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Defensive Medicine: Rhetoric Meets Reality

by Kiren Gopal

In his July 24th piece in the Washington Post, columnist Charles Krauthammer rails against “jackpot justice” and defensive medicine, which he calls “the greatest waste” in our health care system.  He contends that “doctors order [tests] for no good reason other than to protect themselves from lawsuits.”  But his self-righteous claims are more than suspect, considering that overwhelming evidence shows that so-called “defensive medicine” is not a meaningful cause of rising health care costs.  The Congressional Budget Office (CBO), which Krauthammer himself cites in his column to argue that not enough is being done to reduce Medicare spending, has concluded that the link between liability and defensive medicine is “weak or inconclusive” and “at best ambiguous.”  

A reader’s letter responding to Krauthammer’s exaggerated rhetoric presents an additional factor that contributes to health care costs, which he calls “offensive medicine.”  That is, doctors perform more tests and recommend more procedures, primarily because under the reigning fee-for-service model they benefit financially from each test and procedure ordered rather than on patient outcomes.  This and other incentives that the present system engenders have been estimated to cost $700 billion a year – a number that former CBO director Peter Orszag, has discussed often.   

Considerable evidence of misaligned incentives also exists in the case of “self-referral” – where physicians own their own testing equipment or have a financial stake in imaging centers to which they send their patients.  A 2008 study published in Medical Care found that rates of use increased by almost 400 percent for PET scans and 50 percent for MRI and CT scans in cases where physicians self-referred, compared to those originating from a referral to a radiologist or hospital.

By focusing on baseless claims about defensive medicine Mr. Krauthammer indeed does ignore the real troubles facing the U.S. health care system.  Health care reform must expand coverage, improve quality, and reduce cost.  Part of reducing costs must be realigning incentives toward improving patient safety.  Krauthammer unfortunately chooses instead to ring the alarm about defensive medicine with no evidence to back up his claims.  

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