7 ms·

A Fear of Lawsuits Really Does Seem to Result in Extra Medical Tests

105 points by montrose 8y ago

sandworm101 8y ago
>> In the federal government and in states, there are frequent proposals to limit medical liability, but there have been no serious efforts to eliminate medical malpractice rights altogether. Damb right. Take away a patient's right to hold doctors accountable and things go south very quickly, at least in a for-profit systems. >>But American doctors often rail against the country’s medical malpractice system, which they say forces them to order unnecessary tests and procedures to protect themselves if a patient sues them. The patient can only sue if the patient has been harmed. They aren't performing the extra tests in case just wakes up and decides to sue them. They perform the extra tests so that they don't miss something that could harm the patient so badly that they sue. Doctors also forget that, again only in the US system, patients often must sue. A harm caused by malpractice isn't always covered by insurance. Patients need to find the money somewhere. Or if an insurance company does cover, the insurance company will then sue the malpracticing doctor (google "subrogation"). A few years ago several states had liability caps ready to become law (iirc $250k). Then a young woman lost both her breasts after a mixup in test results caused her doctor to recommend a double mastectomy. But at least she could still function relatively normally and the injury was not a financial burden. Imagine the costs associated with a 20yo confined to a wheelchair for the next 60+ years. Setting aside medical expenses, 250k buys you maybe four or five converted vans. While some cases are rightly suspect, many of the multi-million dollar settlements really do get spent on legitimate costs.
- Retric 8y ago
  As someone that lost a close family member because a doctor did not do one of those extra tests I think they are underrated. Cost vs benefit on this stuff is hard to get right, but lives are often on the line.
  - noonespecial 8y ago
    My condolences. But as someone whose father lost a kidney and suffered much un-needed anxiety and pain because of a false positive on one of those "extra tests" (and the general culture of treat-until-lawsuit-proof), I humbly request we meet in the middle.
    - Retric 8y ago
      The middle would trade X deaths for X case of pain and wasteful spending which is not a fair trade. Trading 5-100 of your fathers cases for 1 life is IMO a worthwhile trade as we want a system heavily biased toward savings extra lives. PS: It's the rate of false positives vs saved lives that cause wasted treatments not the number of tests.
      - noonespecial 8y ago
        How 'bout 1000. 10000? Now were just arguing numbers. Don't forget the opportunity cost of unneeded treatments using resources that could have "saved" others as well. We're taking many paths but ending up at some sort of rationing in the end. There's no easy answers.
        Retric 8y ago
        I doubt they would have removed a liver if the risks where that low. So, really it's saving lives at the cost of a fixed but low number of false positives and a lot of wasted tests not a 10,000 extra removed livers per life saved.
      - DanBC 8y ago
        You're making the mistake of thinking that over-testing, over-diagnosis, and over-treatment saves lives, when it probably doesn't, and may well decrease length of life as well as quality of life. The US has massive rates of testing for various stuff. It also has a lower life-expectancy than other similar nations.
        8y ago
- darkerside 8y ago
  > Damb right. Take away a patient's right to hold doctors accountable and things go south very quickly, at least in a for-profit systems. The study cited in the article would seem to rebut that quite vigorously. FTA: > They found that the possibility of a lawsuit increased the intensity of health care that patients received in the hospital by about 5 percent — and that those patients who got the extra care were no better off.
  - sandworm101 8y ago
    Because the test only measured changes in the decisions by doctors. The doctors all work within the same medical culture, one built on the threat of lawsuits. Try telling an insurance company that they cannot be sued. See how many fewer tests get authorized when the actuaries can veto a doctor's recommendation without incurring liability.
  - mywittyname 8y ago
    An side of this that most people aren't aware of is that insurance companies will refuse to pay for any medical test they deem to be unnecessary. So, while a doctor may order additional tests to "CYA," it's pretty likely that the hospital won't be reimbursed for all of them and will just eat the cost of the tests. And, while a hospital may charge thousands for a test, the actual costs might only be in the hundreds. Depending on the hospital system, this can be a win-win because the tax write-off can be worth more than the actual test costs. The healthcare system in the US is insane.
    - ryandrake 8y ago
      > So, while a doctor may order additional tests to "CYA," it's pretty likely that the hospital won't be reimbursed for all of them and will just eat the cost of the tests. What? In the USA, it’s the customer who eats the cost of the test. 1. The doctor tells you to go do all these tests. 2. Neither the doctor, the testing lab, the hospital, or the insurance company knows which ones will be covered by insurance. 3. You do the tests. 4. Insurance company, months later, says “Surprise, sucker! We won’t cover these tests so you have to pay $N,000!” 5. The lab and doctor says “You signed the paper agreeing to cover the costs. F-you Pay me.”
- malcolmgreaves 8y ago
  A patient can sue for any reason. They can be wrong and sue. It's then up to the physican to pay costs for legal defense (i.e. medical malpractice insurance). If the patient is wrong, then the physican can counter-sue. This whole dance is very expensive and, worse, time consuming (which, for a doc, is the ultimate resource). This cost ends up on the patient ad the doc must raise prices to account for the new insurance.
  - mywittyname 8y ago
    Patients normally sue a hospital system though. My partner has been involved in dozens of malpractice lawsuits over the years because every person who interacted with the patient during their stay is named in the lawsuit, not just the doctor(s) who treat them. Hospitals have staff lawyers whose job it is to deal with lawsuits. So it's not terribly time-consuming for doctors outside of depositions. It's safe to say that this is one of the reasons that doctors move from private practice into working in a hospital system. But it's also not a major one (dealing with insurance companies is the major factor).
    - todd8 8y ago
