Health reform helps primary care


During the health care reform debates earlier this year, one of the key issues of contention had been the need for medical malpractice reform, with the debate largely centered on the savings on defensive medicine that would be generated from such a change. Republicans and others in favor of malpractice reform often cited estimates that defensive medicine — extraneous tests and procedures that physicians perform on their patients to reduce the likelihood of missing a diagnosis and later being sued for it — can cost the country as much as $200 billion per year or roughly 10 percent of total national health care expenditures. On the other side, Democrats and opponents of this reform cited much lower figures and repeatedly brought up McAllen, Texas, which in 2006 still ranked as one of the top health care guzzlers per capita in the country despite the state placing a cap on non-economic medical malpractice damages three years earlier.

While medical malpractice reform was ultimately left out of the reform bill amid heart-tug strategies employed liberally by both sides, the issue is worth revisiting, not the least because our representatives missed one of the main reasons why the current medical malpractice system needs to be overhauled. It is not the savings on defensive medicine but the need to ensure that the field of medicine — and especially the primary care setting — continues to attract and retain the brightest scientific minds for the promotion of national health and well-being.

There is no question that there exists a shortage of primary care physicians, which include family doctors, general internists and pediatricians, in this country with the projected deficit for family doctors alone reaching 40,000 by 2020. And with the expansion of insurance coverage under the health care reform bill, this shortage can only be expected to become more significant over time. A myriad of factors is contributing to this situation, including the low pay and prestige associated with the primary care setting, as well as the problem of paying off those $150,000 to $250,000 medical school bills. However, the current tort system is also playing a major role in exacerbating the problem.

Under the current malpractice system, physicians are forced to protect themselves by purchasing medical liability insurance that can cost as much as $200,000 annually depending on geographic location and specialty. Having a malpractice insurance plan does not provide total peace of mind though, because the standard policy limit of $1 million is only half of the average payment awarded in the top-10 percent of medical malpractice judgments every year. While physicians take precautions through increased vigilance and defensive medical procedures, which have potential side effects of their own, the fact that the world of medicine is more gray than black and white prevents even the most renowned and skilled physicians from missing an occasional diagnosis or prescribing an incorrect treatment every so often. And even when they do everything correctly, physicians are still not immune from lawsuits — according to a 2006 Harvard study, 40 percent of malpractice cases do not involve a true medical error.  

While all physicians are affected by the financial burden of the current malpractice environment, primary care physicians are especially hit hard because they have to balance this heavy insurance premium with the higher overhead costs and administrative burdens compared to specialists, in addition to the ever-decreasing reimbursement rates. Therefore, it should come as no surprise that more than 26 percent of solo practitioners — mainly primary care physicians — said in a recent survey they closed or are considering closing their practices.  Nor should it come as a shock that more than 50 percent fewer medical students are going into the primary care setting today compared to just over 10 years ago.  As a result of this reduced supply of general practitioners, timely access to care has become an increasing problem in this country, as evidenced by the finding that only 42 percent of annual visits for newly arising health problems are made to patients' personal physicians compared to 28 percent of visits being made to the emergency department.

Some critics claim the impact of malpractice litigations on the current and projected shortage of physicians in our country has been blown out of proportion, pointing out that the number of claims today is relatively the same as they were more than 20 years ago.  While the number of claims has indeed held relatively constant over the years, the average amount awarded per judgment or settlement has risen 65 percent during this same period of time. And unlike the more experience-based auto insurance rating system, where if someone makes a claim, his individual insurance premiums go up, medical malpractice insurance premiums are more based on claims in the geographic location and specialty. So a large number of physicians are paying every time a settlement is awarded. And even when medical malpractice suits are not successful, physicians still have to spend a countless number of hours with their lawyers and in court during dragged out, multi-year processes, thus losing a significant amount of income while depriving their patients of needed care.  

In terms of fixing the medical malpractice system, I am strongly in favor of the evidence-based strategy that was advocated by Gail R. Wilensky, economist and senior fellow at Project HOPE, in a March article in the New England Journal of Medicine. In her article, Wilensky proposed that physicians and hospitals that adhere to patient-care guidelines developed by national medical societies, such as the American Diabetes Association, should be immune from liability unless there is criminal wrongdoing involved. These guidelines are often based upon many years of experience and extensive research and serve as the best approach we have of utilizing the art of medicine to tackle a particular condition. Their use in reforming the medical malpractice system is also a better alternative to the random payment caps that are in place in several states. While we have relatively few gold-standard guidelines to work with for the moment, an increasing amount of research is taking place in this area, spurred by $1.1 billion in federal commitment under the American Recovery and Reinvestment Act for comparative effectiveness studies. In the meantime, we should make full use of the guidelines that are available.

The adoption of this proposal would significantly lower insurance premiums, thus helping to reduce the exodus of primary care physicians and buckle the downward trend in the number of medical students who choose to go into this setting. In the end, it will be the patients that benefit.

Bo Wang is an Ernest Mario School of Pharmacy sixth-year student and former president of the Pharmacy Governing Council. His column, "Doctor's Orders," runs on alternate Mondays.


Bo Wang

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