Combatting Defensive Medicine

By Alessandra Fodera (NHS ’16)

Growing up with arthritis and other medical issues, I was always a bit fragile. I very easily got hurt, and usually from simple activities. I sprained my ankles so much that I wore a medical boot on a different ankle every other month. I would go ice skating—sprain my ankle; walk on unleveled ground – sprain my ankle; play kickball at the field by the lake at my grammar school – completely miss the ball, watch my shoe fly into the lake and, good guess, sprain my ankle. My orthopedist, a family friend, was aware of my medical condition. He is a remarkable orthopedist who has been practicing for over thirty years. Yet, he needed an X-ray every time I came in. He clearly would state, “It’s another sprain, but let’s do an X-ray just in case.” In case of what? If I, a fifteen year old, knew it was a sprain; my doctor, with thirty years of experience, knew it was a sprain; and the ankle clearly looked like a sprain and not a fracture, why go through the trouble, costs, and harmful radiation of another X-ray? 

Defensive medicine is a direct result of medical malpractice. Medical malpractice occurs when a caregiver provides substandard care that results in injury or even death. This definition is extremely broad and the costs incurred therein are enormous.  For fear of being sued, many doctors practice defensive medicine to protect themselves. The practice of defensive medicine itself has many negative effects. Defensive medicine wastes the time, energy, and money of all parties involved. Extra testing is extremely expensive and adds to the United States’ high healthcare expense. Doctors are trained for years to diagnose and treat patients, but in defensive medicine, rely on technology instead of their own training.

Generally, there are two types of medical testing. The first level occurs when a doctor examines a patient and evaluates their symptoms and truly cannot render a valid diagnosis that they feel strongly about. Therefore, they order tests, for example, blood work on the three diseases they are considering, and use the results to differentiate the diagnosis. The second level of testing occurs when a doctor is positive of a diagnosis but, due to the prevalence of malpractice suits, needs testing to confirm the diagnosis. The first level of testing truly helps in diagnosis and treatment, but second level of testing serves practically no purpose except to rule out an incredibly unlikely diagnosis and legally safeguard a physician.

Numerous effects, some positive and some negative, can occur by having physicians pay for medical tests, X-ray studies, and consultations out of their own pockets.  Having doctors pay out of pocket may provide doctors with the incentive to more wisely choose testing measures. Doctors may more confidently make diagnoses by utilizing their medical knowledge and clinical skills instead of second-guessing themselves and conducting numerous and often unnecessary scans/tests. This would save significant money by reducing the high costs of testing. This also saves the patient from possible negative health risks, such as repeated exposure to radiation from X-rays.

A ten-year-old boy is rushed to the emergency room with high temperature, sharp stomach pain, and blood in his vomit – all clinical signs of appendicitis. He was then rushed into an operating room, where one member of the surgeon’s team asked about the sonogram. It then became clear that a sonogram had not been taken, since all the clinical signs were present. A portable sonogram machine was then brought into the room, minutes before anesthesia would be administered. Much to everyone’s surprise, the sonogram presented a perfectly healthy appendix. My ten-year-old brother almost had his healthy appendix removed because a doctor had thought that the clinical symptoms were enough evidence to cut him open. After evaluation by a urologist and additional testing, my brother was diagnosed with a kidney defect.

Although there are possible positive outcomes, there are also possible negative effects.  Physicians might not appropriately care for their patients due to the costs of tests. Doctors could misdiagnose, or fail to diagnose, by not appropriately using diagnostic testing. If parents bring in an infant who fell off a changing table, and a doctor examines the child who physically seems fine but cannot be analyzed for cognition because of its youth, the child can easily have unnoticed internal bleeding or other problems. If a doctor who doesn’t want to pay for the CT scan releases the patient and the child subsequently has a medical problem, then he may be completely at fault.

Physicians should be able to run numerous tests for confirmation and to see if they missed anything. Many diseases and/or illnesses are asymptomatic or have unclear symptoms, and therefore testing is necessary. For a doctor to have to decide which are necessary and which are not is not fair and possibly unethical.  A last to consider is that reducing testing by having doctors pay out of pocket is a barrier to preventative care and early detection. Preventative care reduces long-term costs. To make doctors bear this cost inhibits preventative care. Diagnosing cancer at the Stage One has much higher rates of success than at Stage Three.

Another possible and likely effect is that doctors will charge a higher rate for all patients (unless insurance companies don’t allow this). Due to the out of pocket expenses of testing, doctors will have to compensate and will shift the costs to the patients.

            Another possible situation is an entirely new insurance market: immediately, doctors will be more careful about ordering tests and will more closely examine patients to come up with firm diagnoses. Instead of ordering excessive tests just because insurance is covering it and because of fear of being sued, in this physician-paying world, doctors will carefully determine which tests are truly necessary for a complete and accurate diagnosis.  If physicians have to pay for testing, they will most likely shift the costs to other stakeholders, such as to the consumers by increasing their rates.

Doctors could increase their rates in one of two ways: Either they could adjust the rates according to what testing is performed, or they could increase their rates across the board. Following the former, depending on what tests were needed for a given patient, the doctor could charge them accordingly. On one hand, adjusting costs would not be fair for those not getting tests to overpay in order to compensate for others. On the other hand, if a doctor chooses a test and the patient can’t afford it, is it ethical for the doctor to not treat the patient?  Doctors can overcharge or undercharge according to incorrect criteria. Standardizing the rate seems the most efficient and rational. Across the board, doctors could increase their rates, having some patients pay more to compensate for others’ testing. Insurance companies would then either have to cover the whole or just a percentage of the costs, leaving the rest of the cost burden to the patients.

A change like this can have many different ramifications. The insurance system may completely be altered. If insurance companies aren’t paying for testing, they will then have to give a larger fee to the doctors who will be paying out-of pocket. They also can charge lower rates to enrollees due to lower costs of testing. Insurance companies may actually save money through this because the higher fee to doctors are minimal costs compared to the higher costs of testing. Doctors may also profit: by increasing their rates, all patients will be paying higher prices, whether or not additional testing is needed.  If 10 patients are seen at $200 per person, and only two patients need additional testing that costs $500 per person; the doctor is paid $2,000 from the 10 visits, with testing costs totaling $1,000. The doctor still profited $1,000. This new model may save or cost consumers: With lower rates from insurance companies, consumers would save money; depending on the rates of the doctor visits, consumers may have to pay additional costs.

This is a very controversial hypothetical situation. I do believe that defensive medicine and the high costs that it burdens patients with have become oppressive. The only reason defensive medicine occurs is because society is enabling it. Doctors should be able to make a diagnosis and only test if they think it is necessary to confirm a diagnosis; they should not be testing in fear of being sued. Doctors should be able to order tests and should not be limited by knowing the cost of a test is out of their own pockets. Tests save lives and diagnose issues that cannot be clinically determined. Doctors shouldn’t singularly bear the costs of testing. Having physicians pay out of pocket creates a dangerous scenario that could easily compromise patient care.  However, having doctors lose something through testing lets them have skin in the game: consider how insurance companies use copayments to ensure that patients are not overusing healthcare and causing unnecessary costs. Through copayments, patients share some of the financial burden and will hopefully choose wisely when it is necessary to seek medical attention. Doctors will be more cautious or prudent in ordering and performing diagnostic tests when they have a financial stake in the cost of such testing.

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