From: russ@wpg.com (Russell Lawrence)
Subject: Rising Medical Costs. Was: Mercury in fillings?
Organization: WP Group
Date: Thu, 3 Sep 1992 04:02:48 GMT

From article <16312@pitt.UUCP>, by km@speedy.cs.pitt.edu (Ken Mitchum):
km> The fact is, there are a lot of unnecesary things being done
km> in medicine today - that is precisely the fact behind the drive
km> to "managed care" and physician accountability: if unnecessary
km> things were not being done, then the people behind these
km> ideas would not have any basis on which to limit costs.

I agree that there are a lot of unnecessary procedures.  

Consider, for example, an HHS study conducted several years ago 
which found that 12% of all doctors who treat medicare patients 
were involved in joint-venture kickback schemes whereby they made 
extra bucks by referring their patients to outside labs which they 
themselves partly owned.  According to HHS, patients who were 
treated by such doctors received 45% more tests than other 
patients.  Yikes!  

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.  

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.  

It's a shame we can't get into the AMA's records and take a close 
look at the responses of the doctors who'd been involved in the 
kickback scheme I described above.  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.  

km> There are many reasons for unnecessary things being done, and
km> I can tell you that ONE of these is the malpractice problem.
km> I can only speak for myself, but I know that many of the tests
km> I order every day are for the chart only: I know what the
km> results are going to be before I order the test, and the chances
km> of the test influencing what happens to the patient are very
km> low.

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

km> You may have studies supporting the view that the possibility
km> of getting sued does not increase costs, but I would have a
km> difficult time accepting them until I see a good control group
km> that has everything American medicine has EXCEPT the malpractice
km> problem. If doctors in such a system order all the same tests
km> that we do, then I would obviously be wrong, and assume that
km> doctors are just inheritly inept at using their training.

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

A Harvard University study funded by the state of New York
found that 1/4 of the "adverse events" suffered by patients
in NY hospitals were the result of negligence.  Only one in
eight of these patients filed suit, and only one in sixteen
collected damages.   Now what, may we ask, were the AMA and AHA
doing to help improve the underlying conditions in those hospitals?   

Let me give you one example.  Here in Louisiana, there were a 
rash of deaths at Charity Hospital several years ago that were 
the result of blatant goofups in blood-typing.  The name slips 
my mind at the moment, but some congressman introduced 
legislation that would have raised standards in such a way 
that such goofups would be far less likely.  What was the AMA's 
response?  You guessed it: such restrictions represented 
unwarranted intrusion of government into the practice of 
medicine.  Go figure.  

km> To be very cynical, I could also point out that doctors are not
km> paid for their time, but by the patient, and it takes several
km> minutes to evaluate the patient and do an exam. It only takes
km> a few seconds to order a CT scan. This problem is, of course,
km> not caused by malpractice problems, but by payment schemes
km> set up by bureauocrats, many of which have law degrees. I
km> don't usually engage in lawyer-bashing, but I do sometimes
km> wonder how lawyers would act if they were not paid for their
km> time, but by the head. I also wonder how they would feel about
km> systems that would impose fixed incomes on lawyers in the same
km> manner as is being proposed for doctors.

I agree that payment schedules are a major problem, and there's ample
evidence to show that these schedules often contribute to care that
doesn't serve the patient's best interests.  There's no evidence
whatsoever to show that we can blame this particular problem on
the lawyer boogie-man.

km> Overall, CR did a useful job in it's report, but I think they
km> glossed over some things, and painted too rosy a picture of
km> the Canadian system. This is surprising, since they did point out
km> major problems with managed care systems. One of the things
km> I have noticed in the debate over how the health care system
km> should be changed is that only a few people involved think
km> that doctors themselves might have some positive ideas about
km> changing the system, and when some of these ideas, such as
km> malpractice reform, are raised, they are given little credence
km> in terms of ability to improve health care and reduce costs,
km> but are instead viewed only as a means of protecting doctors'
km> incomes. I find that a bit cyncial as well.

I don't disagree.   If we stick with the facts and analyze them
very carefully, we'll find plenty of doctors who want to change the
system for the better... without regard to their own financial
incentives.  Then again, we'll find quite a few doctors who're so bound
up by financial interests and ideologies that their suggestions
and objections have little credence.  The AMA's opposition to the
Stark amendment and higher hematology standards are good examples.

-- 
Russell Lawrence, WP Group, New Orleans (504) 443-5000
russ@wpg.com   uunet!wpg!russ
Newsgroups: sci.med