Defensive Medicine Driving Up Healthcare Costs

Posted on: November 16, 2009  |   Author: Jamie
Filed Under: Access to Care, Fraud & Abuse, Health Information, Liability & Litigation, Other   |   Leave a Comment

There is a heated debate currently ensuing between doctors and lawyers about defensive medicine and its effect on the rising costs of healthcare in the U.S.  Doctors attribute the high costs of healthcare to the payments of malpractice insurance and malpractice lawsuit awards.  Trial attorneys, however, are blaming the rising costs on the practice of “bad medicine.”

Of the $2.5 trillion dollars spent each year on healthcare, doctors say that 10 percent of this amount is attributable to practicing defensive medicine and paying for malpractice insurance, while lawyers attribute less than .5 percent of this spending on payments for medical malpractice settlement costs.  Around 720 doctors who responded to a 2008 survey by the Massachusetts Medical Society reported practicing defensive medicine in fear of facing a malpractice lawsuit, estimating the cost of extra tests to be around $281 million and unnecessary hospital admissions around $1.1 billion.  A study by researchers at the Harvard School of Public Health and Columbia Law School performed in 2005 found 93 percent of the 824 doctors who participated reported practicing defensive medicine. Lawyers attribute the rising costs of healthcare to “bad medicine,” insisting that medical malpractice suits protect patients from the devastating effects of medical errors. Lawyers also feel that the extra tests involved in the so-called practice of defensive medicine are really fueled by the self-interest of the doctor, arguing that many doctors have a financial interest in laboratories that conduct extra tests or procedures creating a conflict of interest which could add to the level of unnecessary tests.

Congress is currently deciding how to curb the rising costs of healthcare. A 2009 Congressional Budget Office analysis estimates that government health care programs could save $41 billion over 10 years if national limits on jury awards for pain and suffering in malpractice suits were enacted, along with similar restraints.  Along with this approach, there has also been a drive for less adversarial approaches to limiting rising malpractice costs. The University of Michigan Health System uses a system in which doctors acknowledge mistakes and then offer compensation, causing malpractice claims to fall from 121 in 2001 to 61 in 2006.  Another movement, which has found less support with lawyers, is a campaign enacted in part by the Sorry Works! Coalition urging doctors to apologize for their wrongdoing and provide prompt compensation when appropriate.

Commentary: In the article, Dr. James Wang points out that he makes an effort to tell his patients when the treatments they may be considering are not necessary in order to keep the cost of providing care to a minimum. If the patients insist that they have the unnecessary test done though, Wang admits to ordering or performing the procedure in order to protect himself from a medical malpractice lawsuit later. Wang is among many doctors who admittedly perform defensive medicine in order to protect themselves from suits of medical malpractice. The catch here is that in many cases, doctors are not practicing “bad medicine” and are actually attempting to inform patients that the treatments they seek are not required for their health. In these, the majority of situations, if the choice comes down to protecting themselves from a lawsuit even though they practiced sound medical judgment or ordering tests even though they incur further unnecessary costs, how can society fault doctors for choosing to protect themselves?

msnbc.com, Nov. 4, 2009.

Tough Choices: A Blurb About the Difficult Choices Facing Many Couples in Their Quest for Fertility

Posted on: October 31, 2009  |   Author: David
Filed Under: Drug & Device, HMOs & Health Plans, Health Information, Hospitals & Health Systems, Insurers/Payors, Technology   |   Leave a Comment

It may be one of the hardest decisions an expectant parent would have to make: Reduce the number of fetuses you are carrying or risk losing them all.

Sadly, that is exactly the decision Thomas and Amanda Stansel had to make. After undergoing the popular process of intrauterine insemination in which sperm is injected into Mrs. Stansel’s uterus following hormone injections, Mrs. Stansel received shocking news – she was carrying not one, not two, but six fetuses. However, the Stansel’s excitement was soon crushed when their fertility doctor gave them some additional startling news. Due to the increase in fetuses, the likelihood of delivering six healthy infants was near zero. To save some, he recommended reduction – through a process known as “selective reduction.” The Stansels decided not to reduce, instead relying on their faith to protect them and in August, Mrs. Stansel gave birth to all six babies. Unfortunately, at 14 weeks premature, all weighed in at roughly one pound. The hospital fought valiantly, but three babies died within two weeks. A few months later, another was lost. The two babies remaining continue to struggle, still attached to ventilators and feeding tubes and under constant care in the hospital neonatal intensive care unit.

