearly have to sit in the surgeons lounge to hear who is being sued for what.

        Show me Matt how the affects of our tort system has not affected how medicine is practiced.

      • Matt says:

        I know you argue it does. My point is that the reason it does influence you is ignorance of the risk. In fact your comment about getting your info about lawsuits and the evidence in them and their outcomes from hanging in the surgeons lounge only illustrates the shakiness of the information you rely on in altering your care.

      • Matt says:

        With regard to your second question first there is no “tort system”. There are civil and criminal law systems. Does it have an effect on medicine? Of course.

      • throckmorton says:

        Matt:

        By talking to the people who are being sued, isnt that first hand information? When five of six of your collegues have been sued, does it alter how you practice? You bet.

        I am happy to hear that you agree that the civil and criminal law systems have an affect of how we practice medicine. Now, how do we make it more helpful to the practice of medicine?

      • Matt says:

        If you just got your information from the plaintiff’s expert would you feel you knew all you needed to in order to make a conclusion? I would hope not.

        Were they all sued in the same type of case? With similar patients and outcomes in the patient and trial?

        As to how a lawsuit can make medicine better it probably can’t. That’s not the role of a lawsuit, at least in the context of your typical med mal case. It is simply about determining liability and if necessary damages in regard to a particular incident.

        To the extent physicians can learn anything from lawsuits you would have to have a very large sample of similar cases and results and see if the aggregate info leads you to any conclusions. I would suggest asking your insurer. They have that info.

      • throckmorton says:

        Matt:

        I find it interesting that you argue that you would have to have a very large sample of similar cases and results and see if the aggregate info leads you to any conclusions. We determine a p value and go from there. The problem is that we cant use these conclusions in a court case. As you say, it is not about the aggregate, but about a single incident. Therefore, you can have all the evidence in the world, but the plaintiff’s attorney can always argue you shoud have done that extra test.

        It is interesting that you mention looking at the medmal insurance data. When you look at that data you will be compelled to order even more tests as what that data tells you is that most of the cases involve claims of misdiagnosis, failure to treat and unrecignized complications. Their advice is test, test, test.

        So, how can we use the legal system to help save and take care of more patients medically? The answer is to make sure that we have an established standard of care that is created by evidence based research and then hold this up in court. We need to use healthcare dollars to treat patients not to pad the chart for possible lawsuits.

        So, Matt, if I can diagnose a condition with 98% certainty, there is still a 2% chance that I can be wrong and this may result in a suit. I can order 2 more tests and increase my percentage to 99% but this still means 1% chance. What percentage do I have to be to be sure I will not be sued? This is the question that we as a country need to decide. With evidence based studies we can determine the positive and negative predictive values as well as outcomes. We can then set the policy that this is the optimal treatment plan. We then have to have courts that will hold this up.

      • Matt says:

        You telling me what the data says and you allowing us to see it are two different things aren’t they? I am unaware of this unfiltered data being released to the public for examination.

        Now, as to the rest of your post you are correct. But the first step in all that must come from physicians. You set the standard of care after all. Which goes back to my point that right now you’re telling me that you’re applying a standard of care based on coffee talk in the lounge, not any real examination of the cases.

        The other salient fact is that right now, the only real reform being proposed and with any legislative traction is damage caps, which apply regardless of the merit of the case. That’s what the battle is about. Your ideas are great, but frankly they aren’t really tailored toward what the money behind tort reform is about-making it harder for individuals to recover for negligence and limiting the amount they can recover.

        I expect we agree on much. But where we will not agree is that we need more politicians deciding the value of cases as opposed to the jury that heard the evidence.

      • Matt says:

        I forgot to address your question about what percentage do you need to ensure you will not be sued. The short answer is there is no such percentage, for a couple of reasons.

        One, you assume all the facts about a case will always be known prior to filing. That’s simply not the case. The only way to get them all is to file suit and compel the other side to produce them. None of you are going to submit to pre-filing depositions are you?

