The uninsured..........

[SoCalCoug]

Originally Posted by JohnnyLingo

It is my opinion that malpractice suits are the major problem here. If not for these suits, health care would be a lot less expensive, and therefore people could afford it much more readily.

And you've therefore fallen for the propaganda of the insurance industry.

[creekster]

Originally Posted by UtahDan

The truth is that med-mal payouts have been more or less static for years and yet the premiums continue to rise.

Can you exapnd on this? It is my sense that verdicts have been rather static, even when controlled for MICRA or other tort reform efforts, but I don't have any evidence I can put my hands on without too much effort.

As to yourt criticism of the insurance lobby, I think you are overstating it, but you do add another wrinkle to the issue showing why both cost fo care and access issues defy easy solution.

[creekster]

Originally Posted by Jeff Lebowski

Yes, I understand. But the last page of the report argues that they have under-estimated the deaths. To support this argument, they cite several other studies that have shown higher numbers, including this study that did in fact account for socio-economic factors. The 13,000 deaths number was just for one age group.

So is that 13k of the total 18k (or thereabouts)? How signficant is this given that these are elderly or near elderly folks? Would these 13k typically live another 6 months or are they missing out on 15 years? Either way I guess we are safe in giving them a CT becasue they certainly won't be lielky to make it 30 or more.

[Jeff Lebowski]

Originally Posted by creekster

So is that 13k of the total 18k (or thereabouts)? How signficant is this given that these are elderly or near elderly folks? Would these 13k typically live another 6 months or are they missing out on 15 years? Either way I guess we are safe in giving them a CT becasue they certainly won't be lielky to make it 30 or more.

They were two different studies. So it would be 13K out of the total ???. Since they compare insured vs. uninsured, the "near-death" factor should be accounted for.

In any case, here is the entire article. See for yourself (page 4):

http://www.urban.org/UploadedPDF/411...ured_dying.pdf

Here is a full copy of the paper referenced. I have not had a chance to read through it yet.

http://content.healthaffairs.org/cgi.../full/23/4/223

[ERCougar]

Ok, creekster, we're both arguing things we know little about, so let's go after some summary points I hope we can agree on.

1) Defensive medicine is bad. It's bad for the patient involved (Need a non-carcinogenic example, besides the cardiac one? Needless breast biopsies for questionable findings on mammograms.). It's bad for the patients whose care is delayed because of overcrowded ERs. It's bad for society who has to pay for needless tests. The example I gave with the kid falling from the bunk bad isn't real, but it's possible. I HAVE seen people die in the waiting room because of an overcrowded ER. I have seen needless tests contribute to overcrowding. I have seen healthcare costs go up because of more tests. I've personally ordered tests solely to "buff up" a chart if it were to go to court. We're only beginning to understand the risks of excessive medical testing (beyond just carcinogenic risks--needless followup workups from whole-body CT providers for example). Does every head CT on a kid result in a person dying in the waiting room? Obviously not. But the links are there.

2) A responsibility for medical errors is a good thing. There are times when a fear of a lawsuit has kept me on my toes, where compassion or a sense of professional responsibilities has failed because of fatigue or other factors.

3) The layperson is NOT qualified to judge medical errors. It's ridiculous that a high school dropout is going to be asked to evaluate what can be a very complex medical decision. Indiana has an outstanding system where every lawsuit is evaluated by a board of experts before going to trial who give a preliminary decision. The plaintiff can still go to trial if the board decides against them, but at least the jury has access to an expert opinion, not some hired gun. Physicians have sought to expand this to other states and this has been fought vigorously by the Bar association. IMO--a shameful display of greed.

4) Medical malpractice reform will not solve our health care financing issues. Many studies have shown this. However, if health care reform occurs, there will inevitably be some rationing of care, and malpractice reform MUST accompany this for the system to succeed.

Final note--I've practiced medicine in four states: Indiana, Michigan, Nevada, and Utah. Two of those are considered high-liability states (MI and NV). I assure you, malpractice liability directly affects practice. To take the example of the kid's head CT. In IN and UT, I would have the guts to discuss the option of sending a kid home after discussing the unknown effects of radiation, signs to watch for at home, etc. No way in MI and NV--you sign out AMA. The problem needs to be fixed so we can do the right thing for the patient.

[ERCougar]

Originally Posted by creekster

Can you exapnd on this? It is my sense that verdicts have been rather static, even when controlled for MICRA or other tort reform efforts, but I don't have any evidence I can put my hands on without too much effort.

As to yourt criticism of the insurance lobby, I think you are overstating it, but you do add another wrinkle to the issue showing why both cost fo care and access issues defy easy solution.

Agree with second point. Insurance lobbies are involved. However, there has been a significant decrease in malpractice premiums following tort reforms--Texas is a perfect example of this.

I don't have the numbers on the first point, but it certainly goes counter to my sense.

[MikeWaters]

Originally Posted by ERCougar

Ok, creekster, we're both arguing things we know little about, so let's go after some summary points I hope we can agree on.

