Watchdog Blog

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.   

Ignoring Patient Safety = $1 Trillion Waste

Former Bush administration Treasury Secretary Paul O’Neill identified a simple but crucial element that should be front and center in the health care reform debate and legislation: improving patient safety, which would, in turn, reduce health care costs.

O’Neill rhetorically asked in this New York Times op-ed piece:

• Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?

• Which of the proposals will eliminate the annual toll of 300 million medication errors? 

• Which of the proposals will eliminate pneumonia caused by ventilators?

• Which of the proposals will eliminate falls that injure hospital patients?

• Which of the proposals will capture even a fraction of the roughly $1 trillion of annual “waste” that is associated with the kinds of process failures that these questions imply?

“So far,” O’Neill wrote, “The answer to each question is ‘none.’”

O’Neill calls it waste – that is, the unnecessary harms done to patients on a daily basis and, he estimates, a trillion dollars in annual costs to address those harms. He said that hospitals themselves can adopt simple processes, such as hand-washing and proper preparation of surgical sites, to cut down on costly injuries and deaths. He also suggested that members of Congress seek more information on the dire problem of hospital-acquired infections, provider errors and other similar “waste indictors.”  To sum up, he said: “(A)ny health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate.”

Congress should heed O’Neill’s call. 

Misplaced Malpractice Reform

by Kiren Gopal

According to President Obama, health care reform should control costs, expand coverage, improve care, and guarantee choice.  As Congress works to find politically palatable solutions to achieve those goals and health care interests continue to lobby – to the tune of $1.4 million daily – some legislators instead choose to offer proposals to limit medical liability.

These proposals are based in part on the theory that frivolous malpractice claims are epidemic and represent a significant component of health care costs.  But according to the latest Public Citizen study of the National Practitioner Data Bank, nearly two-thirds of the individuals who were compensated in 2008 suffered an injury that resulted in “significant permanent injury, major permanent injury, quadriplegia, brain damage or the need for lifelong care, or death.” These claims can hardly be described as frivolous. Perhaps the most telling point from the NPDB study is that the medical malpractice liability system accounts for just 0.6 percent of national health care costs. Reducing accountability for medical malpractice is clearly an unsuitable focal point for reducing unnecessary costs. 

Sorry Works: Change We Can Believe In?

by Kiren Gopal

At a recent speech before the American Medical Association, President Obama expressed a concern for medical malpractice lawsuits and said that “we need to explore a range of ideas” to tackle the issue. However, the president hasn’t offered much in the way of clarification of his position on medical liability reform.  The only indication was a reported comment of a White House spokeswoman who “pointed to his support as a senator for a mediation program known as ‘Sorry Works.’”

In 2006, then-Senators Obama and Clinton introduced MEDiC (National Medical Error Disclosure and Compensation).  They wrote in the New England Journal of Medicine that the program would provide grant money to health care providers to “implement programs for disclosure and compensation.”  In practice, this means that health care providers would disclose medical errors to the patient, offer an apology, and then try to negotiate compensation.  Additionally, the data yielded from the program would be analyzed to determine best practices.  The potential benefits of such a program are manifold: improved quality of care, more effective doctor-patient communication, and lower administrative and legal costs.

Pollan for Secretary of Ag?

by Kendra Pierre-Louis

There’s a rumor circulating around the foodie and agricultural corners of the internet that President-Elect Obama might choose best selling author and New York Times contributing writer Michael Pollan as his new Secretary of Agriculture.

At first blush this seems to be a ludicrous idea.

After all, Michael Pollan’s own biography lists him first as a writer and secondly as a professor (he is the Knight Professor of Journalism at UC Berkeley). His educational background, he received a B.A. from Bennington College, where he focused on literature, and an M.A. in English from Columbia University, only seems to add to the ridiculousness of the idea. Where is his agriculture experience? In fact, words such as “farmer”, “agriculturalist” or “agronomist” appear nowhere on his CV.

Mr. Pollan seems a foolhardy choice, until one examines the substance of his writing. From The Botany of Desire, to his most recent, In Defense of Food, Pollan shows a nuanced understanding of how our food systems should behave, namely to feed people in a manner that sustains life. Instead, our current food system lines the pockets of agribusiness while wreaking havoc on the environment and compounding our health and energy problems.

To even a casual observer our current system of agriculture does not make sense.

The Other Bad News for Consumers: Forced Arbitration

Due to the extensive coverage of the recent economic meltdown and the presidential race, it's been easy to miss some other news very relevant to consumers and corporate accountability.  Over at Tortdeform, they have some excellent posts about issues covered by the New York Times. 

First, Kia Franklin relayed the news that a recent Department of Health and Human Services study cited 94% of nursing homes for violations of federal health and safety laws.  This underscores the need for legislation banning forced arbitration, which nursing homes use to immunize themselves from the accountability when they violate the law or hurt their residents through negligent treatment or abuse.  (Follow up on the Times story from Tortdeform here.  Read more about the nursing home arbitration bill here.)