        Two, in any dispute resolution system, there will have to be a filing before it can be dismissed. There is no way for someone to read the mind of a litigant and stop the filing. You can file suit against the president for peeing in your cereal and the clerk will take your money and you can serve the president with it before a judge will get it and dismiss it. That will be the case in any dispute resolution system.

        If the mere act of being brought into a dispute resolution system at all is what you hope to avoid then I can’t help you and no one in a democracy can. What you should focus on is winning those disputes.

      • Max Kennerly says:

        throckmorton,

        Sounds like you’re referring to a “safe harbor” for doctors who follow the CER guidelines, which makes sense to me.

        My concern is twofold: first, I worry the CER guidelines will explode into blanket immunity and, second, it should be far easier for a plaintiff injured by a physician’s failure to follow the CER guidelines to recover compensation.

        Take cerebral palsy. Where would we set the CER guideline for which a c-section should not be performed? If the answer is politically chosen to be “never” just to screw patients, well, that’s not good enough: even ACOG admits there are specific circumstances under which HIE can cause cerebral palsy. If the answer incorporates actual science on FHR and indications of HI, then, great, we can start talking.

  9. paul says:

    same goes for “unnecessary” admissions. oh, insurance will never pay for this admission. i hear it all the time.

    these decisions should be made prospectively. the medical director of the insurance company should be called to approve or disapprove the admission in real time (say, 3am when that atypical chest pain is ready for dispo) and be held completely responsible if the patient is sent home and has a bad outcome.

    • Fyrdoc says:

      Actually you bring up one of the easiest ways that we could bring about meaningful reform of the health insurance industry – repeal ERISA and the anti-trust exemptions given the health insurance industry.

      ERISA protects the insurer from the malpractice ramifications of their decisions. I’m sorry, but when a doctor, working for an insurance company declines a treatment as “unnecessary”, they are offering a medical opinion and should be held to the standards of practice. Under ERISA, they are absolutely immune. That needs to stop.

      The anti-trust exemptions allow the companies to work together to set repayments, outside of the free market system. So they can collect all they want, but returns to the system are manipulated. This is also unfair.

      A large portion of the “Health Care Crisis” could be fixed not by passing new laws, but repealing old ones.

  10. Soronel Haetir says:

    Matt,

    I doubt most docs care much whether any particular case is upheld on appeal or not. The vast majority of people have a visceral dread of going through trial. Witness how various immunity doctrines serve to shield government actors from having to go through trial at all. Process can be just as punishing as any award that is eventually paid out.

    • Matt says:

      Not sure what immunity doctrines you’re referring to, but I agree as to the dread. However, any process to resolve disputes that we develop will be dreaded by the parties to the dispute.

      What I’m talking about is physicians claiming they follow a “medical-legal” standard when they have little knowledge of the facts of the cases they claim to be reacting to.

      • Soronel Haetir says:

        And I would state that the fact that docs have little knowledge of the actual case is either irrelevant or simply cumulative to the problem. If docs are under the impression that they will get sued (and lose) if they don’t order every possible test regardless of whether that test is actually useful under the circumstance, guess what? They are going to choose the test, especially when someone else is going to bear the cost of that test.

    • Matt says:

      I agree. I just don’t believe that we should be enacting laws which limit individual rights just in response to fears which are based on limited or incomplete information.

      Of course the fact that they still seem to order those tests even after they limit the rights of victims would suggest that lawsuit fear is not what’s driving them to order the tests. So perhaps we should consider other possible reasons for those tests being ordered.