      Hacker news readers may not realize that joint liability exists in many states. Under this doctrine, the plaintiff can collect all awarded damages from even very peripherally involved people. A person with deep pockets can end up paying for others mistakes. For example, a plaintif’s attorney might drag everyone into a lawsuit they can over a disappointing surgical result. The jury could be persuaded that an operating room nurse is 1% liable for a failed operation and the surgeon 99% responsible. If the surgeon can’t pay their part of a two million dollar judgement (brand new doctor perhaps) the nurse may end up paying the two million (maybe the nurse is married to a software engineer).
  - forapurpose 8y ago
    > the doc must raise prices to account for the new insurance As I understand it, the portion of additional costs that the doctor eats and the portion that they charge to their patients actually depends on the elasticity of the market for the doctor's medical services. I can't comment on the market for the hypothetical doctor's medical services (in the U.S. AFAIK that market is very complex and opaque, and it probably depends on the doctor, location, and the specific service), so speaking generally about sellers and buyers: The portion of a cost increase that is eaten by the seller or charged to the buyer depends on elasticity. Computer memory is highly elastic: If your costs go up and you try to increase your price $10/DIMM, then I'm going to buy my DIMM someplace else (unless your DIMMs are very special); a small change in price causes a large change in demand. Superstar developer salaries are highly inelastic: If the developer's costs increase (a new baby!) and they ask for more money, I probably have to give it to them because I'm not going to find a replacement. You see that more publicly with superstar athletes: Cristiano Ronaldo is irreplaceable; the market for his services is at the extreme of inelasticity; he can almost name his price for running around in shorts, playing games.
- dv_dt 8y ago
  This is where a universal healthcare system takes some causes for inefficiency out of the system, reducing at least one source of major need for lawsuits - the need to fund future medical care.
  - dsfyu404ed 8y ago
    That said, government administrated systems can become just as bad or worse because you don't have meaningful alternatives or the alternatives that exist aren't practical/affordable.
    - dv_dt 8y ago
      The statement is more generally true if you take out the word 'government', and come to think of it, take out 'administrated' too.
- grasshopperpurp 8y ago
  No idea why this is being downvoted. Maybe they missed the qualifier? > . . . at least in a for-profit systems.
  - mywittyname 8y ago
    I don't get it either. People outside of healthcare probably aren't aware of how ridiculously common it is for medical mistakes to be made. Dozens of overworked people are coordinating with one another to take care of you.
  - pc86 8y ago
    Probably because it's flat out wrong and shows a shockingly incorrect view of how things actually work. > The patient can only sue if the patient has been harmed. No, the patient can sue for whatever reason they want to. The doctor's malpractice insurance is going up regardless. Even a completely frivolous lawsuit will cost the physician real money out of his or pocket for years to come, not to mention the cost (if they choose to pursue it) of counter-suing the patient.
    - grasshopperpurp 8y ago
      That part is incorrect; however, the overall message of the post is correct. In a for-profit system, it's the patient's only recourse. Don't like it? Fight against for-profit healthcare.
      - pc86 8y ago
        Whether healthcare is for-profit or non-profit does not change how the legal system works.
        sandworm101 8y ago
        But it does change the math. Where patients do not have to pay for their own injuries, ie under a national health service, they don't need to collect in order to pay for later care.
- conanbatt 8y ago
  > he patient can only sue if the patient has been harmed. They aren't performing the extra tests in case just wakes up and decides to sue them. They perform the extra tests so that they don't miss something that could harm the patient so badly that they sue. Unfortunately this is not how good medicine is practiced. Medicine is not a straightforward hard-science. Tests are expensive, patients dont follow through, they have personal consequences, chances you got something are 100% but chances you got something specific are 0.0001%. It is digestible for a doctor to have liability but compare it to other professions: does a web developer that botched a UI for a bank transfer and introduces some consequence go to jail for robbery? Doctors have too high a burden. And a decision or an oversight that makes someone die could be as stupid as a misprint on a paper.
deleted 8y ago
[deleted]
patrickg_zill 8y ago
Wait until the NY Times finds out that c-sections have greatly increased because of high-dollar awards like the one that made John Edwards (yes the politician) a millionaire...
- grasshopperpurp 8y ago
  I somehow missed this. What a jerk. https://drjengunter.wordpress.com/2011/06/03/john-edwards-indicted-by-grand-jury-obgyns-everywhere-rejoice/ https://drjengunter.wordpress.com/2011/06/03/john-edwards-in...
- everdev 8y ago
  My wife is a doula and apparently the injury and mortality rates for mother and child are much higher than through natural childbirth. But because of their insurance coverage, if a mother or baby dies during natural childbirth the doctor is at greater risk for malpractice. So, they will rush mother's into C-section at any excuse (it saves them hours of work too not having to sit through a long labor). Unfortunately, money and efficiency have taken priority over natural processes.
  - Xixi 8y ago
    But are the injury and mortality rates higher because C-sections are riskier, or because high risk childbirth are done through C-section? You need to control for the prior, otherwise the statistic is not very useful.
    - everdev 8y ago
      From what I understand C-sections are much riskier for the mother than we might think. It's significant surgery which can always lead to complications or infection. The other factor is delivering a child naturally that gets stuck and didn't get enough oxygen but lives is probably the most expensive outcome for doctors because that child can live with severe physical or mental handicaps and need support the rest of their lives.
howard941 8y ago
Link to the study: http://www.nber.org/papers/w24846 http://www.nber.org/papers/w24846
rayiner 8y ago
> Any law that limits the cases where patients can sue, or the amount of money they can collect, is likely to lower medical use in the hospital by less than the 5 percent they measured in their study. The telling thing about laws to address malpractice liability is that they typically are focused on capping large verdicts. But such laws are illogical: generally, large verdicts will be awarded where a doctor screwed up and caused the most damage. Cases with large verdicts are the most meritorious ones, and the ones where limiting liability is least likely to eliminate over-testing that does not contribute to quality of care. If states actually wanted to address the costs of defensive medicine, they would do something like create affirmative defenses for doctors who adhered to certain established testing protocols.
