Newsgroups: sci.med
Subject: Re: Rising health care costs. Was: Mercury in fillings
From: king@reasoning.com (Dick King)
Date: Fri, 4 Sep 1992 17:09:15 GMT
Organization: Reasoning Systems, Inc., Palo Alto, CA

In article <Bu0M4L.CIr@wpg.com> russ@wpg.com (Russell Lawrence) writes:
>
>In article <Btx0Hr.3Dw@wpg.com> russ@wpg.com (Russell Lawrence) writes:
>rl> BTW, did you get a chance to read the special article on the 
>rl> crisis in US health care in the July issue of _Consumer Reports_?  
>rl> A special insert on pg 443 explained that the AMA's chestbeating 
>rl> about malpractice concerns is a "straw man", albeit widely 
>rl> believed by the US public.  The conclusions of Consumer Reports 
>rl> were supported by studies conducted by HHS as well as a Harvard 
>rl> University study funded by the state of NY.  
>
>From article <16319@pitt.UUCP>, by geb@dsl.pitt.edu (gordon e. banks):
>gb> Since I am in a better position to know about that issue than
>gb> the author of the article, I disagreed.  I see cases every day
>gb> where physicians use the malpractice argument to justify
>gb> ordering expensive tests.  Every day.  
>
>What you're saying is that malpractice is the major problem 
>because many doctors believe that malpractice is the major 
>problem.  Yet the fact remains that the cost of liability 
>insurance is less than 1% of the total health care budget.  Yes, 
>yes, we know you're afraid of lawyers, but your fear alone
>doesn't strongly support the notion that lawyers are the root 
>cause of rising health care costs anymore than fear of demons 
>would support the demonic causation theory of disease.
>

Even a correct assertion that liability insurance is a small part of the cost
of medical care does not refute GEB's assertion that fear of malpractice cases
motivates unnecessary tests and cost substantial bucks.

Consider the following set of facts:

  * 99.9 % of the patients with Farfle Syndrome will heal in two weeks without
    complications, after a simple treatment that costs a few hundred dollars.

  * The rest will walk with a slight limp for the rest of their life unless you
    apply the Foo Procedure.  

  * The Foo Procedure must not be applied to the 99.9 %, and costs $5000

  * A Widget Test, which costs $2000, will accurately find the 0.1% who need
    the Foo Procedure.  

  * Juries will routinely award a $250,000 malpractice award if you needed the
    Foo Procedure, but didn't get it because no Widget Test was performed.

  * Insurance companies routinely pay for the Widget Test.

On this set of facts i would order a Widget Test for all my Farfle Syndrome
patients, even though it is is not economically justified unless you think that
each avoided "slight limp for the rest of one's life" is worth $2 million.
Every rational doctor would do the same, and there would be no malpractice
awards for Farfle-Syndrome-induced limps, yet malpractice awards ARE the
problem because they do not consider whether a low-yield test that undeniably
prevents a bad result when it hits should nevertheless not be performed because
the economics don't make sense.

GEB, perhaps you can flesh out the bones of my hypothetical with a real
routinely-applied low-yield test?  The key points of my hypothetical are...

  * The economic decisions are not made bcs different people pay for the tests
    and for the malpractice awards

  * Juries are unwilling to hear arguments of the form "yes, we could have
    prevented this, but at what an economic cost!!!  $2 M / case"

-dk