HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

Correspondence to:

SPECIAL ARTICLE: M. R. Nuwer, G. J. Esper, P. D. Donofrio, J. P. Szaflarski, G. L. Barkley, and T. R. Swift Invited Article: The US health care system: Part 1: Our current system Neurology 2008; 71: 1907-1913 [Abstract] [Full text] [PDF]

Correspondence: Submit a response to this article

Correspondence published:

Invited Article: The US health care system: Part 1: Our current system

Roger L. Albin   (6 February 2009)

Reply from the authors

Marc R. Nuwer, Gregory J Esper, Gregory L Barkley, Jerzy Szaflarski, Peter D Donofrio, Thomas R Swift   (6 February 2009)

Invited Article: The US health care system: Part 1: Our current system 6 February 2009
Roger L. Albin, Dept. of Neurology, University of Michigan 5023 BSRB, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200 Send Correspondence to journal: Re: Invited Article: The US health care system: Part 1: Our current system ralbin{at}umich.edu Roger L. Albin	Nuwer et al. provide a concise overview of problems with organization of health care delivery in the US. [1] As is often the case with physician discussions of health care costs, they highlight the role of malpractice costs and litigation in fueling rising health care costs. This emphasis may be misplaced. Some experts argue that the relationship between litigation and the vicissitudes of malpractice markets is tenuous. Malpractice premium ‘crises’ are driven by the peculiar dynamics of insurance markets. [2] These same experts argue that direct malpractice costs and torts play only a modest role in rising health care costs. [2] A common yet difficult argument is that medical malpractice litigation has a large adverse penumbra because of ‘defensive’ practice, resulting in considerable duplication of tests and services. In my experience, however, ‘defensive’ practice results more from the fragmented nature of our health care system than from fear of litigation. Duplication of tests and services occurs most commonly when seeing patients who have previously had studies but when results, like in the case of radiologic studies, original images, are not available. In these situations, fear of litigation because of an incomplete evaluation is understandable. Correcting this problem requires not tort reform but better integration of medical records. It is likely that high administrative overhead, lack of investment in primary care, and the fragmented nature of health care delivery are significantly greater contributors to rising health care costs than malpractice related costs. Efforts at reform should focus on these difficult problems rather than pursuing feel good efforts at changing our tort system. References 1. Nuwer MR, Esper GJ, Donofrio PD, Szaflarski JP, Barkley GL, Swift TR. The US health care system: Part 1: Our current system. Neurology 2008;71:1907-1913. 2. Sloan FA, Chepke LM. Medical Malpractice. MIT Press, Boston, MA. 2008 Disclosure: The author reports no disclosures.
Reply from the authors 6 February 2009
Marc R. Nuwer, UCLA Dept Neurology 710 Westwood Plaza, Los Angeles, CA 90095, Gregory J Esper, Gregory L Barkley, Jerzy Szaflarski, Peter D Donofrio, Thomas R Swift Send Correspondence to journal: Re: Reply from the authors MRN{at}UCLA.edu Marc R. Nuwer, et al.	We appreciate Dr. Albin’s opinion that defensive medicine is only one part of the soaring cost of medical care. We concur that fragmented care, lack of primary care investment and support, and high overhead also significantly contribute to the health care crisis. These are mentioned in our report. [1] However, we disagree that the threat of malpractice litigation is over-emphasized in the discussion of the rising cost of health care in the US. We offer considerable evidence that supports this claim. [1] In addition, numerous other publications in multiple specialties have suggested that defensive medicine is a major element in combating malpractice litigation. Birbeck and colleagues concluded that higher malpractice concerns were associated with more test ordering in several scenarios. [3] Another study suggested that the reduction in defensive practices in patients with ischemic heart disease that can be achieved with direct malpractice reforms is smaller in areas with high managed care enrollment. [4] This suggests a tradeoff from one potential cause of high health care costs to another. Additionally, malpractice claims arise much less frequently in countries outside the US. [5] Finally, we encourage discussion of the four avenues of health care reform delineated by Kessler et al. including: conventional tort reform; reform to the standard of reasonable care; restrictions on contingent and conditional loss; and alternative compensation mechanisms such as no-fault and private alternative dispute-resolution system. [6] For these reasons, we do not believe that defensive medicine from fear of malpractice litigation should be disregarded as one of the factors that drive up health care costs. References 3. Birbeck GL, Gifford DR, Song J, Belin TR, Mittman, B S, Vickrey BG. Do malpractice concerns, payment mechanisms, and attitudes influence test-ordering decisions? Neurology 2004;62:119-121. 4. Kessler D, McClellan M. Malpractice law and health care reform: optimal liability policy in an era of managed care. Journal of Public Economics 2002;84:175-197. 5. Anderson GF, Hussey PS, Frogner BK, Waters HR. Health spending in the United States and the rest of the industrialized world. Health Aff (Millwood) 2005;24:903-914. 6. Kessler DP, Summerton N, and Graham JR. Effects of the medical liability system in Australia, the UK, and the USA. Lancet 2006;368:240-246. Disclosure: The authors report no disclosures.