- ghein 8y ago
  Large verdicts have been delivered where no or minimal injury was suffered. As others have mentioned, John Edwards had great success as a lawyer suing over cerebral palsy, claiming that it was caused by actions during delivery. While possible, most cases are caused by other factors such as infections, IVF, or low birthweight. At trial, you have a sympathetic plaintiff with large needs vs a "rich" doctor and hospital. They might have caused this, they have insurance. So you systematically get very large verdicts against defendants who are unlikely to have done anything wrong. Edwards was very good at theatrics and not good on science. Trials that rely on science and math are not great to take to a jury. Even discussions here get emotional when you deal with subjects like appropriate risk analysis and tradeoffs. Saying that you have a formula to only fix defects that kill more than x people or cost less than y per life saved is a great way of losing at trial and getting destroyed in a thread. It's also how every company and government makes decisions around safety - where stop signs go, guardrails, drug approval, armor in tanks... Getting tort law right is hard - you want true injuries to be compensated but discourage people that are looking for lottery tickets.
  - rayiner 8y ago
    > Large verdicts have been delivered where no or minimal injury was suffered. We live in a country of 300 million people. Every permutation of things that can happen has happened. But that doesn't mean that large verdicts "where no or minimal injury was suffered" happen often enough to account for a significant share of medical malpractice payouts. There was a Harvard study that looked at this issue pretty systematically, and concluded that the idea of "systematically" "large verdicts against defendants who are unlikely to have done anything wrong" does not fit the data: http://archive.sph.harvard.edu/press-releases/2006-releases/press05102006.html http://archive.sph.harvard.edu/press-releases/2006-releases/.... Most importantly, claims are about as likely to get denied despite the presence of error as they are to get paid despite the absence of error. (So improving the accuracy of the system would not necessarily decease payouts.)
dahdum 8y ago
Aren't a lot of these costs baked into all services due to malpractice insurance itself? If these doctors could be sued by some of their patients (the families), they still need to cover the cost of that insurance. Beyond that, once defensive medicine is the status quo, why would they make a choice to not order their usual defensive panels? They aren't paying for them themselves.
- mrfredward 8y ago
  True, but here's a point the NYT missed: caps on malpractice claims don't have to change how doctors practice medicine to reduce costs. By capping liability, they should make malpractice insurance cheaper and thus reduce the cost of providing care.
  - dragonwriter 8y ago
    Caps on malpractice claims exist in numerous jurisdictions, and studies have shown them to have no discernable effect on either total healthcare costs or even specifically on malpractice insurance costs.
    - briandear 8y ago
      I am sorry but you are just completely wrong. Exactly the opposite of what you said is true: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/ “In summary, there exists considerable evidence that medical malpractice reform measures reduce medical malpractice awards and also the losses incurred by medical malpractice insurance companies.”
      - Digory 8y ago
        Reduced Awards =! Reduced Premiums or Costs Texas seems to have set caps so low that it has reduced premiums for doctors. But "making malpractice cheaper" isn't much of a policy goal. Nationally,'tort reform' caps have had mixed results. "...better-designed studies show that damages caps reduce liability insurance premiums. The effects of damages caps on defensive medicine, physicians’ location decisions, and the cost of health care to consumers are less clear." [0] [0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690332/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690332/
jl2718 8y ago
Extra tests... the cost of diagnostics is a tiny fraction of the cost of doctor time, and most patients just go to the doctor to get the test. The doctor is an irellevant gatekeeper 90% of the time. How about we start talking about ‘extra’ doctor visits because patients don’t have access to tests. There are some diagnostics where this gatekeeping is literally causing a public health crisis. ‘Extra tests’ are only an issue because of the untreated disease they reveal, which costs insurers money to treat. This ‘concern’ is all part of their lobby.
- patrickg_zill 8y ago
  That is very accurate... I had an injury that I knew required specific surgery, but when I called the surgeon's office to make an appointment I was told that they only accepted referrals from family doctors, that is, I had to pay to visit a family doctor first. This applies nowadays to most specialists as well.
  - SkyPuncher 8y ago
    I don't really consider this a problem. Specialists are packed to the gills already and very expensive. Specialists don't want to spend time with patients who don't actually need specialized care and insurance doesn't want to pay specialists without first qualifying the issue.
    - patrickg_zill 8y ago
      I agree; however the first thing he did was to order a CT scan to confirm the diagnosis and get the exact location. So the family doctor visit was thus duplicative.
      - imglorp 8y ago
        I hope the specialist didn't get a kickback from the imaging company
        8y ago
CrankyBear 8y ago
Doh
mattnewton 8y ago
So make tests cheaper - sounds like an opportunity that gets a win for everyone without political miracles. (I don’t know the market I am talking about at all, but) Maybe they could incentivize cheap tests by capping the cost per test that can be administered without some large red tape process. The market will provide tests under that cap where possible, so they can be administered more frequently & frictionessly. Patients are thoroughly tested, Doctors cover their butts, and test supply companies get to keep selling lots of tests.
- subhobroto 8y ago
  EXACTLY! I wrote about this here: https://news.ycombinator.com/item?id=17620197 https://news.ycombinator.com/item?id=17620197
subhobroto 8y ago
