Defensive Medicine: Cautious Or Costly?

When Doctors Cover Bases By Ordering Extra Tests, It Can Cost Patients Big

(CBS)  It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room.

There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.

But her father did - when he got the $8,500 bill, $6,500 of which was that CT scan.

“I was pretty flabbergasted,” said Robert Varipapa, himself a physician.

Varipapa says his daughter's pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound.

“A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.

But the hospital defends the CT scan, saying an ultrasound might have missed something more serious.

“It would not have ruled out appendicitis obviously, it would not have ruled, necessarily, out a kidney stone,” said Dr. Bob Powell, ER medical director of Bon Secours St. Mary’s Hospital.

Varipapa agrees, but asks why not start simple - and do the CT scan only if necessary?

“Well it's my opinion this is defensive medicine,” Varipapa said.

Defensive medicine is what happens when doctors order too many tests because they are afraid of missing a diagnosis and later losing a multi-million dollar lawsuit for malpractice. Defensive medicine these days is so pervasive, some estimate its yearly cost at more than $100 billion.

Dr. Kevin Pho runs the popular medical blog, Kevin M.D., where doctors routinely confess exactly how they run up costs by practicing defensive medicine.

“Defensive medicine is bad medicine,” Pho said.

In a post, one ER doctor says he's just admitted two patients to the hospital - when he was sure "neither was having cardiac (problems), but what am I to do?"

Another admits that in his practice, “every patient with a headache gets a (CT) scan.”

“It's much easier to defend the fact that you ordered a test than it is to not order the test at all,” Pho said.

And the costs of defensive medicine today are increasingly paid by patients, even those with insurance - because of rising deductibles and co-payments.

“There’s no doubt in my mind this is a significant driver in health care costs today,” Pho said.

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Couric & Co. Blog: Do I Need This Test?

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But there are ways the patient can sort out the necessary from the unnecessary tests.

Experts tell CBS News you should ask basic questions.

First: Why is this test needed? Ask about the cost and if there's a less expensive, alternate test. Ask if the test results might change your diagnosis - or treatment. And, "what is the risk if I don't have the test?"

“They didn't really talk to me about doing anything else,” Alexandra Varipapa said.

In Varipapa's case, the hospital insists her CT scan was medically required, given her symptoms.

But in the end, the hospital did present an $8,500 dollar bill - for a condition that went away on its own.

[dr_noshots]

As an allergic reaction to Defensive Medicine, I was thinking on becoming an Executioner. After all, in the post-electric chair era, who knows better than an anesthesiologist how to administer intravenous drugs ?

But, as all American doctors are, I am obsessed by the possible legal implications of such choice. What happens if "the patient" survives ?

DO I HAVE TO BUY EXECUTIONER MALPRACTICE INSURANCE ?

[dr_simmons]

I have found your series on Defensive Medicine interesting and informative. Two things strike me regarding it''s presentation however. Does anyone really think one can question one''s Doctor and get straight answers as to risks and decision alternatives? If you are right, the Doctor''s interest is the avoidance of such testimony. Second, and I admit here I have some proprietary research to guide this comment: the over - prescription of tests may have nothing to do with the patient- Doctor assessment process. Rather it may be due to the economics of medicine under current conditions. We are faced as a nation with a medical community ramped up to serve at a considerable cost which is experiencing a major drop in demand because of a rapidly declining base of insured patients to treat. The over-prescriptions, and perhaps over-recommendation of procedures, could be driven by the need for capacity utilization rather than concern for the patient. To test my point, see if you can find a frequent story of defensive medicine practiced on street people; else your hypothesis of what is going on may only be partially correlated with reality.

[dr_noshots]

Defensive Medicine: A NON-HYPOCRITIC OATH.

I swear:
To obey the law and practice medicine to the best of my knowledge and according to my local judges, medical malpractice lawyers, jury decisions, mandatory second opinions, liability insurance companies and HMO limitations.
If abortions remain legal, I will or I will not produce them, depending on my own personal beliefs, on the number of abortion clinics burned in my immediate vicinity, and on the number of anti-abortion people picketing the local hospitals.
I will give no deadly medicine to anyone if asked, nor suggest any such counsel. Unless, of course, a euthanasia law is finally passed and I will then make such desperate decisions case by case.
Whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men or women which ought not to be spoken of here or abroad, I will not divulge, as reckoning that all such should be kept secret.
Unless of course, their charts are subpoenaed by medical liability attorneys, requested by Medicare or Medicaid, checked by the hospital peer review committees or investigated by the department of Health.
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art of Defensive Medicine.

(Sorry but....it had to be repeated !)

