September 7th, 2010
Medical malpractice and reform proposals have been a longstanding battleground of U.S. health policy. On the one hand, studies have shown that health care is rife with errors and avoidable injury to patients. On the other, doctors and hospitals fear frivolous lawsuits and resent high malpractice insurance premiums. It’s been generally agreed that one result is billions of dollars in “defensive medicine”— tests or treatments that physicians prescribe largely to avoid lawsuits.
How much medical liability really costs has therefore been a subject of intense debate. Now, a comprehensive analysis in the September 2010 issue of Health Affairs pegs the cost of malpractice at approximately $55.6 billion a year, or 2.4 percent of annual health care spending.
“We cannot debate the potential for medical liability reform to bring down health care costs in any meaningful way without realistic cost estimates,” said Michelle Mello, lead study author and professor of law and public health at the Harvard School of Public Health. “Some of the numbers bandied about in policy discussions were quite imaginative and we wanted a more defensible estimate.”
This is just one of the articles dealing with medical liability and patient safety in the September Health Affairs issue, released today. Several issue updates on medical liablity and patient safety, which briefly summarize the material and policy recommendations in the September issue, were also released today.
In addition, the new issue contains a cluster of articles on the increasing use of emergency rooms for nonemergenices and ways to reduce this phenomenon; these articles will be described in a blog post tomorrow. Both medical liability and ER use will be discussed today at a release event for the issue at the National Press Club in Washington D.C. You can join us at the briefing or follow it through live Tweets on HA_Events at #HAmedmal.
More on medical liability and patient safety. Mello and colleagues at Harvard and Brigham and Women’s Hospital in Boston analyzed various components of the medical liability system, including payments made to malpractice plaintiffs; defensive medicine costs; administrative costs, such as lawyer fees; and the costs of lost clinician work time.
“Physician and insurer groups like to collapse all conversations about cost growth in health care to malpractice reform, while their opponents trivialize the role of defensive medicine,” said Amitabh Chandra, a study author and professor of public policy at Harvard’s Kennedy School of Government. “Our study demonstrates that both these simplifications are wrong—the amount of defensive medicine is not trivial, but it’s unlikely to be a source of significant savings.”
Defensive medicine costs alone were estimated at $45.6 billion per year. The researchers did not assess social costs such as the reputational and emotional costs for physicians being sued.
Tort reforms, such as capping noneconomic damages, may reduce liability costs but are likely to have little impact on overall health care spending, according to the study authors. Other reform proposals, such as moving away from fee-for-service reimbursement, may have a greater effect, they add. Meanwhile, expanded health insurance coverage under federal health reform may reduce medical liability costs if fewer people need to file claims to recoup out-of-pocket medical expenses incurred because of malpractice.
Other studies in the September issue of Health Affairs examine additional aspects of medical malpractice, as follows:
- National tort reform and a resulting decline in malpractice insurance premiums would probably have little impact on costs in terms of reductions in defensive medicine, according to J. William Thomas, visiting professor at the Muskie School of Public Service, University of Southern Maine, and his colleagues. Their analysis shows that estimated savings from a 10 percent decline in malpractice premiums would translate into reductions in defensive medicine equal to less than 1 percent of total medical care costs in every specialty.
- Misdiagnoses account for nearly 20 percent of all medical errors, but the patient safety field has all but ignored this problem, writes Robert M. Wachter, professor and associate chair of the Department of Medicine, University of California, San Francisco. The relative inattention, he argues, is driven by the “human nature” of these mistakes—failures of cognition are less amenable to “systems solutions” such as checklists and standardization. He recommends a number of ways to improve diagnostic accuracy, including increasing use of computerized decision support and better training of young doctors in the science of diagnostic reasoning.
- Physicians fear being sued for malpractice even in states where objective indicators suggest their risk is relatively low, according to Emily Carrier, senior health researcher for the Center for Studying Health System Change, and her colleagues. In a survey of 4,720 physicians, the authors found physicians’ concerns are likely to be driven less by their actual risk and more by their perception that the malpractice tort process is unfair and arbitrary. Traditional state tort reforms do little to reduce these perceptions, say study authors.
- Hospitals can save money and improve quality by adopting the World Health Organization (WHO) Surgical Safety Checklist, say Marcus E. Semel, resident in general surgery at Brigham and Women’s Hospital, and co-authors. They calculated that in a typical hospital with a “baseline” major complication rate after surgery of at least 3 percent, the checklist generates cost savings once it prevents at least five major complications per year. Based on that analysis, authors recommend adoption of the checklist in U.S. hospitals.
- Thirty-four states and the District of Columbia have adopted laws to encourage health care providers to apologize to patients for medical mistakes without fear of legal recriminations. But shortcomings in these “apology” and “disclosure” laws may actually discourage honest communication between doctors and patients, and limit their effectiveness at reducing malpractice lawsuits, according to Anna C. Mastroianni, associate professor at the University of Washington School of Law, and co-authors.
- The next generation of physicians will drive a culture of patient safety in health care, say Darrell G. Kirch, president and chief executive officer of the Association of American Medical Colleges, and Philip Boysen, executive associate dean for graduate medical education at the University of North Carolina, School of Medicine. Although teaching hospitals and medical schools have made strides in teaching patient safety both in the classroom and in clinical practice, they are increasingly finding that residents are the true agents of change, mentoring both peers and faculty. An expansion in health information technology and an investment in comparative effectiveness research will help these leaders find ways to improve care at the bedside, the authors say.
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