1) Defensive medicine is bad. It's bad for the patient involved (Need a non-carcinogenic example, besides the cardiac one? Needless breast biopsies for questionable findings on mammograms.). It's bad for the patients whose care is delayed because of overcrowded ERs. It's bad for society who has to pay for needless tests. The example I gave with the kid falling from the bunk bad isn't real, but it's possible. I HAVE seen people die in the waiting room because of an overcrowded ER. I have seen needless tests contribute to overcrowding. I have seen healthcare costs go up because of more tests. I've personally ordered tests solely to "buff up" a chart if it were to go to court. We're only beginning to understand the risks of excessive medical testing (beyond just carcinogenic risks--needless followup workups from whole-body CT providers for example). Does every head CT on a kid result in a person dying in the waiting room? Obviously not. But the links are there.

2) A responsibility for medical errors is a good thing. There are times when a fear of a lawsuit has kept me on my toes, where compassion or a sense of professional responsibilities has failed because of fatigue or other factors.

3) The layperson is NOT qualified to judge medical errors. It's ridiculous that a high school dropout is going to be asked to evaluate what can be a very complex medical decision. Indiana has an outstanding system where every lawsuit is evaluated by a board of experts before going to trial who give a preliminary decision. The plaintiff can still go to trial if the board decides against them, but at least the jury has access to an expert opinion, not some hired gun. Physicians have sought to expand this to other states and this has been fought vigorously by the Bar association. IMO--a shameful display of greed.

4) Medical malpractice reform will not solve our health care financing issues. Many studies have shown this. However, if health care reform occurs, there will inevitably be some rationing of care, and malpractice reform MUST accompany this for the system to succeed.

Final note--I've practiced medicine in four states: Indiana, Michigan, Nevada, and Utah. Two of those are considered high-liability states (MI and NV). I assure you, malpractice liability directly affects practice. To take the example of the kid's head CT. In IN and UT, I would have the guts to discuss the option of sending a kid home after discussing the unknown effects of radiation, signs to watch for at home, etc. No way in MI and NV--you sign out AMA. The problem needs to be fixed so we can do the right thing for the patient.

Why don't you have the guts to do what is right for the patient?

Any doctor who operates defensively is a bad doctor. A good doctor always acts in a way that is best for the patient.

Do you disagree?

[ERCougar]

Originally Posted by MikeWaters

Why don't you have the guts to do what is right for the patient?

Any doctor who operates defensively is a bad doctor. A good doctor always acts in a way that is best for the patient.

Do you disagree?

Ideally, no, I don't disagree.

Here's the problem...Take chest pain, for example--one of our most common presenting problems. Say I see 100 people with chest pain in a month. Protocols exist to determine who I need to admit and who I need to discharge. The most conservative protocols can get my miss rate down to nearly zero, by just admitting everyone to the hospital and watching them overnight. But then we're defensive medicine and its consequences. So I have to choose an acceptable miss rate--which right now is about 2%.

This is what would be "right for the patient" and right for society.

The problem is that the plaintiff doesn't care about right for society. The attorney just knows that you missed one and you're gonna pay. If I see 100 people with chest pain in a month, that means I will miss 2 people every month with a serious cardiac issue. In some states, that's OK. In Florida, I'll be forced out of practice because I can't pay malpractice insurance.

Now...what's right for the patient?

[MikeWaters]

Originally Posted by ERCougar

Ideally, no, I don't disagree.

Here's the problem...Take chest pain, for example--one of our most common presenting problems. Say I see 100 people with chest pain in a month. Protocols exist to determine who I need to admit and who I need to discharge. The most conservative protocols can get my miss rate down to nearly zero, by just admitting everyone to the hospital and watching them overnight. But then we're defensive medicine and its consequences. So I have to choose an acceptable miss rate--which right now is about 2%.

This is what would be "right for the patient" and right for society.

The problem is that the plaintiff doesn't care about right for society. The attorney just knows that you missed one and you're gonna pay. If I see 100 people with chest pain in a month, that means I will miss 2 people every month with a serious cardiac issue. In some states, that's OK. In Florida, I'll be forced out of practice because I can't pay malpractice insurance.

Now...what's right for the patient?

In this case, you are balancing the risk to the patient versus the risk to society (i.e. cost). The question the doctor must answer is "what is best for the patient?" It can't be the doctor that is making societal questions about cost. For example, a psychiatrist may feel a certain medication is the best, but that it is very expensive and might not be covered or affordable. That should not mean that the doctor doesn't present the patient with that option.

[ERCougar]

Originally Posted by MikeWaters

In this case, you are balancing the risk to the patient versus the risk to society (i.e. cost). The question the doctor must answer is "what is best for the patient?" It can't be the doctor that is making societal questions about cost. For example, a psychiatrist may feel a certain medication is the best, but that it is very expensive and might not be covered or affordable. That should not mean that the doctor doesn't present the patient with that option.

I see what you're saying, but here we're talking about a cost to the patient/society versus a cost to me. Unless you're advocating we just admit every patient to the hospital, in order to never miss a serious event. But even that's not 100%, as you need to then follow up with some sort of stress test--yup, more radiation and possibly more nephrotoxic dye--I don't think that's really beneficial to the patient either. Ideally, yes, we should always come down on the side of the patient, but then ultimately, we'd all be working for free, right (or at least a minimal subsistence to survive on)? The other problem is that those who are trying to "do the right thing" are getting forced out of practice (witness OBs in PA, ER docs in FL, neurosurgeons/orthos refusing to take call for liability reasons, etc.).

I think an expert panel would alleviate a lot of the issues. Europe has it, Canada has it, we don't. Why not?