[radmdtx]

Socialized medicine is the last thing we need. If you think you have to wait to see your doc now it will only worsen- see rf36. This country is already short of docs and socialized medicine will only worsen that- who the hell would want to be a doc for $100g/yr or less when there are a lot of other careers that pay much better with out all of the BS? I already would not recommend medicine to anyone as a career. Plus we will have to fill the need with yet more foreign doctors- see England (almost 50%) and some of them are want to kill christians. No, liberal boy, more government interference will drive more people out of medicine- we need less interference. (i.e. some agencies require a 6 hour class one how to put your finger in someone *** to get stool!!!!) And don''t go to the ER for stupid stuff. Half those people don''t need to be there, and the more free it is the more show up. I have had many people tell me they don''t care why they are there, It''s free!!! Which leads to my $5 co pay for all non emergencies. I don''t care how poor you are- you can cut out one pack of cigs if your going to the ER. When people pay for something, even if just a small token fee, they respect it more- see you kids. and will not abuse the system as much

[mathewcs-2009]

As for the price of the CT they showed on the segment, it seemed a bit high, about twice as much as I have seen at several facilities. You have the right to know the price of any procedure before it is done. As the patient, you have the right to deny any test that is ordered. Many facilities will negotiate the price with you if you talk before the exam is done, and often after. If you do not have insurance, and pay cash upfront, or work out a payment plan, you could get the test for half off. Go to a not for profit hospital and apply for charity care, they may pick up the tab. Easier to do when you are not tying up an ER bed.

[mathewcs-2009]

To avoice, instead of your Dr. sending you to the ER, and incur an additional $1000.00 minimum for the ER visit, He or she could have sent you to the hospital for an outpatient CT or Ultrasound. These are available 24 hrs. a day. All you need is a written order. You could have gotten the results from your Dr. via the radiologist within 30 minutes of your exam. But that would require your Dr. being able to take the call from the rad. after hours, instead of leaving your personal care up to an Er physician that just met you. Just because your Dr. sent you to the ER, it doesen''t mean the Er will order the test your dr wanted. Some doctors have x-ray equipment at their office, but I would never recommend anyone having an x-ray there. The "radiology" techs at most offices go thru a 6 week course to do limited exams. ARRT technologists go thru a minimum 2 year radiology program to learn proper equipment operation, positioning, and radiation safety. I have seen exams from doctors offices, and the quality is very poor, and the equipment usually is too. You can also have outpatient x-rays 24 hrs. a day. the wait time is much less than the ER. Ask if your tech is ARRT Registered......

[drivelphobe]

If there aren''t enough sick and injured people to treat, then promote over-testing and the great new disease, "preventive medicine".

This is one reason why our health insurance premiums are outrageous. Most doctors are probably competent to diagnose a condition within their specialty. The use of high priced testing equipment is not required on a routine basis. It''s revenue builder. Don''t let them do it to you. Just say "no"! Don''t go to the doctor for annnual physicals and routine visits urged by the physician. Go when you are sick or hurt.

Now here is a "classic example" how the medical professionals look at a situation and figure out how to get the most money possible. A few competent doctors might have diagnose her correctly but when you can easily order such test for a bigger piece of the pie this is a no brainer for this money driven industry. Socialize medicine is the only way to straighten up this mess that is doing nothing bout getting worse.

[rf36]

My wife has been forced into the ER on several occasions because she cannot get seen in a timely manner at our base Medical Treatment Facility (new term for base clinic). She''ll try to get an appointment on the 5th of the month, be told there are no opening for the rest of that month and they can''t book into the next month. Call back on the first of next month. By that time, the condition has either resolved itself or gotten so much worse, the only option to releive the pain is to go to the ER. Some time ago, the Air Force''s HMO set up a "nurse advice line" for people to call in and get medical advice from an RN. We have used it several times and the advice has ALWAYS been "go to the ER." It''s our healthcare system that has turned the ER into a 24 hour clinic, not us. Oh, and just try forming a lasting relationship with a doctor when you (and the Drs) get moved every 3-4 years or less.