  11. Nurse K says:

    There’s no way to make a blanket statement that such-and-such test is always good and such-and-such is always bad. Unnecessary testing is like porn…you know it when you see it

    I think you can make some pretty reasonable blanket statements for the ER, however, like “no extremity MRIs” (it used to be standard for a couple of our docs to XR–>CT—>MRI knee pains in the ER–WTF) or “no MRIs for atraumatic back pain w/o bowel or bladder dysfunction or extreme weakness” or “use PERC for PEs” etc…

  12. ERP says:

    I think you are right – the tests are not always “unnecessary” but they are often performed at inappropriate times (ie in the ER upon initial presentation of obvious sciatica in the case of an MRI) and in an inappropriate place (the ER). Obviously, these tests need to be done eventually but not always right away. Many of these conditions are self limited and clinically obvious but patients demand them and fear of lawsuits drives us to order them.

    • Matt says:

      Given that costs and tests don’t decline when you get the lawsuit reform you want evidently there are some other causes that drive your actions. Unless you have a lot of really demanding patients in states with “reform”.

      • throckmorton says:

        Matt:

        There has not been any lawsuit reform in which attempts were used to define the standard of care based on evidence based medicine. What has been done is limit awards. Lets look at the big problem which is establishing what tests are acceptable and what degree of sensitivity and specificity is appropriate.

        An intersting thing is that since Florida has limited attorney fees and put an end to the ability fot attorneys to charge for endless hours ontop of their contingency fees, liability insurnace premiums have dropped considerably.

        Here is the others side of determining what it what is an appropriate test. In the UK, if you come in with all the signs of a potentially fatal PE, you get a CT angiogram as long as it is before 5 pm and on a weekday. Otherwise you wait until the next business day and they start you on heparin or if you are low risk they send you home. Here in the US, you get a CT immediately to determine what is going on becuase there is a risk that if we start you on heparin you could bleed to death. The mortality from PE is about the same in the UK and the US with the different treatments. The difference is that here if you dont get an immediate CT and start someone on heparin, you can get sued. If the patient goes home and dies you get sued. So, we test more and since you can still get sued, will pay more to cover the cost of the insurance.

      • Matt says:

        Throck,

        I agree with you there has not been. Nor will there be. For one simple fact. The real backers of tort reform, the insurance industry and tobacco industry, aren’t really interested in standards of care and such. Because they can’t guarantee those things will protect THEIR interests, which is keeping more money in their pocket. Brighter line rules don’t really help them, and in fact, it could lead to more people figuring out they have claims. They’re interested in reducing their exposure, period. You can wax poetic about the reform you propose, and again we’ll probably agree, but in the real world it’s all about damage caps. Nothing more, nothing less. That is what I oppose vehemently. What you’re talking about sounds interesting, and if it reaches a stage beyond idle chat to serious legislative discussion, then perhaps it will be relevant to the current debate.

        You make all these statements about “if I do X, I still get sued.” Except you have no idea if that’s true. Again, you have no idea how much malpractice is committed, or even how many suits are filed. It’s likely that the vast majority of malpractice never even sniffs a claim file. You’re reaching conclusions without any evidence whatsoever.

        If you want to adopt UK healthcare and legal systems, that’s fine. You ready for the pay cut?

        As to Florida, I don’t know what you’re talking about – got a link? What you’re saying doesn’t seem to make much sense in terms of hourly fees plus contingency. As far as the government limiting attorney’s fees between two contracting parties, I would oppose that no matter what industry we were talking about. The less the government has to do with business relationships between individuals, the better, I believe. You may be more of a big government nanny state type though, and that’s probably a political philosophy difference we can’t resolve.

  13. throckmorton says:

    Matt:

    You are right in that I do not know how much malpractice is committed. I do know that in my state 78% of all medmal suits end with no payment to the plaintiff and of the cases that go to trial over 80% are decided for the defense. I am supprised you dont know that Florida has limited attorney fees by constitutional amendment. As to payment, in the UK physicans only have to work for the NHS 36 hours a week. As to a pay cut, just how much do you think physicians make? I can assure you that an internist, pediatrician and family practive doc make far less than your average attorney.

