Malpractice claims may be associated with increased imaging utilization
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Physicians living in regions with a high incidence of medical malpractice claims may be more susceptible to ordering advanced Medicare imaging as a defensive medicine strategy, according to published results.
Alexander Villalobos, MD, and colleagues from the Emory University School of Medicine analyzed claims data from a 5% sample of Medicare beneficiaries from 2004 to 2016 to find associations between regionally adjusted rates of Medicare imaging orders and paid physician malpractice claims. Villalobos and colleagues used National Practitioner Data Bank files to calculate paid claim frequencies and payout amounts, according to the study.
During the sample period, nationwide Medicare imaging utilization declined by 31.4%, from 355,057 to 243,517 examinations, and overall spending declined by 47.2%, from $28,591,146 to $15,099,291. During the same period, paid medical malpractice claims declined by 46.4%, from 4.83 to 2.59 claims per 100,000 people, and payout amounts decreased by 39.6%, from $1,803,565 to $1,089,112 per 100,000 people.
After controlling for secular trends and state fixed effects with multivariate regression models, Villalobos and colleagues found a positive association between Medicare imaging utilization and the lagged number of paid malpractice claims per capita. Investigators found a 1% increase in average paid malpractice claims was linked with a subsequent 0.2% increase in imaging order, according to the lagged 5-year rolling paid malpractice averages.
States with the greatest increases in paid malpractice claims were West Virginia (+12.5%), Indiana (+11.4%) and Rhode Island (+6.0%), while states with the greatest decreases in paid malpractice claims were South Dakota (-91.0%), North Dakota (-86.9%) and Vermont (-73.9%), according to the study.
“Each additional paid malpractice claim over the course of 5 years (thereby contributing to an unfavorable malpractice litigation environment) was associated with an average of 1,389 additional advanced imaging examinations in the Medicare population alone in the subsequent year,” Villalobos and colleagues wrote in the study.
“In recent years and across the United States, overall Medicare imaging utilization and paid medical malpractice claims have both declined,” they wrote. “Nevertheless, the high costs of both remain important issues for physicians and policymakers alike, particularly as they seek to ameliorate the negative effects of defensive medicine,” they added.
Perspective
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Jack M. Bert, MD
In my experience reviewing claims in western Wisconsin, Minneapolis and St. Paul, Minnesota, there are variable costs for 1.5 Tesla MRI scans, including the interpretations by board-certified radiologists. The costs vary between $590 and $5,000.
It is important to have objective data prior to performing surgery on a patient. Most insurers in Minnesota and Wisconsin do not accept clinical exams to confirm a diagnosis. For example, with a torn meniscus, even if a patient has mechanical symptoms, such as locking, effusion and a positive Steinman test, they will demand an MRI to confirm the diagnosis before approving a surgical procedure. Thus, not only are physicians obtaining MRIs whenever they believe more than a simple strain has occurred to a joint, but they are performing MRIs to get insurer’s approval to proceed with surgery.
As telemedicine becomes more common, inexpensive MRIs are going to be the standard of care in my opinion so the orthopedic surgeon can make a diagnosis with certainty while remote and without examining the patient. I would make the argument that a $590 MRI of a knee or shoulder is going to potentially reduce the care costs for patients as opposed to sending the patient for several PT sessions.
Once objective information is obtained confirming the diagnosis, appropriate care and treatment can be rendered in a cost-effective fashion without concern about legal liability for a “missed diagnosis.” Furthermore, if cost-effective MRIs are available, the “case costs” will dramatically decrease. Thus, with respect to the positive correlation between practicing “defensive medicine” and obtaining MRIs, multiple factors are involved which in essence force the orthopedic surgeon to obtain scans commonly on patients.
Legal liability prevention to obtain objective data, insurance approval demands and remote telemedicine justification to determine an accurate diagnosis are the three main reasons why an increase in MRIs for musculoskeletal disorders has occurred. However, some of the exorbitant charges occurring for scans are inappropriate. Employers and insurers are beginning to incentivize patients to seek less expensive scanner locations.
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