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Defensive medicine costs must be weighed against the societal costs
Cultural norms and understanding of patient safety will continue to contribute to health care costs.
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This month’s 4 Questions interview deals with the term “defensive medicine.” We cannot say with certainty what actual costs can be attributed to defensive medicine in the United States as the projected range varies tremendously. But it is clear that defensive medicine requires more definitive studies. I have turned to B. Sonny Bal, MD, JD, MBA, for some of his thoughts related to this growing area of medicine. He has given considerable thought to the issues of defensive medicine, and I think you will find his responses stimulating and helpful.
Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: There have been numerous studies of the costs and numbers of defensively ordered tests. Without getting into the mind of individual physicians, how do you define a defensively ordered test?
B. Sonny Bal, MD, JD, MBA: Definitions vary, of course, but my definition of a defensively ordered test is one in which the fear of a lawsuit, and the resulting assurance or avoidance behavior are the only reason why the test was ordered. If there is patient benefit from the test or any other reason for ordering a test, then the test is not ordered defensively. It may be that a physician ordering a test, for whatever reason, may also feel that the test will serve to protect against a legal claim. Such reasoning is not defensive medicine since there would be at least one legitimate reason for ordering that test, even in the absence of a fear of litigation.
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Jackson: When the costs of these tests are projected, their impact on the overall costs of health care in the United States varies but are usually low. These can vary tremendously between trial lawyers and insurance companies. What is your interpretation of their impact on the overall health care dollar spending in the United States?
Bal: This is an important question, and a very serious concern among policymakers and stakeholders. If expenses are driven up only because doctors are worried about a hostile litigation environment, with no benefit for patients, then obviously this concern needs to be investigated, quantified and addressed. If on the other hand, incremental costs incurred by practicing medicine defensively simply reflect careful, prudent decision-making by physicians, then defensive medicine may be a good thing. The costs invested in defensive medicine in that instance must be weighed against the societal costs that would accrue from patient disability and injury in the absence of our tort system.
Going forward, we must address, from a scientific standpoint, the precise extent to which defensive medicine exists; agree on a definition of this term; investigate how the fear of litigation affects physician behavior, and the resulting impact on costs. What may be very difficult to demonstrate is whether or not defensively practiced medicine is financially beneficial to society, and if so, the extent to which it is so.
Jackson: A negative imaging study can be reassuring to the patient and physician that nothing is being missed. Many of these tests are not necessary but are often used as a second opinion or to reinforce a treatment decision. How does one separate these from defensive tests?
Bal: I do not view a negative test that was ordered for patient reassurance, or even physician reassurance that nothing was missed, as constituting defensive medicine. This may simply be desirable, prudent care or a reflection of our third-party payer system whereby the patient is not fully exposed to the costs of tests and may pressure the physician into ordering a test just to make sure everything is fine. We clinicians are well familiar with this phenomenon whereby a patient may insist on a knee MRI, for example, to make sure there is nothing wrong, or to address pain, anxiety or both.
Defensive medicine, at least in my opinion, occurs when the fear of litigation is the major motivating factor, and probably the only factor in the physician ordering that test. Thus, a defensively ordered test has no benefit for the patient whatsoever. If there is any benefit to the patient, even reassurance, then the test, at least by the definition proposed here, is not part of defensive medicine.
Jackson: As orthopedic surgeons treating patients with high expectations and who do not want to wait periods of time to observe their symptoms, what is a reasonable percentage for defensively ordered tests?
Bal: Again, this is a reflection of our culture, pace of life, patient expectations, third-party payment systems and perception of technology. We want, as physicians and patients, to get to the bottom line, fix things, make them better and we want them now. Ordering more tests and utilizing technology more than other countries without attendant benefit may reflect cultural norms in our society, rather than a defensive posture by physicians who want to avoid litigation.
Cultural norms, expectations, perceptions of technology, and increasingly, our understanding of patient safety will continue to contribute to costs in our health care system. A concern is that defensive medicine may become a catch-all phrase, to justify tests and interventions that are motivated by other reasons, however valid, than merely the fear of litigation.
- B. Sonny Bal, MD, JD, MBA, is an associate professor, Department of Orthopaedic Surgery, University of Missouri School of Medicine, Columbia, Mo. He can be reached at 573-882-6762; email: balb@health.missouri.edu.
- Disclosures: Bal has no relevant financial disclosures.