I see no issue with Extra Medical Tests. More data points do not hurt a diagnoisis if a proper scientific method is followed. The primary issue here is the resulting cost. As the article points out: "about 26 percent of every dollar spent." You probably won't complain paying 26 cents for a $1 popsicle, but if the same popsicle cost you $100, you might be upset paying $26. But is not the bigger question: Why is the popsicle $100 when it could have cost $1? Here is a useful chart to show where the money goes: https://qph.fs.quoracdn.net/main-qimg-d68aea3ca1e466f166752e261b9e28d3 https://qph.fs.quoracdn.net/main-qimg-d68aea3ca1e466f166752e... Where do you think malpractice costs fit there? I personally feel sad everytime malpractice fears enter the discussion of costs - its a tiny, ignorable portion right now of total expenses. However, to a typical layperson, it sounds like a big deal to worry about but actually distracts the attention costs should be getting. As a result, I have tried to cover it here: https://www.quora.com/Why-does-one-believe-that-malpractice-insurance-is-the-primary-reason-for-US-health-care-being-so-expensive https://www.quora.com/Why-does-one-believe-that-malpractice-... Real input from real practitioners in the industry in the real world. Sure, Malpractice overhead exists but it's analogous to a drop in the ocean. There is severe waste elsewhere that need to be handled first. It's a nosebleed in a patient hemorrhaging blood through a punctured artery. The argument that ordering extra tests offer doctors "additional defense" in case of a lawsuit is absolute hogwash. If anything, the test results put the doctor at a further disadvanatge wrt defense because they had an additional datapoint they should have considered in their diagnoisis but did not. The primary issue with Healthcare in the U.S. is cost - for those who have the money and the will to spend it, it's one of the best in the world. A lot of the rich visit the US for their Healthcare needs. Healthcare in the U.S. is optimized for profit: https://www.quora.com/What-makes-the-US-healthcare-system-so-expensive-Why-is-the-US-so-expensive-compared-to-Canada/answers/33451192 https://www.quora.com/What-makes-the-US-healthcare-system-so... This is very wrong as it encourages short term profit seeking behavior which is absolutely the opposite of what healthcare should be (eg: C Sections being preferred over natural but long childbirth) A for-profit system does not help the doctor/provider either (although it gives an illusion of it) - in such a system, the patient's only recourse is to sue the doctor/provider for damages instead of both parties focusing on the root cause which brought the patient to the doctor/provider in the first place. Extra Medical Tests might be suboptimal but the real pain points are the marginal costs of each test. Tests in the U.S. are extremely expensive. There is no standardized pricing for any test in the U.S. unlike the rest of the world. While the rest of the world has pretty much agreed, for example, that a blood group test might be no more than $10 (In India, it costs 20 cents upto 70 cents at current INR-USD exchange rates), in the U.S. depending on which lab you go to, your insurance coverage, your ability to pay and other factors, you might be billed anywhere from $0 - $2000. That is completely insane. Also, labs in the U.S are not setup to take requests from customers directly. There are kits you can order and all that Everytime I try to send a blood sample to a lab on my own, the lab staff seem to be lost - they want my insurance information, my EHR information, my NPI ID and when I explain to them I am not a doctor they ask me to provide my physcian's who ordered the test. (my physcian didn't order the test - I did). I have had a few labs bill me outrageous out of network fees because the lab tests were not ordered by an in network provider (because I ordered them and I am not a doctor) and the amount of calls and paperpushing I had to do to correct the billing has made me just give up and let a doctors office handle this. I can read a lipid panel. I don't need to go to a doctor's office to drive in traffic, wait an hour or more just to draw my blood and have it sent to a lab and then have the doctor read the panel to me. I read spreadsheets every hour of the day. I know what mean median and mode is and the lab result often offer these values anyways as part of the report. I just need the test report. Now, if my HDLs are too high and I cannot figure out why, sure, I do need to discuss this with a professional. The solution to this madness? An "all payer rate set" system. EVERYONE pays the same for the same procedure. Who pays for the care, while important, comes later, not before.
joshuaheard 8y ago
If a doctor is sued for malpractice, that means they made a mistake. If they are performing extra tests to avoid malpractice, that means they are performing extra tests to avoid making mistakes. That is a good thing.
- TheSoftwareGuy 8y ago
  It can also be a very expensive thing. Extra tests are unnecessary, hence why they are “extra”
- danepowell 8y ago
  Not necessarily. Tests have costs and risks of their own. I would consider a test not justified in terms of cost and risk to be a "mistake". However doctors are far less likely to be sued for a thousand small mistakes than one big one, so they err on the side of too many tests.
- n8henrie 8y ago
  So if a physician were to do every test on every patient every time, could they expect to never be sued? Would that be a good thing? “1 of everything please.”
  - conanbatt 8y ago
    You would go for an annual checkup and you get a CAT-scan and get cancer from it, then the doctor can say "Well, now we know you have it, you wouldnt without the test!"
- esmi 8y ago
  If a doctor is sued for malpractice it means someone thinks there is a possibility the doctor made a mistake. After all, doctors win lawsuits sometimes too. The doctors are ordering the extra tests to avoid the lawsuit being raised in the first place.
- psychometry 8y ago
  There's an error in literally every sentence you just wrote. 1. A person can be sued without being guilty in a criminal or civil sense. 2. They are performing extra tests to cover their asses, not to avoid making mistakes. 3. It is clearly not a good thing as shown by the authors of the study.
briandear 8y ago
Is there empirical evidence for “Defensive Medicine?” https://www.ncbi.nlm.nih.gov/pubmed/19201500/ https://www.ncbi.nlm.nih.gov/pubmed/19201500/ “The net effects of medical malpractice tort reform on health insurance losses: the Texas experience” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/
dhdhshd 8y ago
Bone marrow biopsies suck. And on top of that I have to be thankful I don’t have cancer while the bills keep coming.
zelon88 8y ago
I thought medical errors were the third leading cause of death in the U.S. with 10% of all deaths attributed to medical error. With that error rate, is it fair to say that the extra tests are truly "unnecessary?"
- LorenPechtel 8y ago
  That's a severe distortion of the reality. Most of those "errors" are not a healthy patient dies, but cases where the patient was dying, the only question being exactly when.

