Reform Update: Doctors order unnecessary tests without even realizing it

Physicians order unnecessary tests and procedures to inoculate themselves from legal liability more than they realize, according to a new survey of physicians at several hospitals in one Massachusetts health system.

Nearly a third of the orders that the surveyed physicians placed were defensive on some level. The researchers argue that clear communication about evidence-based guidelines and tort reform that would protect clinicians when they follow those guidelines would help reduce providers' fear and improve patient care.

Fear of frivolous lawsuits may be so pervasive that it has changed what is considered an acceptable diagnostic approach, said Dr. Michael Rothberg, vice chair for research in the Medicine Institute of the Cleveland Clinic and lead author of a summary of the findings published in JAMA Internal Medicine.

“Some people might say it's defensive, and other people might think it's the standard of care,” Rothberg said. “There's really more of a culture about how people treat a particular problem, and many may not recognize it as being defensive.”

The study found 28% of orders and 13% of costs were judged to be at least partially defensive among the hospital medicine services at three institutions within one Massachusetts health system. About 2.9% of costs were considered to be completely defensive, meaning the only reason a test was ordered was fear of a lawsuit. Most costs were associated with the hospitalists prolonging a patient's hospital stay.

Thirty-six physicians from Baystate Health System's Medical Center in Springfield, Mass., Franklin Medical Center in Greenfield, Mass., and Mary Lane Hospital in Ware, Mass., rated 4,215 orders for 769 hospital inpatients.

The results suggested that physicians aren't reliable judges of what's driving their own decisions. Physicians who were most inclined to describe orders as influenced by liability fears did not actually drive more costs or order more tests than their colleagues who said they “practiced in a very nondefensive way,” Rothberg said.

Republicans have argued that the Obama administration and congressional Democrats missed an opportunity to tackle tort reform in the Patient Protection and Affordable Care Act, which conservative policy experts and many physicians say would do more to improve the efficiency of the U.S. healthcare system than any of the law's payment and delivery reforms.

The reform law did authorize $50 million to fund grants to states to develop and test alternatives to medical liability litigation.

The Agency for Healthcare Research and Quality has said in a report (PDF) that one demonstration program achieved a 40% decline in the number of malpractice claims, an 80% reduction in the time it took to settle cases and a 20% decrease in defensive medicine services.

Still, when the American College of Surgeons hosted its third annual leadership and advocacy summit in Washington this past spring, medical liability reform was a primary topic.

Attendees called on lawmakers to support additional initiatives that lawmakers have introduced to curb frivolous lawsuits. For example, the Saving Lives Saving Costs Act (PDF) would give legal cover to providers who adhere to physician developed best-practice and appropriate-use guidelines from groundless lawsuits. The Health Care Safety Net Enhancement Act protects emergency on-call specialists. The Good Samaritan Health Professionals Act protects health professionals who provide voluntary care in response to federally declared disasters.

Follow Sabriya Rice on Twitter: @sabriyarice



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