A 2015 study is coming back to the forefront with a new interview by Dr. Anupam Jena. Dr. Jena authored the 2015 study, Physician spending and subsequent risks of malpractice claims: an observational study. The study attempted to answer the question: is a higher use of resources by physicians associated with a reduced risk of malpractice claims, finding that “across specialties, greater average spending by physicians was associated with reduced risk of incurring a malpractice claim.”
The Study
Jena and the other researchers matched the spending of 25,000 Florida physicians in 2000-2009 to their malpractice claims. In all specialties, higher resource use was associated with lower rates of malpractice claims in the following year. For example, in internal medicine, 1.5% of physicians in the bottom fifth of spending incurred a malpractice claim, compared to only .3% in the top fifth.
In an analysis of roughly 225,000 C-section births, nearly 6% of obstetricians in the bottom fifth of caesarean deliveries had a malpractice claim the following year, compared with 3% in the top fifth.
Concluding the study, the authors noted, “Without evidence on rates of errors associated with greater resource use, we cannot definitively conclude that defensive medicine … reduces the number of malpractice claims. However, our findings still suggest that greater resource use is associated with fewer claims, which is consistent with physician beliefs that higher resource use, more generally, is associated with reduced liability of malpractice.”
The Interview
In his recent interview, Dr. Jena discussed the study’s results, methods and limitations, as well as its implications for research on defensive medicine and healthcare spending. Dr. Jena further detailed how the study shows a correlation between increases in physician spending and a lower likelihood for that physician to be subsequently sued for malpractice.
Though the study has several limitations that are addressed during the interview, it helped to shed light on important aspects of healthcare spending, the doctor-patient relationship and the difference between appropriate healthcare spending and defensive medicine.
Dr. Jena gave an example of how defensive medicine works, “if a malpractice environment leads a physician to order colonoscopies more appropriately than he or she had been doing before, and what you find is that cancer screening rates go up and that patient outcomes improve, we wouldn’t call that defensive medicine. That’s actually the intent of the malpractice system to get physicians to practice appropriately… Defensive medicine [on the other hand] means additional tests and procedures that are done that actually deliver no benefit to the patient.” Therefore, the extent that greater use of healthcare services improves patient outcomes is not defensive medicine. While it may reduce liability, it is not specifically defensive medicine as much as it is good medicine.
According to Dr. Jena, the most interesting thing the researchers found was that,
There appears to be this potential link between spending more and getting sued. There are a number of reasons why you might think that there should be a link. For instance, one might think that the reason that doctors get sued has very little to do with the number of tests or procedures that they order, but has more to do with the relationship that they have with the patient. And if that were the case, then we wouldn’t expect to see any relationship between the general level of spending of a doctor in his or her lawsuits. But none the less, we do find it. We do find that doctors who spend more get sued less often.
And so that certainly does suggest a possibility that spending could have a deterrent effect on suits, whether it be through a defensive mechanism, in which case patients may be less likely to sue a doctor because they thought that all exhaustive options were done, or whether it’s through a what I would call a “good medicine mechanism”, in which case better outcomes actually resulted in the doctor was sued less often.
Dr. Jena also discussed some of the conclusions he would like physicians to take away from the study, including:
It makes complete sense that lawsuits could be related to the relationship between a physician and a patient. Makes complete sense. And physicians shouldn’t look at the study and say that, “Wow, I got sued not because of how I treated the patient in terms of respect and apologizing for a mistake occurred, but I got sued because I didn’t order a test.”
That’s not what I think physicians should take from this. What I think physicians should take from this is that yes, it’s certainly possible that ordering an additional test or a procedure could lower your risk of being sued because you detect something that you couldn’t detect before. And I think as long as people are open to that possibility and say, “Look, it’s not the case that all the healthcare spending is necessarily wasteful,” which is something that we hear often, but it could be the case that in some instances, it actually is beneficial in terms of improving patient outcomes, and there may also be this tangible benefit to physicians of being sued less often. I don’t think physicians should run and change their behavior because of the study, but what I think it should do is at least open up that conversation on a national policy level and certainly in their minds that this is something that we should consider, something that we should watch out for as we start to implement other reforms of healthcare.