From: km@cs.pitt.edu (Ken Mitchum)
Newsgroups: sci.med
Subject: Re: Rising Medical Costs. Was: Mercury in fillings?
Date: 4 Sep 92 15:58:51 GMT
Reply-To: km@cs.pitt.edu (Ken Mitchum)
Organization: Computer Science Dept., University of Pittsburgh

In article <BtzHwq.31u@wpg.com> russ@wpg.com (Russell Lawrence) writes:
>
>You may recall that the Stark amendment was designed to eliminate 
>these kickback schemes.  The American College of Surgeons, the 
>American College of Radiologists, and the editors of the New 
>England Journal of Medicine came out in favor of that amendment, 
>but the AMA adamantly opposed it...  claiming that it violated 
>the rights of doctors as businessmen.  

I am no friend of the AMA, but the government has carried the
ban on "self-referrals" a bit too far: you can no longer charge
a medicare patient for an EKG that you do in your office. If
we extended this principle to other activities (and perhaps
we should), the shop that diagnoses what is wrong with your
car should not be allowed to profit from fixing it. While I think
it is wrong for doctors to invest in services that others
perform which they refer patients to, I think that is very
different from charging for a test you do yourself (EKGs).
Of course, the government figures that the only reason you
do the EKG is to make money, and that the patients never
really need them. And if the EKG is normal, you certainly
didn't need it...

>HHS has been evaluating the cost of US medical care for many 
>years and their studies have consistently shown that the cost of 
>medical liability insurance is consistently less than 1% of the 
>total health care budget.  The AMA countered the most recent HHS 
>study by conducting a study of their own, wherein they asked 
>their own membership to make guesstimates about the "hidden" 
>costs of unnecessary procedures they perform because of 
>malpractice fears.  I suppose such anecdotes may have some 
>value, but in view of the special interests at stake here, I'm 
>rather skeptical.  

This is where we have a big disagreement. I agree that the cost
of the insurance is not the problem, unless you are in some
specific high-risk specialties. The problem IS the unncessary
tests that are being done, and it is hard to demonstrate because
after a few years, the unnecessary test becomes the "standard
of care" due to common usage. If everyone else orders the test,
you damn well better order the test, or catch hell. This has
increased as the scope of malpractice claims has widened to
include things such as "failure to diagnose." Patients catch
on to this and demand more services as a result: "Gee, doctor,
I had a headache last week. My friend had heacaches and her
doctor ordered a CT scan. Aren't you going to order one?"
Pretty soon, it becomes the standard of care: everyone with
a headache gets a CT scan. 

The problem is compounded by the difference between the nature of
medicine and the nature of law: medicine is full of uncertainty, and
what is reasonable medicine may not sound reasonable in court.  If
someone has a history that sounds like tension headache and had a
totally normal neurologic exam, they ALMOST certainly have tension
headahces. But somewhere at some time, someone undoubtably went to a
doctor with what sounded like tension headaches, had a normal
neurological exam, but actually had an undiagnosed brain tumor, not
related to the headaches at all. This will happen because people with
tension headaches get brain tumors like anyone else, and the tumors
don't initially cause any symptoms, i.e. the tension headaches and the
brain tumor are a coincidence. Try convincing a jury of that. It only
takes one or two cases like this for everyone to catch on, and CT
scans then become the standard for everyone with headaches, whether it
is medically appropriate or not.

>Somehow I have the feeling 
>that such doctors would exaggerate the overprescription of 
>testing because of malpractice fears while completely overlooking 
>overprescription tied to financial kickbacks.  

The "AMA types" might, I don't know. Personally, I work for a
salary so that kickbacks are impossible. 

>It must be nice to know what the results of a test will be before
>you order the test.  Are you ever wrong? :-)

For tests I order for legal reasons, rarely. Every CT scan I have
ordered to please other people has been normal, as has every
skull film after a fall where the physical examination was
negative. For tests I order for medical reasons, I am often
wrong in  predicting the outcome - generally the test is normal
when I think it won't be.

>
>Let's not forget the root problem of malpractice litigation...
>namely fraudulent or substandard medical care.

This is not really true. As you state yourself, many cases
of malpractice are never persued. The real cause of
malpractice litigation is the failure of the doctor-patient
relationship, usually caused by the doctor. Nice doctors
don't get sued, no matter what they do, while the ones
with brash manners who treat their patients like dirt get
sued no matter how good they are. Many lawsuits represent
the patient's only way to get back at a person who should
have treated them better.

 -km





Newsgroups: sci.med