The Cost of Defensive Medicine
The Cost of Defensive Medicine

Dr. Alex Jahangir
Vanderbilt Study is Latest to Reinforce Need for Malpractice Protections

Manish Sethi, MD, remembers his father as a “salt-of-the-earth” primary-care physician practicing in the small Middle Tennessee town of Manchester. He even recalls once going with his father to pick a patient up at home and take that patient to the emergency room. Then his dad was diagnosed with liver cancer and given the heartbreaking prognosis of just three months to live.

It was during those final months that a former patient sued Sethi’s father for malpractice, a case that Sethi described as “absolutely ridiculous.” While the suit was eventually dropped, the experience gave Sethi valuable insight into the stresses of malpractice litigation. “Literally the day that my father died, I was at a deposition,” he said.

The suit against his father first prompted his anger – and then his intellectual curiosity. “The more I looked at it, the more I realized that medical-liability issues are destroying the economics of healthcare because they’re incentivizing doctors to protect ourselves to order tests that we really don’t need,” he said.

Today, Sethi and his colleague Alex Jahangir, MD, also a Tennessee native, are both assistant professors of orthopaedic surgery and rehabilitation at Vanderbilt University and co-directors of the Vanderbilt Orthopaedic Institute (VOI) Center for Health Policy. Their research interest? The cost to America’s healthcare system of defensive medicine.

Sethi first published on the subject four years ago, when he was co-author of a study in Massachusetts examining defensive medicine among all subspecialties in the state. “What we showed there was that about 30 percent of most tests across all specialties, whether it was orthopaedics, general surgery or primary care, were defensive in nature – tests that were only ordered because of the fear of liability,” he said. Those findings confirmed similar 2005 findings by Harvard researchers, who surveyed Pennsylvania physicians in six specialties at high risk of litigation (emergency medicine, general surgery, orthopaedic surgery, neurosurgery, obstetrics/gynecology and radiology). Of those physician respondents, 93 percent acknowledged practicing defensive medicine, with 43 percent reporting the use of imaging technology in clinically unnecessary circumstances.

Now Sethi and Jahangir are authors of medicine’s most recent research on the subject. In February, the Vanderbilt duo released the results of a study that found that U.S. orthopaedic surgeons create approximately $2 billion per year in unnecessary healthcare costs by practicing defensive medicine. The findings are from a national survey of 2,000 orthopaedic surgeons in all 50 states selected randomly through a list provided by the American Academy of Orthopaedic Surgeons. Of the respondents, 96 percent reported practicing defensive medicine. Sethi said this overwhelming figure accounts for 24 percent of all imaging studies, laboratory tests, consultations and hospital admissions among the survey’s cohort. That’s $101,820 per respondent annually for defensive medicine.

“It shows that doctors in general across the United States really practice a lot out of fear, and that costs the system a lot of money,” Sethi said.

Jahangir said the study breaks defensive medicine down into two categories: positive and negative. Positive defensive medicine is, as previously described, the increased use of unnecessary medical tests and procedures. Yet negative defensive medicine comes at a cost, too. That’s when doctors avoid treating certain patients – those who are obese or have diabetes, for example – or avoid procedures or interventions that are perceived as high risk. “That becomes an issue of access,” he said. In fact, 70 percent of study respondents reported reducing the number of high-risk patients they treat, while 84 percent reduced or eliminated high-risk services and procedures.

Jahangir and Sethi are the first to examine the issue of defensive medicine related just to their specialty, and Jahangir said the study and its implications “resonated well” with their orthopaedic colleagues nationwide.

“Physicians and a lot of people in healthcare are aware that part of their practice is defensive in nature. The bigger issue here is not that defensive medicine is taking place, but the fact that we are now entering a phase in our national discourse about healthcare costs and saving money,” he said. “This is an area of expense that could possibly be prevented.”

Indeed, Jahangir and Sethi are selling their message with something akin to missionary zeal. They contend that defensive medicine’s run-amok costs could be reined in if state and federal governments would provide malpractice protections for physicians who follow evidence-based clinical guidelines. “We could save potentially billions of dollars across healthcare by setting up clinical-practice guidelines that are evidence-based and that allow physicians to provide care in a proven method without the fear of lawsuits,” Jahangir said. “Therefore, they are not ordering as many tests and are bringing healthcare costs down. It’s a discussion that people respond to very well.”

Jahangir stressed that such guidelines wouldn’t result in “cookbook” medicine, but would instead offer protection from that “one-in-a-million chance that he or she missed a diagnosis.”

Both Maine and Oregon have tested these waters with some success, said Sethi, who acknowledged that competing lobbying interests are preventing what would obviously be a paradigm shift in medicine. “Doctors want to get involved. They want to make change. They want to make a difference. They want to make an impact,” he said. “They realize there’s something wrong in our country right now, and our budget is out of control and healthcare costs are part of that budget, so we have to do something.” Unfortunately, Sethi added, the federal Patient Protection and Affordable Care Act doesn’t address defensive-medicine costs.

Sethi said he and Jahangir “very deeply care about Tennessee healthcare and about Tennessee in general. Right now, healthcare costs are killing our state. If we’re paying a dollar for healthcare, that’s a dollar we’re not paying for education or building roads.” He noted the same is true for other Southeastern states.

A step in the right direction is the textbook Sethi and Jahangir have written, which delineates evidence-based clinical guidelines for specific types of orthopaedic trauma. The textbook should be published in a few months.