It's actually a good signaling subject.

Malpractice insurance itself is not a large expense for most doctors (OB/GYN and neurosurgeons being the most serious exceptions).

In my conversations with doctors, they have admitted to me that defensive medicine is primarily practiced not to avoid money costs, but because doctors don't like being sued. It's a reputational and personal embarrassment.

As a practical matter, if true, that suggests that tort reform which handles suits quietly and discreetly, with a minimum of aspersions cast upon the doctor and a minimum amount of time required from the doctor to defend himself, would be far more effective at reducing the cost of defensive medicine than tort reform that reduces malpractice awards, even if they reduce them very substantially.

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@ Bill: "There may be differences in outcomes, but not on a risk adjusted basis. You see, if it is really risky, and where you have a systemic risk, the docs do it in the hospital."

Not in our community. The figures *are* risk adjusted. Our docs purposely take the risky cases to our hospital because it has the best post-op care and the best chance of patient survival. In reality, the results have caused one of the local non-profits to shut down their heart program, and to buy a percentage of our facility. It is *the hospital*.

True enough about the Medicare compensation when we started, but there have been *huge* cutbacks, and our margin in quite small. It's nor nearly as good an investment as say my wife's Merle Norman cosmetic franchise.

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Responding to retired urologist on heart hospital results:

1. Medicare and other payment systems have overcompensated heart procedures as a way to funnel money to tertiary hospitals for their uncompensated care. Heart docs figured this out, and had the incentive to build their own hospitals. Now, there are some efficiency benefits from this--scheduling, etc.and having dedicated staff.

2. There may be differences in outcomes, but not on a risk adjusted basis. You see, if it is really risky, and where you have a systemic risk, the docs do it in the hospital. They also like to do the no-pays in the hospital as well. What a surprise.

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I agree with retired urologist. I have practiced in Europe and am now practicing in the US. In addition to the costs for extra tests mentioned by him/her, I am simply less productive here in terms of patients examined and treated per hour. Causes include 1) increased documentation requirements (needed for liability protection), 2) ordering and interpreting extra tests (needed for liability protection), 3) extensive consenting patients for even simple procedures (needed for liability protection), 4) exhaustive repeats of training on prodecural matters (the institution needs for liability protection), for example HIPAA.Physicians are used to base most of what they do on scientific evidence. However, there is surprisingly little or no evidence, across the board, for these 'legal' requirements. Nevertheless there is ever more of this. [I am making exceptions for specific measures such as presurgical time-ouits, which have been shown to work.]In my opinion, physicians in the US are markedly better trained, but less productive, for the reasons cited above. Though small in number, there should be enough physicians who have practiced on both sides to allow comparisons to be made.

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We limited malpractice damages in Ohio in 2003, and it hasn't done anything to slow health care costs.

I think the big cost driver is the sheer number of uninsured people. Hospitals know they'll be hit with a certain percentage of charity care, so they pass on costs to insurers. Insurers usually have a few middlemen, who all pass on costs (plus a bit extra for safety).

Then they have to jack up the price further, because a lot of people will go bankrupt and won't be able to pay. You gotta save some room for the collections agency.

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The Heart Hospital of Lafayette, a for-profit facility, was conceived and built by doctors, who own the facility, all its equipment, and the laboratories, as well as providing all the services. It's results are superior to the three non-profits in town in all areas: mortality, complications, length of stay, and cost per diagnosis treated. Patients and their families vote it tops for service. It gets the best results for the lowest price. It is in the Top 100 Heart Hospitals in the US. Go figure.

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When exactly did Obama "talk to enough doctors"? I do not believe him. How many is "enough", anyway? This is a fellow who got the reimbursement for an amputation wrong by at least an order of magnitude. Why does nobody hold his feet to the fire on such statements? Oh, and calling people "teabaggers" is hardly reasoned debate. In fact, it's offensive and utterly undercuts any other arguments the offender may make.

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MM is two thousand just like XX is twenty and not hundred.