    Do I want a NHS here. No. I want to practice medicine where I can give my patients their options and let them decide what they want done as opposed to trial attorneys, governments and insurance providers. I want patients to pay for what they get, not to offset the trial lawyer industry.

    Here is an interesting bit of data. It costs $7.18 for every patient appointment in our practice just to cover the medmal insurance. Where does that money go. It goes into the mutual insurance fund. (Medmal insurance is not some high proffit company, ours like many others is a mutual). That fund is used primarily to handle all the court costs for all the 78% of cases that end without settlement.

    • Matt says:

      Throck,

      Do you mean 78% of all claims end with no payment to the claimant? And as to those that go to trial, I have typically heard 75% but I wouldn’t be surprised if once in awhile it goes to 80%. Although that doesn’t seem to be an argument AGAINST the jury system.

      As to Florida’s limiting of attorney’s fees, do you have a link? I don’t doubt you, I’d just like to see the details. And I’m curious, do you think that’s a good thing for the government to be in the business of what two private parties can contract for? We may just have different philosophies regarding govt. regulation. And I think I also recognize more than you that as an individual, if I’m injured by someone’s negligence and they won’t pay, I don’t want the government hamstringing my attorney while the other side can pay whatever they want.

      As to pay, most sources I’ve seen put average US physician pay a little north of $150K. Average physician pay is around $100K. And average UK physician salary, as best I can tell from the stats I can find, is about 25% less than that in the US. All those numbers are easily searchable.

      Trial attorneys (by which I assume you mean plaintiff’s attorneys who represent individuals like you and I in negligence claims) have no control over what you do. You can do whatever you want. They do help individuals like us hold others accountable if their negligence harms us, though.

      As to your data, how much do you believe you should have to pay to cover the potential cost of your errors? If you got to keep that money in your pocket, how much would you set aside to pay for those errors? And how much would damage caps reduce that figure?

      As to the profitability of your insurer, can you provide a link to their financial statements so we can see just how profitable they are and where those profits and losses come from? Forgive me if I don’t buy every insurer’s line that they are losing money constantly and where their money goes.

    • Matt says:

      Also with Florida you said liability premiums had dropped considerably – can you give me the various dates of the drop and how much? Also, was it more or less than states without such reforms? I often see the claim made in states with caps that premiums fell, but then when you look at states without caps you see that they fell or rose nationwide regardless of caps. Which isn’t surprising considering the tie to the overall economy.

    • Max Kennerly says:

      “I do know that in my state 78% of all medmal suits end with no payment to the plaintiff and of the cases that go to trial over 80% are decided for the defense.”

      That could mean a lot of things. One possibility is that ~80% of suits do not involve provable negligence.

      Another possibility is that juries and/or judges are, to some degree, biased against medical malpractice plaintiffs.

      Another possibility is that standards for proving malpractice are too strict, but that lawyers have not come to terms with that, and are too optimistic.

      Or some combination of those three and other possibilities. Correlation != causation.

  14. SeaSpray says:

    Nothing like a little light reading before bed. Well now I can skip the melatonin! ;)

    Actually ..this is interesting… getting an inside look at physicians and lawyers perspectives.

    Wish I had something worthwhile to contribute. Just taking it all in. :)

  15. Patient says:

    What a ridiculous rant. Decent doctors can quickly identify those tests that are required versus the borderline tests versus the unnecessary testing.

    How about including the patient in the decision making process by providing factual information and allow the patient to make a FULLY INFORMED decision that includes how much the tests costs and alternatives to the testing. It’s ridiculous how much hospitals charge patients and to make these decisions without involving the patient while leaving them with 100% of the financial liability.

  16. Gammy says:

    Every doctor visit to renew my ADHD meds, they make me take a ‘pee test’ & charge me $40 every time! This has been ongoing for three years now, & EVERY time, the test comes back negative. Is this a racket, or what? I have no medical insurance, and this is a BIG chunck of my income.

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