105 points by montrose 8y ago

>> In the federal government and in states, there are frequent proposals to limit medical liability, but there have been no serious efforts to eliminate medical malpractice rights altogether. Damb right. Take away a patient's right to hold doctors accountable and things go south very quickly, at least in a for-profit systems. >>But American doctors often rail against the country’s medical malpractice system, which they say forces them to order unnecessary tests and procedures to protect themselves if a patient sues them. The patient can only sue if the patient has been harmed. They aren't performing the extra tests in case just wakes up and decides to sue them. They perform the extra tests so that they don't miss something that could harm the patient so badly that they sue. Doctors also forget that, again only in the US system, patients often must sue. A harm caused by malpractice isn't always covered by insurance. Patients need to find the money somewhere. Or if an insurance company does cover, the insurance company will then sue the malpracticing doctor (google "subrogation"). A few years ago several states had liability caps ready to become law (iirc $250k). Then a young woman lost both her breasts after a mixup in test results caused her doctor to recommend a double mastectomy. But at least she could still function relatively normally and the injury was not a financial burden. Imagine the costs associated with a 20yo confined to a wheelchair for the next 60+ years. Setting aside medical expenses, 250k buys you maybe four or five converted vans. While some cases are rightly suspect, many of the multi-million dollar settlements really do get spent on legitimate costs.

Retric 8y ago
As someone that lost a close family member because a doctor did not do one of those extra tests I think they are underrated. Cost vs benefit on this stuff is hard to get right, but lives are often on the line.
- noonespecial 8y ago
  My condolences. But as someone whose father lost a kidney and suffered much un-needed anxiety and pain because of a false positive on one of those "extra tests" (and the general culture of treat-until-lawsuit-proof), I humbly request we meet in the middle.
  - Retric 8y ago
    The middle would trade X deaths for X case of pain and wasteful spending which is not a fair trade. Trading 5-100 of your fathers cases for 1 life is IMO a worthwhile trade as we want a system heavily biased toward savings extra lives. PS: It's the rate of false positives vs saved lives that cause wasted treatments not the number of tests.
    - noonespecial 8y ago
      How 'bout 1000. 10000? Now were just arguing numbers. Don't forget the opportunity cost of unneeded treatments using resources that could have "saved" others as well. We're taking many paths but ending up at some sort of rationing in the end. There's no easy answers.
      - Retric 8y ago
        I doubt they would have removed a liver if the risks where that low. So, really it's saving lives at the cost of a fixed but low number of false positives and a lot of wasted tests not a 10,000 extra removed livers per life saved.
    - DanBC 8y ago
      You're making the mistake of thinking that over-testing, over-diagnosis, and over-treatment saves lives, when it probably doesn't, and may well decrease length of life as well as quality of life. The US has massive rates of testing for various stuff. It also has a lower life-expectancy than other similar nations.
      - 8y ago
darkerside 8y ago
> Damb right. Take away a patient's right to hold doctors accountable and things go south very quickly, at least in a for-profit systems. The study cited in the article would seem to rebut that quite vigorously. FTA: > They found that the possibility of a lawsuit increased the intensity of health care that patients received in the hospital by about 5 percent — and that those patients who got the extra care were no better off.
- sandworm101 8y ago
  Because the test only measured changes in the decisions by doctors. The doctors all work within the same medical culture, one built on the threat of lawsuits. Try telling an insurance company that they cannot be sued. See how many fewer tests get authorized when the actuaries can veto a doctor's recommendation without incurring liability.
- mywittyname 8y ago
  An side of this that most people aren't aware of is that insurance companies will refuse to pay for any medical test they deem to be unnecessary. So, while a doctor may order additional tests to "CYA," it's pretty likely that the hospital won't be reimbursed for all of them and will just eat the cost of the tests. And, while a hospital may charge thousands for a test, the actual costs might only be in the hundreds. Depending on the hospital system, this can be a win-win because the tax write-off can be worth more than the actual test costs. The healthcare system in the US is insane.
  - ryandrake 8y ago
    > So, while a doctor may order additional tests to "CYA," it's pretty likely that the hospital won't be reimbursed for all of them and will just eat the cost of the tests. What? In the USA, it’s the customer who eats the cost of the test. 1. The doctor tells you to go do all these tests. 2. Neither the doctor, the testing lab, the hospital, or the insurance company knows which ones will be covered by insurance. 3. You do the tests. 4. Insurance company, months later, says “Surprise, sucker! We won’t cover these tests so you have to pay $N,000!” 5. The lab and doctor says “You signed the paper agreeing to cover the costs. F-you Pay me.”
malcolmgreaves 8y ago
A patient can sue for any reason. They can be wrong and sue. It's then up to the physican to pay costs for legal defense (i.e. medical malpractice insurance). If the patient is wrong, then the physican can counter-sue. This whole dance is very expensive and, worse, time consuming (which, for a doc, is the ultimate resource). This cost ends up on the patient ad the doc must raise prices to account for the new insurance.
- mywittyname 8y ago
  Patients normally sue a hospital system though. My partner has been involved in dozens of malpractice lawsuits over the years because every person who interacted with the patient during their stay is named in the lawsuit, not just the doctor(s) who treat them. Hospitals have staff lawyers whose job it is to deal with lawsuits. So it's not terribly time-consuming for doctors outside of depositions. It's safe to say that this is one of the reasons that doctors move from private practice into working in a hospital system. But it's also not a major one (dealing with insurance companies is the major factor).
  - todd8 8y ago
    Hacker news readers may not realize that joint liability exists in many states. Under this doctrine, the plaintiff can collect all awarded damages from even very peripherally involved people. A person with deep pockets can end up paying for others mistakes. For example, a plaintif’s attorney might drag everyone into a lawsuit they can over a disappointing surgical result. The jury could be persuaded that an operating room nurse is 1% liable for a failed operation and the surgeon 99% responsible. If the surgeon can’t pay their part of a two million dollar judgement (brand new doctor perhaps) the nurse may end up paying the two million (maybe the nurse is married to a software engineer).
- forapurpose 8y ago
  > the doc must raise prices to account for the new insurance As I understand it, the portion of additional costs that the doctor eats and the portion that they charge to their patients actually depends on the elasticity of the market for the doctor's medical services. I can't comment on the market for the hypothetical doctor's medical services (in the U.S. AFAIK that market is very complex and opaque, and it probably depends on the doctor, location, and the specific service), so speaking generally about sellers and buyers: The portion of a cost increase that is eaten by the seller or charged to the buyer depends on elasticity. Computer memory is highly elastic: If your costs go up and you try to increase your price $10/DIMM, then I'm going to buy my DIMM someplace else (unless your DIMMs are very special); a small change in price causes a large change in demand. Superstar developer salaries are highly inelastic: If the developer's costs increase (a new baby!) and they ask for more money, I probably have to give it to them because I'm not going to find a replacement. You see that more publicly with superstar athletes: Cristiano Ronaldo is irreplaceable; the market for his services is at the extreme of inelasticity; he can almost name his price for running around in shorts, playing games.
dv_dt 8y ago
This is where a universal healthcare system takes some causes for inefficiency out of the system, reducing at least one source of major need for lawsuits - the need to fund future medical care.
- dsfyu404ed 8y ago
  That said, government administrated systems can become just as bad or worse because you don't have meaningful alternatives or the alternatives that exist aren't practical/affordable.
  - dv_dt 8y ago
    The statement is more generally true if you take out the word 'government', and come to think of it, take out 'administrated' too.
grasshopperpurp 8y ago
No idea why this is being downvoted. Maybe they missed the qualifier? > . . . at least in a for-profit systems.
- mywittyname 8y ago
  I don't get it either. People outside of healthcare probably aren't aware of how ridiculously common it is for medical mistakes to be made. Dozens of overworked people are coordinating with one another to take care of you.
- pc86 8y ago
  Probably because it's flat out wrong and shows a shockingly incorrect view of how things actually work. > The patient can only sue if the patient has been harmed. No, the patient can sue for whatever reason they want to. The doctor's malpractice insurance is going up regardless. Even a completely frivolous lawsuit will cost the physician real money out of his or pocket for years to come, not to mention the cost (if they choose to pursue it) of counter-suing the patient.
  - grasshopperpurp 8y ago
    That part is incorrect; however, the overall message of the post is correct. In a for-profit system, it's the patient's only recourse. Don't like it? Fight against for-profit healthcare.
    - pc86 8y ago
      Whether healthcare is for-profit or non-profit does not change how the legal system works.
      - sandworm101 8y ago
        But it does change the math. Where patients do not have to pay for their own injuries, ie under a national health service, they don't need to collect in order to pay for later care.
conanbatt 8y ago
> he patient can only sue if the patient has been harmed. They aren't performing the extra tests in case just wakes up and decides to sue them. They perform the extra tests so that they don't miss something that could harm the patient so badly that they sue. Unfortunately this is not how good medicine is practiced. Medicine is not a straightforward hard-science. Tests are expensive, patients dont follow through, they have personal consequences, chances you got something are 100% but chances you got something specific are 0.0001%. It is digestible for a doctor to have liability but compare it to other professions: does a web developer that botched a UI for a bank transfer and introduces some consequence go to jail for robbery? Doctors have too high a burden. And a decision or an oversight that makes someone die could be as stupid as a misprint on a paper.