For couples having difficulties becoming pregnant, there are several options available. First, most doctors recommend utilizing low-potency fertility drugs in order to stimulate the process. If unsuccessful, the next step is intrauterine insemination with hormone injections or in vitro fertilization. This decision is often influenced by two related factors: insurance and costs. The cost of in vitro fertilization costs between $12,000 and $25,000 while intrauterine insemination only costs $2,000 to $3,000 per attempt. As such, many insurance companies will cover multiple rounds of intrauterine insemination before one round of in vitro fertilization. The preference though, is not without drawbacks. Intrauterine insemination, while front-end cheaper, can present significant problems. Excessive hormone injections can lead to an overstimulation of the ovaries which in turn can lead to the increase in probability of having multiples. In fact, the Centers for Disease Control and Prevention supported this theory when it found that the intrauterine insemination process was more likely to result in multiples than in vitro fertilization. And with increased multiples, come increased risks, especially with premature births which carry the risk of long-term complications and disabilities. Multiples, like the Stansel babies, who arrive early, require the highest level of acute care for a longer time than any other patients. This can add up to astronomical financial hardships in the long-run. In addition to money, multiples with increased risks of complications can put families in very difficult decision like the one faced by Thomas and Amanda Stansel- whether to abide by religious beliefs against the perception of abortion or a doctor’s recommendations to reduce.

The current position taken by insurance companies is baffling. Intrauterine insemination is largely undocumented today, but has been shown to be less successful and more dangerous (with respect to increasing risks for premature multiples) than in vitro fertilization. The main upside, cost. Due to the less invasive nature of intrauterine insemination there is a significant cost difference between the two procedures leading many insurance companies to favor the treatment. In doing so, insurance companies may be overlooking two major issues. One, as this procedure becomes more popular, the costs associated with premature multiples will also grow- likely at a much higher rate than the cost of the initial fertility treatment. Second, many couples attempting to start a family do not understand the possible consequences of their actions – the psychological and financial considerations of having a tragic result. Insurance companies have long acted as a gatekeeper in providing medical treatment and should take a second look at their current preference towards intrauterine insemination.

The New York Times, October 11, 2009.

Does Chantix fit into Health Reform?

Posted on: October 22, 2009  |   Author: Blake
Filed Under: Access to Care, Drug & Device, Health Information, Healthcare Reform, Life Sciences, Medicaid, Medicare, Other, Tax & Finance   |   Leave a Comment

As the health reform debate continues, the headlines are dominated by discussion about the cost of reform, the public option, insurance exchanges, and an individual mandate, but what about some of the minutiae that is involved. Some of these less talked about changes could have potentially large effect on those involved.

For example the health care bill that the Senate Finance proposed last week requires Medicaid programs to pay for smoking cessation drugs, such as Pfizer’s Chantix and GlaxoSmithKline’s Zyban. Currently, states can choose whether or not their Medicaid program will pay for these types of drugs. Approximately three quarters of the states now include some smoking cessation coverage with their Medicaid program, however the policies vary and are sometimes limited to 90 days of treatment.

It probably comes as no surprise that cancer advocacy groups and the drug industry are supporters of the Senate Finance bill. A spokesman for the American Cancer Society said the group would like to see similar mandates with Medicare and private insurance as well.

Commentary: According to the American Caner Society, tobacco use is responsible for nearly 1 in 5 deaths in the United States and smoking is the most preventable cause of premature death in our society. Therefore it’s hard to hard to argue against Congress requiring the states to cover smoking cessation products on their Medicaid formularies.

However, I would be surprised if Chantix was required to be covered by Medicaid. On one hand, Chantix has a unique mechanism of action compared to that of other smoking cessation aids, but its efficacy is still being questioned. Although studies have shown Chantix had a substantial benefit, some argue the methodology of these studies was flawed. Additionally, the FDA has required that Pfizer put a boxed warning on the prescribing information of Chantix that warns people about the psychiatric side effects that are associated with the drug. Unlike many of the other smoking cessation products, Chanix is not available in a generic form and therefore carries a much higher cost.

That said I’m not advocating that Chantix is a bad drug or is ineffective, but rather I’m suggesting that Congress should be careful where they choose to set their minimal requirements with regards to smoking cessation products. With questions looming about efficacy, a substantial side effect profile, and such a high price tag, I would be more in favor of leaving it up to each state to decide if they want to add this drug to their Medicaid formulary.

The Wall Street Journal, October 16, 2009

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