[dr_noshots]

FICTION ?
http://www.americanauthorsassociation.com/Book%20Review-TerrO.R.%20-%20Neuschatz.htm

[radmdtx]

As a radiologist I benefit some from useless test being ordered from the ER. But I do not like the lack of skills of todays ER doctors. To the point that I am going to work in an outpatient center to get away from them. Today most of them order useless test because they are not confident in their assesments. Or they have not looked at the patient yet- which happens where I am at a lot. My state has tort reformed and it has helped a bunch but the ER refuses to practice hands on medicine. They say the same thing the doc on the report says "...but I could miss something..." Cry me a river!!! If you use sound judgement and EXAMINE the patient you have the whole medical community to back you up. Quit being triage nurses and be a physician!!!!!! I am tired of reading CAT scans on body parts that don''t even hurt!!!! That cost all of us $$$$

[mathewcs-2009]

If people did not treat the ER as their personal doctor, maybe healthcare prices would drop. I do CT scans and x-ray, and see defensive medecine all the time. Patients should get a personal Dr. Going to the ER for a cough, or abdomen pain that has gone on for weeks is not an "emergency". I''m tired of people complaining of the wait times in the "ER"/ clinic. They themselves are increasing wait times. It is the amount of patients the doctors must see, and having to get every patients full medical history in minutes or a couple of hours that forces them to get the best tests quickly to diagnose a ruptured appendix, so they can get to a patient with a rash that has been there for a month. We should change the name of the "Emergency" Department to 24 hr. clinic.

[hippychicky-2009]

Dr_Noshots: Non-Hypocritic Oath

Thats pretty amusing, and sadly true. I think alot of MDs are gun shy of people who may sue them for malpractice. And then they tend to go over board in the assessments of their patients.
Defensive medicine..very cute. We just have to protect our license, right?

[bm6005]

Not only the expensive tests but afterwards you cannot get insurance when you retire due to a physician ordering exploratory tests previously!

[dr_noshots]

The Non-Hypocritic Oath

I swear:
To obey the law and practice medicine to the best of my knowledge and according to my local judges, medical malpractice lawyers, jury decisions, mandatory second opinions, liability insurance companies and HMO limitations.
If abortions remain legal, I will or I will not produce them, depending on my own personal beliefs, on the number of abortion clinics burned in my immediate vicinity, and on the number of anti-abortion people picketing the local hospitals.
I will give no deadly medicine to anyone if asked, nor suggest any such counsel. Unless, of course, a euthanasia law is finally passed and I will then make such desperate decisions case by case.
Whatever in connection with my professional practice, or not in connection with it, I see or hear, in the life of men or women which ought not to be spoken of here or abroad, I will not divulge, as reckoning that all such should be kept secret.
Unless of course, their charts are subpoenaed by medical liability attorneys, requested by Medicare or Medicaid, checked by the hospital peer review committees or investigated by the department of Health.
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art of Defensive Medicine.

[dr_noshots]

alphaa10 said:

"Professional peers are already allowed in jury cases-- they are called expert witnesses. "

Expert witnesses are exactly that: WITNESSES. They don''t take part in the legal decision. And the carefully selected juries don''t always understand the pathological facts.

Do you want to be rejected from jury duty in a medical liability case ? Just tell them your spouse or your best friend is a physician. It happened to my wife.

[dr_noshots]

Suing and collecting from physicians who did nothing wrong, IS EASY:

http://www.americanauthorsassociation.com/Book%20Review-TerrO.R.%20-%20Neuschatz.htm

[alphaa10-2009]

scoliosuxs said, "Tort reform is desparately needed in this country. It is too easy for someone to sue when they don''''t understand the underlying basis of medicine and hospital care..."
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But a courtroom exists to establish that underlying basis. If it can be taught to you, it can be presented to others, as well. Should people no longer have the right to sue for justice in medical cases, simply because you fear they may not agree with you?

In any event, the tort reform you suggest has nothing to do with proper understanding of the merits of a case. Its sole purpose is to isolate and limit the ability of a jury to decide what is just. Tort reform is an effort to limit legal recourse.

Put another way, if only technical practicioners have the facts and know the truth, how could they be held accountable under law for their actions? Some medical professionals do not seem worried by that prospect.

Professional peers are already allowed in jury cases-- they are called expert witnesses. Medical professionals who are not satisfied with this approach seem to want a "tribunal", a closed-session adjudication similar, perhaps, to the disciplinary procedures of a medical associaton. In other words, "We''ll handle this in-house. The public need not inquire further."

This would place medical malpractice above the law.

[hissteps4u]

There is some truth that some procedures are needlessly ordered and often cash incentives are given to Physicians who keep things in House rather than out sourcing and second Opinions. HMO''s have done similar things for many years.

Medicine as practiced currently needs to be changed and MEDICINE and Particularly Pharmaceuticals with their Adds pushing Medicines hoping to claim a portion of the Money and all they can Grab.

REP Dinners, gifts, Incentives, they are totally out of control and Their Millions BUY allegiance from many physicians and even entire clinics who use their Money to expand and push prophets even further upward as costs continue to spiral.

[hissteps4u]

Unfortunately in a litigious society Defensive medicine is a requirement and safe guard even if it adds to the over all Bill better safe than sorry. Either that or TORT REFORM which seems unlikely in todays society.