deleted 8y ago

[deleted]

patrickg_zill 8y ago

Wait until the NY Times finds out that c-sections have greatly increased because of high-dollar awards like the one that made John Edwards (yes the politician) a millionaire...

grasshopperpurp 8y ago
I somehow missed this. What a jerk. https://drjengunter.wordpress.com/2011/06/03/john-edwards-indicted-by-grand-jury-obgyns-everywhere-rejoice/ https://drjengunter.wordpress.com/2011/06/03/john-edwards-in...
everdev 8y ago
My wife is a doula and apparently the injury and mortality rates for mother and child are much higher than through natural childbirth. But because of their insurance coverage, if a mother or baby dies during natural childbirth the doctor is at greater risk for malpractice. So, they will rush mother's into C-section at any excuse (it saves them hours of work too not having to sit through a long labor). Unfortunately, money and efficiency have taken priority over natural processes.
- Xixi 8y ago
  But are the injury and mortality rates higher because C-sections are riskier, or because high risk childbirth are done through C-section? You need to control for the prior, otherwise the statistic is not very useful.
  - everdev 8y ago
    From what I understand C-sections are much riskier for the mother than we might think. It's significant surgery which can always lead to complications or infection. The other factor is delivering a child naturally that gets stuck and didn't get enough oxygen but lives is probably the most expensive outcome for doctors because that child can live with severe physical or mental handicaps and need support the rest of their lives.

howard941 8y ago

Link to the study: http://www.nber.org/papers/w24846 http://www.nber.org/papers/w24846

rayiner 8y ago

> Any law that limits the cases where patients can sue, or the amount of money they can collect, is likely to lower medical use in the hospital by less than the 5 percent they measured in their study. The telling thing about laws to address malpractice liability is that they typically are focused on capping large verdicts. But such laws are illogical: generally, large verdicts will be awarded where a doctor screwed up and caused the most damage. Cases with large verdicts are the most meritorious ones, and the ones where limiting liability is least likely to eliminate over-testing that does not contribute to quality of care. If states actually wanted to address the costs of defensive medicine, they would do something like create affirmative defenses for doctors who adhered to certain established testing protocols.