Next, Justinian Lane recaps a study by two law professors about the reluctance of companies to use arbitration when dealing with one another.  The professors cited in the story have been following this issue for some time now, and their results have consistently shown the hypocrisy of corporations that tout arbitration as a fair, efficient, less costly method of dispute resolution between companies and consumers, or employers and employees, but not between one another.

Protect the Elderly from Forced Arbitration

by David Arkush and Christine Hines

Yesterday the Senate Judiciary Committee followed its counterpart in the House and approved an important arbitration bill to protect residents in nursing homes and assisted living facilities, the Fairness in Nursing Home Arbitration Act, S. 2838. The legislation, which a House committee approved in July, will make it easier to hold these facilities accountable for negligent or reckless acts that harm their residents. It prevents nursing homes from forcing residents to agree to arbitration before a dispute arises, allowing residents to turn to the courts in the event their nursing homes cause them serious injuries or death. Without this protection, nursing homes can force residents to take disputes to private arbitrators chosen by the nursing home itself. Guess who wins cases there?

New Medicare Rule May Improve Patient Safety

Safety incidents for Medicare patients resulted in a shocking 238,337 potentially preventable deaths and cost Medicare $8.8 billion from 2004 to 2006, according to HealthGrades fifth annual Patient Safety in American Hospitals Study [pdf]. But improvements may be on the way. Starting in October, Medicare will stop reimbursing hospitals for procedures in which inexcusable errors are made.

The HealthGrades Study measured the incidence of 16 patient safety indicators among Medicare patients at virtually all of the nation’s nearly 5,000 nonfederal hospitals. The patient safety indicators used had been developed by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ).

In 1999, the Institute of Medicine estimated that as many as 98,000 people die every year and countless others suffer injuries because of medical errors. At that time, IOM believed that it was a reasonable goal to cut medical error-related deaths and injuries by 50 percent over the next five years. While the HealthGrades study reported some progress in reducing overall death rates among Medicare patients that experienced one or more patient safety incidents (-5 percent), some indicators showed an increase. The incidence of bed sores; post-op respiratory failure; post-op pulmonary embolism or deep vein thrombosis (clot); post-op sepsis (infection); and post-op abdominal wound separation/splitting actually increased when compared to 2004. Unfortunately, as the HealthGrades study demonstrates, progress in reducing the toll of medical errors has been uneven at best.

Stupak’s Effort to Arm the FDA with Subpoena Power Over Company Records

After years of discussion, Rep. Bart Stupak, the Michigan Democrat who runs the investigations panel of the House Commerce Committee, has, again, wisely urged the FDA to support Congress’s addition of subpoena power to FDA’s arsenal of tools needed to make our food and drug supply safe. Some food and drug industry folks immediately criticized the idea, claiming the result would simply be more bureaucratic meddling in their affairs. To date, there has been no official response from the FDA.

Recent episodes of contaminated foods and drugs again raise disturbing questions about whether the Food and Drug Administration has the tools and resources necessary to protect the public. Often the agency, it seems, is the last to learn of hazards threatening us all.

The FDA does no testing of its own, and in making decisions it must rely on the test results submitted by manufacturers. Dr. Sidney Wolfe, director of Public Citizen’s Health Resource Group, previously noted that “the FDA is extraordinarily dependent on the companies to be honest.”

If the FDA is really serious about cracking down on unsafe products, why doesn’t it accept Stupak’s offer to authorize the subpoena power?  Some fear that the FDA no longer has consumer protection as its first priority, but has been co-opted by the industry it is supposed to oversee.

Nursing Home Arbitration

The Wall Street Journal recently published ($) an excellent front-page article describing one of the more egregious incarnations of binding mandatory arbitration – nursing home admission agreements. The money quote:

Nursing homes' average costs to settle cases have begun dropping, according to an industry study, even as claims of poor treatment are on the rise. The industry notes arbitration is slicing the number of patients winning big punitive judgments, the added penalties for severe negligence that can pump up the size of jury awards. Meanwhile consumer advocates, plaintiffs’ lawyers and even some arbitrators are decrying the practice.

The article goes on to describe the case of one Mary Hight, whose nursing home wouldn’t call an ambulance despite her being dehydrated and ill for days. Her daughter, Janice Cowart, resorted to pushing her uphill to a nearby hospital, where she died the next day. Even though the “arbitrator found the home was negligent both in allowing Ms. Hight to become dehydrated and failing to get her to an emergency room,” he only awarded $90,000. After legal fees from the arbitration, “We didn’t get one cent,” said John Estep, Janice Cowart’s brother.

Maryland Doctors Cry "Wolf" Again!

