health policy

Tort Reform

This got me riled up.
So, like the procrastinator I am, I’m going to unrile.

Part of Mr. Baker’s argument for why tort reform is “a red herring” is that it only accounts for 1% of health care costs:

We have approximately the same number of claims today as in the late 1980s. Think about that. The cost of health care has doubled since then.

One major reason that the cost of health care has doubled in the last twenty years is the explosion of technology and testing.  If you’ve got the machine — the MRI/CT scanners, the Doppler suite, the cath lab — you’re going to use it.  I can’t tell you how many times, already, I’ve seen tests ordered with no clinical suspicion, but just because “we don’t want to miss anything.” Why does everyone walking into the ER get a head CT? Rule out sub-arachnoid hemorrhage, of course. (But then there’s the issue of the 10% of SAH that aren’t visible on CT, and what do we do about them?)

(Then there was that moment on neurology when I was presenting a case to my teaching attending, and when I read out the list of labs we’d sent, she made me stop and give a reason for each one based on the history and physical exam.  Have you ever tried to come up with a reason for sending a Chem 7 for a patient with no signs or symptoms of electrolyte disturbances?)

The interviewer, to her credit, tries to get Mr. Baker to talk about defensive medicine.  And he brushes it aside:

Doctors will say that. But when you dig down, you find that what’s really happening is that doctors tend to do what other doctors around them do. They go along with the prevailing standard of care in their region — which in many cases isn’t even a state, but a city or county.

That’s a ridiculous non-answer, something I’d expect from a politician, not a professor. What, pray, is wrong with practicing the “standard of care”?  The alternative seems to be “make it up as you go along,” so forgive me if I prefer to use treatments that have been proven to be effective.  I don’t get his problem with a narrow definition of “region,” either.  New York City is very different from the rest of New York State.  What’s wrong with taking sociocultural forces and environment into account?

I’m totally willing to grant that medical malpractice is not the major driver of rising health care costs. (Can we say “insurance bureaucracy”?)  What’s getting lost in this whole brouhaha is the fact that even though we pay more for health care than any other country in the world, our outcomes are miserable. On rankings of things like maternal and child health, we are sandwiched somewhere between, like, Uganda and Bosnia.

Seriously. It’s almost enough to make you want to move to Canada.

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3 thoughts on “Tort Reform

  1. When he talks about “prevailing standard of care in their region”, I am pretty sure he isn’t referring to the variety of ilnesses in that region, rather the approach to its resolution; THAT, should be standard, and region-independent.

    1. The treatment plan still has to take environmental factors into account, and that’s region-specific. A lot of the cheap interventions for major problems like obesity, such as diet and exercise, require that patients have access to parks and fresh produce. As a resident of a poor immigrant neighborhood in New York City, I can tell you that’s not always feasible.

      Plus, if everything was totally standardized and region-independent, you wouldn’t need doctors at all. You could just put your symptoms in a computer, the computer would spit out a script, and done! For obvious reasons, I’m not a fan of this approach. 🙂

  2. I take your point about parks and fresh produce.

    Much treatment is based upon what the Dr prescribes. That should be more standardised rather than less. Hospitals DO standardise their remedies. If you move to another hospital they too will have a different standard. Other than the reasonable environmental factors you pointed out, there is little reason for such discrepancies to exist. Most is due to the preferences and anecdotes of those in power… this is not evidence-based medicine.

    ps Drs are the only profession constantly trying to put themselves out of business.

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