ghein 8y ago
Large verdicts have been delivered where no or minimal injury was suffered. As others have mentioned, John Edwards had great success as a lawyer suing over cerebral palsy, claiming that it was caused by actions during delivery. While possible, most cases are caused by other factors such as infections, IVF, or low birthweight. At trial, you have a sympathetic plaintiff with large needs vs a "rich" doctor and hospital. They might have caused this, they have insurance. So you systematically get very large verdicts against defendants who are unlikely to have done anything wrong. Edwards was very good at theatrics and not good on science. Trials that rely on science and math are not great to take to a jury. Even discussions here get emotional when you deal with subjects like appropriate risk analysis and tradeoffs. Saying that you have a formula to only fix defects that kill more than x people or cost less than y per life saved is a great way of losing at trial and getting destroyed in a thread. It's also how every company and government makes decisions around safety - where stop signs go, guardrails, drug approval, armor in tanks... Getting tort law right is hard - you want true injuries to be compensated but discourage people that are looking for lottery tickets.
- rayiner 8y ago
  > Large verdicts have been delivered where no or minimal injury was suffered. We live in a country of 300 million people. Every permutation of things that can happen has happened. But that doesn't mean that large verdicts "where no or minimal injury was suffered" happen often enough to account for a significant share of medical malpractice payouts. There was a Harvard study that looked at this issue pretty systematically, and concluded that the idea of "systematically" "large verdicts against defendants who are unlikely to have done anything wrong" does not fit the data: http://archive.sph.harvard.edu/press-releases/2006-releases/press05102006.html http://archive.sph.harvard.edu/press-releases/2006-releases/.... Most importantly, claims are about as likely to get denied despite the presence of error as they are to get paid despite the absence of error. (So improving the accuracy of the system would not necessarily decease payouts.)

dahdum 8y ago

Aren't a lot of these costs baked into all services due to malpractice insurance itself? If these doctors could be sued by some of their patients (the families), they still need to cover the cost of that insurance. Beyond that, once defensive medicine is the status quo, why would they make a choice to not order their usual defensive panels? They aren't paying for them themselves.

mrfredward 8y ago
True, but here's a point the NYT missed: caps on malpractice claims don't have to change how doctors practice medicine to reduce costs. By capping liability, they should make malpractice insurance cheaper and thus reduce the cost of providing care.
- dragonwriter 8y ago
  Caps on malpractice claims exist in numerous jurisdictions, and studies have shown them to have no discernable effect on either total healthcare costs or even specifically on malpractice insurance costs.
  - briandear 8y ago
    I am sorry but you are just completely wrong. Exactly the opposite of what you said is true: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/ “In summary, there exists considerable evidence that medical malpractice reform measures reduce medical malpractice awards and also the losses incurred by medical malpractice insurance companies.”
    - Digory 8y ago
      Reduced Awards =! Reduced Premiums or Costs Texas seems to have set caps so low that it has reduced premiums for doctors. But "making malpractice cheaper" isn't much of a policy goal. Nationally,'tort reform' caps have had mixed results. "...better-designed studies show that damages caps reduce liability insurance premiums. The effects of damages caps on defensive medicine, physicians’ location decisions, and the cost of health care to consumers are less clear." [0] [0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690332/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690332/

jl2718 8y ago

Extra tests... the cost of diagnostics is a tiny fraction of the cost of doctor time, and most patients just go to the doctor to get the test. The doctor is an irellevant gatekeeper 90% of the time. How about we start talking about ‘extra’ doctor visits because patients don’t have access to tests. There are some diagnostics where this gatekeeping is literally causing a public health crisis. ‘Extra tests’ are only an issue because of the untreated disease they reveal, which costs insurers money to treat. This ‘concern’ is all part of their lobby.

patrickg_zill 8y ago
That is very accurate... I had an injury that I knew required specific surgery, but when I called the surgeon's office to make an appointment I was told that they only accepted referrals from family doctors, that is, I had to pay to visit a family doctor first. This applies nowadays to most specialists as well.
- SkyPuncher 8y ago
  I don't really consider this a problem. Specialists are packed to the gills already and very expensive. Specialists don't want to spend time with patients who don't actually need specialized care and insurance doesn't want to pay specialists without first qualifying the issue.
  - patrickg_zill 8y ago
    I agree; however the first thing he did was to order a CT scan to confirm the diagnosis and get the exact location. So the family doctor visit was thus duplicative.
    - imglorp 8y ago
      I hope the specialist didn't get a kickback from the imaging company
      - 8y ago

CrankyBear 8y ago

Doh

mattnewton 8y ago

So make tests cheaper - sounds like an opportunity that gets a win for everyone without political miracles. (I don’t know the market I am talking about at all, but) Maybe they could incentivize cheap tests by capping the cost per test that can be administered without some large red tape process. The market will provide tests under that cap where possible, so they can be administered more frequently & frictionessly. Patients are thoroughly tested, Doctors cover their butts, and test supply companies get to keep selling lots of tests.