Once again Maryland doctors are raising the specter that patients will be denied access to medical care because doctors will be leaving Maryland as the cost of medical liability insurance increases.  The last time they used this scare tactic they convinced the Assembly to subsidize their premiums.  Now as those subsidies are set to expire they’re back with the same tired threats. Citing an emerging doctor shortage, doctors are urging Assembly members to enact “tort reforms” designed to slam the court house door on injured patients.

First, claims of an emerging doctor shortage are not borne out by the facts.  A recent report to The Governor’s Task Force on Health Care Access and Reimbursement indicated that data collected from the American Medical Association and the American Osteopathic Association and adjusted on a consistent basis shows that Maryland has the 4th highest patient care physician to population ratio in the U.S.

A Self-Inflicted "Crisis"

When NY’s Superintendent of Insurance announced a 14 percent across-the-board rate hike for medical liability insurance on July 1, 2007, doctors raised a hue and cry that the increase threatened a crisis in access to care because doctors could no longer afford to practice in New York and would be leaving the state or otherwise restricting their medical practices.  As in the past, doctors again blamed the premium increases on skyrocketing claims and lottery awards and demanded tort reforms that would cripple meritorious malpractice claims by the victims of medical negligence.

Today Public Citizen released a report that exposes these claims of the doctors as full blown, deliberate and obvious exaggeration: A Self-Inflicted “Crisis:” New York’s Medical Malpractice Troubles Caused by Flawed State Rate Setting and Raid on Rainy Day Fund. These same claims have been made by doctors during each of the three cycles of rising premiums that have occurred over the past thirty-plus years. Our report shows that rising malpractice premiums are not the result of any escalation in the frequency or severity in malpractice payments. The increase has nothing to do with patients, lawyers, judges, or our courts. It reflects an insurance problem.

Public Citizen’s analysis of the best available New York data demonstrates that the number of malpractice payments made on behalf of doctors in 2006 was at its lowest point since 1991. The total amount of malpractice payments for doctors, adjusted for inflation, was near or below fifteen year average in three of the past five years.

The amount of malpractice litigation in New York has not changed appreciably over the past eleven years. Thus, it is clear that the 14 percent increase in premiums did not reflect a sudden or dramatic change in either malpractice payments or litigation behavior.

License to Malpractice

Some of you might have heard about the doctor in New York, Dr. Harvey Finkelstein, who risked exposing over 600 people to HIV, hepatitis and other deadly diseases by reusing syringes. Among the many horrendous practices brought to light with this case, there are two that particularly highlight issues with the state’s health officials and medical board.

State health officials delayed the public release of the information to patients, which inexcusably delayed testing and possible treatment for those exposed. Then the state’s medical board incredibly found “no evidence of wrongdoing.”

Unfortunately, this is by no means a singular example of the worst medical malpractice offenders being ignored by the New York State Medical Board. Of the 127 doctors in New York who have made 10 or more malpractice payments since 1990, less than one-third have had reportable licensure actions taken against them.

It is clear that we need to fix the system that allows monstrous unaccountability like Finkelstein. As our Director, Laura MacCleery, put it, “The ‘I’ll scratch your back’ culture in medicine, in which doctors have claimed they are competent to police themselves, must end before more people are killed by criminal negligence.”

Stay tuned for Public Citizen’s upcoming in-depth analysis of the state of medical malpractice and insurance in New York.

Taking a Bite out of the Great Medical Malpractice Hoax

Laura MacCleery, Director of Public Citizen's Congress Watch division, debated Jim Copland of the Manhattan Institute for Policy Research on WNYC's "The Brian Lehrer Show."

The segment gets heated as they debate New York State's 14% increase in malpractice insurance and the civil justice system in preserving victim's rights. 

The show asks: what can be done to improve patient safety and hold the most dangerous doctors accountable? Is there really a medical malpractice crisis?

Click below to hear Laura debunk the myths and expose the lies told about doctors, patients and the insurance industry.

Another attempt to lead us down a blind alley from PRI

Pacific Research Institute (PRI) last Friday launched another in a series of briefing papers that advance the interests of its business sponsors.  Need a study that shows expanding health insurance coverage for children is actually bad?  Look no farther than PRI.

The latest pen-to-paper embarrassment from this flack shop is the just-released U.S. Index of Health Ownership by John R. Graham. While it purports to promote health care ownership, its clear purpose is to roll back government. Although it bills itself as non-partisan, PRI’s bias against single payer systems is blatant:  “PRI also demonstrates why a single-payer, Canadian model would be detrimental to the health care of all Americans.” 

Within a section full of self-praise for its index, PRI quotes Newt Gingrich:  “How free are we to control our own health care?  That’s the question the Pacific Research Institute boldly answers in this state by state ranking of health freedom.  While others advocate ‘universal health care’ through greater government control, PRI stands up for ‘universal choice’ where the patient and the doctor are back in control.”