Ask the DOC

Last month, my column was based on one of a series of articles written by Dr. Edward Hoffer, concerning America’s broken health care system. Today I would like to continue that by looking at other broken areas. For example, our current malpractice system does not well serve doctors or patients. Medical malpractice insurance is a substantial cost of operating a medical practice. A standard $1.3/3.9 million policy can run $30-40,000 a year for a family practitioner with no surgery to well over $150,000 for an obstetrician or neurosurgeon. Comparable policies in Canada run about $2000 a year. New York is one of the states with the highest rates. The at-fault litigation-oriented system in the U.S. results in long delays before patients are compensated for harm and too much money goes to lawyers, and litigation costs instead of to those who were injured or harmed. Even cases that are closed with no payment made to any party generate costs averaging $36,000. This means that plaintiff attorneys are unwilling to take on cases that will likely result in low payments, even if the malpractice was clear-cut.

In addition to its direct effect on costs, the at-fault system encourages doctors to practice “defensive medicine.” Doctors readily admit to ordering more tests than necessary out of a fear of being sued. The annual cost of this defensive medicine has been estimated to be between $56 and $162 billion. For example, researchers have found that in states with caps on malpractice payments, the rate of coronary angiograms for chest pain was 24% lower than in states with no caps. The adversarial system also discourages doctors and nurses from reporting adverse events, especially “near misses” from which the system might learn. All doctors make mistakes; we are human. Good doctors learn from their mistakes and share that learning.

Fraud and waste are other issues that drive up costs. Health care insurers are in business to make money. An entire industry has sprung up to help insurers make their enrollees appear sicker than they actually are. In 2017, a congressional auditor testified that more than $6 billion in extra payments were improperly made to Medicare Advantage plans because of inflated estimates of enrollees’ sicknesses. Also, many hospitals pressure doctors to pick a diagnosis for a discharged patient that generates a higher payment. This is called upcoding. Younger doctors order more tests and rely more on imaging studies, because they lack confidence in their physical examination skills. As an example of waste, many cardiology groups order an EKG on every patient every time the patient visits the office despite the fact that the American College of Cardiology guidelines recommend against such routine electrocardiograms.

Lastly, in 2009, the Obama Administration attempted to bribe doctors and hospitals to use electronic medical records (EMR) on the assumption that it would lead to better care and lower costs. Those not using EMR received lower Medicare and Medicaid reimbursements. Unfortunately, the advent of EMR has had a number of negative effects. Doctors' offices with EMR have been able to get higher payments, or upcode, because the EMR is much longer than a paper record would be. Doctors with EMR spend more time on entering data and less time with the patient. One estimate of a 10-hour E.R. shift found that E.R. doctors made about 4000 clicks per shift. A 2018 Mayo Clinic survey found that the leading cause of physician dissatisfaction was the number of hours of data entry and box-checking they must complete. Will our elected representatives ever address these issues, or will lobbyists continue to run Congress?

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