subhobroto 8y ago
EXACTLY! I wrote about this here: https://news.ycombinator.com/item?id=17620197 https://news.ycombinator.com/item?id=17620197

subhobroto 8y ago

I see no issue with Extra Medical Tests. More data points do not hurt a diagnoisis if a proper scientific method is followed. The primary issue here is the resulting cost. As the article points out: "about 26 percent of every dollar spent." You probably won't complain paying 26 cents for a $1 popsicle, but if the same popsicle cost you $100, you might be upset paying $26. But is not the bigger question: Why is the popsicle $100 when it could have cost $1? Here is a useful chart to show where the money goes: https://qph.fs.quoracdn.net/main-qimg-d68aea3ca1e466f166752e261b9e28d3 https://qph.fs.quoracdn.net/main-qimg-d68aea3ca1e466f166752e... Where do you think malpractice costs fit there? I personally feel sad everytime malpractice fears enter the discussion of costs - its a tiny, ignorable portion right now of total expenses. However, to a typical layperson, it sounds like a big deal to worry about but actually distracts the attention costs should be getting. As a result, I have tried to cover it here: https://www.quora.com/Why-does-one-believe-that-malpractice-insurance-is-the-primary-reason-for-US-health-care-being-so-expensive https://www.quora.com/Why-does-one-believe-that-malpractice-... Real input from real practitioners in the industry in the real world. Sure, Malpractice overhead exists but it's analogous to a drop in the ocean. There is severe waste elsewhere that need to be handled first. It's a nosebleed in a patient hemorrhaging blood through a punctured artery. The argument that ordering extra tests offer doctors "additional defense" in case of a lawsuit is absolute hogwash. If anything, the test results put the doctor at a further disadvanatge wrt defense because they had an additional datapoint they should have considered in their diagnoisis but did not. The primary issue with Healthcare in the U.S. is cost - for those who have the money and the will to spend it, it's one of the best in the world. A lot of the rich visit the US for their Healthcare needs. Healthcare in the U.S. is optimized for profit: https://www.quora.com/What-makes-the-US-healthcare-system-so-expensive-Why-is-the-US-so-expensive-compared-to-Canada/answers/33451192 https://www.quora.com/What-makes-the-US-healthcare-system-so... This is very wrong as it encourages short term profit seeking behavior which is absolutely the opposite of what healthcare should be (eg: C Sections being preferred over natural but long childbirth) A for-profit system does not help the doctor/provider either (although it gives an illusion of it) - in such a system, the patient's only recourse is to sue the doctor/provider for damages instead of both parties focusing on the root cause which brought the patient to the doctor/provider in the first place. Extra Medical Tests might be suboptimal but the real pain points are the marginal costs of each test. Tests in the U.S. are extremely expensive. There is no standardized pricing for any test in the U.S. unlike the rest of the world. While the rest of the world has pretty much agreed, for example, that a blood group test might be no more than $10 (In India, it costs 20 cents upto 70 cents at current INR-USD exchange rates), in the U.S. depending on which lab you go to, your insurance coverage, your ability to pay and other factors, you might be billed anywhere from $0 - $2000. That is completely insane. Also, labs in the U.S are not setup to take requests from customers directly. There are kits you can order and all that Everytime I try to send a blood sample to a lab on my own, the lab staff seem to be lost - they want my insurance information, my EHR information, my NPI ID and when I explain to them I am not a doctor they ask me to provide my physcian's who ordered the test. (my physcian didn't order the test - I did). I have had a few labs bill me outrageous out of network fees because the lab tests were not ordered by an in network provider (because I ordered them and I am not a doctor) and the amount of calls and paperpushing I had to do to correct the billing has made me just give up and let a doctors office handle this. I can read a lipid panel. I don't need to go to a doctor's office to drive in traffic, wait an hour or more just to draw my blood and have it sent to a lab and then have the doctor read the panel to me. I read spreadsheets every hour of the day. I know what mean median and mode is and the lab result often offer these values anyways as part of the report. I just need the test report. Now, if my HDLs are too high and I cannot figure out why, sure, I do need to discuss this with a professional. The solution to this madness? An "all payer rate set" system. EVERYONE pays the same for the same procedure. Who pays for the care, while important, comes later, not before.

joshuaheard 8y ago

If a doctor is sued for malpractice, that means they made a mistake. If they are performing extra tests to avoid malpractice, that means they are performing extra tests to avoid making mistakes. That is a good thing.

TheSoftwareGuy 8y ago
It can also be a very expensive thing. Extra tests are unnecessary, hence why they are “extra”
danepowell 8y ago
Not necessarily. Tests have costs and risks of their own. I would consider a test not justified in terms of cost and risk to be a "mistake". However doctors are far less likely to be sued for a thousand small mistakes than one big one, so they err on the side of too many tests.
n8henrie 8y ago
So if a physician were to do every test on every patient every time, could they expect to never be sued? Would that be a good thing? “1 of everything please.”
- conanbatt 8y ago
  You would go for an annual checkup and you get a CAT-scan and get cancer from it, then the doctor can say "Well, now we know you have it, you wouldnt without the test!"
esmi 8y ago
If a doctor is sued for malpractice it means someone thinks there is a possibility the doctor made a mistake. After all, doctors win lawsuits sometimes too. The doctors are ordering the extra tests to avoid the lawsuit being raised in the first place.
psychometry 8y ago
There's an error in literally every sentence you just wrote. 1. A person can be sued without being guilty in a criminal or civil sense. 2. They are performing extra tests to cover their asses, not to avoid making mistakes. 3. It is clearly not a good thing as shown by the authors of the study.

briandear 8y ago

Is there empirical evidence for “Defensive Medicine?” https://www.ncbi.nlm.nih.gov/pubmed/19201500/ https://www.ncbi.nlm.nih.gov/pubmed/19201500/ “The net effects of medical malpractice tort reform on health insurance losses: the Texas experience” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5701901/

dhdhshd 8y ago

Bone marrow biopsies suck. And on top of that I have to be thankful I don’t have cancer while the bills keep coming.

zelon88 8y ago

I thought medical errors were the third leading cause of death in the U.S. with 10% of all deaths attributed to medical error. With that error rate, is it fair to say that the extra tests are truly "unnecessary?"

LorenPechtel 8y ago
That's a severe distortion of the reality. Most of those "errors" are not a healthy patient dies, but cases where the patient was dying, the only question being exactly when.