Does 'Defensive' Medicine Differ From 'Careful' Medicine?

Mark Crane

Disclosures

March 10, 2015

In This Article

Divided Opinion on Medical Need vs Defensive Medicine

From 2000 through 2010, total Medicare spending for imaging services paid under the physician fee schedule rose by 80%, increasing to $11 billion a year, according to a 2012 Medicare Payment Advisory Commission report. Spending has declined somewhat in recent years, owing to greater use of clinical guidelines and intense scrutiny by government and other insurers. Still, spending on advanced imaging, such as CT, magnetic resonance imaging, and nuclear medicine, rose substantially faster than other imaging services, such as ultrasonography or radiography, according to a Government Accountability Office study.

A December 2012 study in the Archives of Internal Medicine found repeated echocardiography tests for Medicare beneficiaries, suggesting overutilization of the test. More than one half of Medicare patients who had echocardiography had a second test within 3 years. Imaging stress tests also were repeated within 3 years for 44% of patients. Nearly 50% of pulmonary function tests were repeated over the same period.

How much of that spending is justified by medical need? How much is the result of defensive medicine? How much is simply overutilization under a fee-for-service system that rewards doing more?

There are no simple answers. As the Government Accountability Office notes, cutting-edge image technology can help diagnose and treat life-threatening diseases and help physicians arrive at earlier diagnosis. But the rampant growth in these services indicates that something else might be going on.

For more than 20 years, the Dartmouth Atlas Project has used Medicare data to document glaring variations in how medical resources are distributed and used in the United States.

For example, a report issued in December[1] found that older men in some regions of the country are 15 times more likely to get prostate-specific antigen (PSA) screening tests than in others. The study of male Medicare beneficiaries aged 68-74 years found the national average rate of PSA testing was 34.5%. The regional rates varied widely, from a low of 3.6% in Lebanon, New Hampshire, to a high of 58.4% in Miami, Florida. There also are discrepancies in treatment, which include surgery and radiation. The use of surgery was eight times higher in Munster, Indiana, than in Ocala, Florida.

In a highly influential 2009 article in the New Yorker,[2] general surgeon Atul Gawande, MD, looked at why two similar Texas border towns had such different experiences. In 2006, patients in McAllen received vastly more diagnostic tests, hospital admissions, operations, specialist visits, and home nursing care than patients in El Paso, although the quality of care in McAllen was no better.

Defensive medicine couldn't account for the disparity, he concluded. Instead, McAllen doctors ordered more services because of a "system of care that was highly fragmented for patients and often driven to maximize revenues over patient needs."

Overtesting also occurs because patients, especially those with insurance who are shielded from the true costs of care, demand it.

"I'd never order a test if it isn't indicated. But there are gray areas where an elective test can be either deferred or done early," says Marc Siegel. "I'll explain my thinking. But if the patient insists and the test won't hurt him, I'll probably go along. It's ultimately his choice.

"It isn't just fear of lawsuits that drives testing," he adds. "There's a philosophy of practice that encourages defensive medicine. It's part of the culture of not wanting to miss anything and not being criticized for not covering all the bases."

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