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don't let M be a typo, it's the roman numeral for a thousand, so you you were dead on accurate. a million would be MM, a thousand thousand.

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I think you have to disaggregate the cost of medical malpractice insurance from the cost of the alleged defensive practice of medicine. States with high insurance malpractice costs may have low medical costs and states with low medical malpractice costs may have high medical costs.

What I see in the real world are costs unrelated to medical malpractice costs.

1. Doctors doing tests because, guess what, they make money for doing tests and procedures. Texas has low malpractice costs, and its doctors make oodles of money running tests. Obama has singled out one such enclave in Texas, but you can also find them in Fla, Ga, and elsewhere...would be an interesting research study looking at med mal rates and frequency of testing procedures associated with certain diagnostic related groups. Also, if med mal rates are uniform across the state, there would not be such a money making disparity of "defensive" but well paying medicine across a state.

2. There is probably a bigger correlation between defensive practices and whether the doctor owns an interest in the equipment or lab, whether the doctor is an employee of the hospital which owns the equipment, or whether he practices on his own and uses the hospitals facilities.

3. Here are some examples of where you paya. Hospitals generally provide for "free" autopsies if requested--rolled up into your hospital bill--they claim for quality assurance.b. JCAH may mandate tests for a hospital to be certified, even though those tests are useless...Case in point: test is required by JCAH if patient presents himself with certain symptoms; tests are returned in 3 days from the lab; in three days the doctor or nurse (ande even well instructed patient) would have been able to see the symptoms without the test.4. When doctors own equipment, and get paid for using it, they use it even though there is marginal utility. Case in point: medical device and disposable reduce symptom and discomfort for 6 months; at the end of 6 months, patient receives surgury, or is better. In Europe, this device and disposable is not used because doctors go directly to surgery. So why is it used in the US...because there is a drg code for it and docs make money twice--one treatment with the device, and then the surgery. Go figure.

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Assuming physicians reflect a cross-section of society, I feel certain there are many who maximize the patient's bill for their own benefit, especially if they know the insurance deductible has been met, and the patient's out-of-pocket expense will not increase (until he gets his premium increase!). Those who do so would seem unlikely to alter their behavior should malpractice tort reform occur.

As to estimating the costs of defensive medicine, perhaps a mathy reader (you?) could come up with some analysis of the health spending in countries that deliver similar results as the US at much lower cost. We've looked at the ones with better results for less spending, but I haven't seen the analysis of the *same* results with less spending. Whatever countries those are almost surely have no contingency-pay tort system, since we seem to be alone in that category.

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What would you say is driving the cost increase in medicine? It seems like the best leverage the medical industry can get in this debate is speaking to the other 28% increase in costs not addressed by malpractice. Ultimately we're having this discussion due to cost exceeding what people can pay for services they otherwise need. Is it regulatory, overprescription of testing or medication, or something else?


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retired urologist,

I'd always thought those seemingly-unnecessary (and often painful!) tests were primarily ways to milk money from the insurer. Do you think they would still occur in a more efficient malpractice environment?

How could we go about estimating the costs of defensive medicine? It seems like a difficult thing to measure.

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The link I posted displayed badly:


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I also wouldn't argue that malpractice costs are a major part of the increase in healthcare costs. The big impact on the practice of medicine is concentrated on physicians, who bear the cost of malpractice insurance, and can leave localities that are affected. Pennsylvania and Illinois are good examples (PA link: http://www.pewtrusts.org/ne....

If the goal is to increase access to care for patients, then these states' models (which favor plaintiffs strongly) are clearly not the way to go.

Nationally, it's hard to imagine people moving abroad to practice medicine, but it is less hard to imagine fewer people going into medicine because there is no income reward for years of study and debt. News bulletin: medicine is hard, and if there's no reward, people won't do it. And again, patients won't get their care.

For the pro-cap, anti-public option people - are you calling and writing and meeting your Democratic reps and making reasoned (i.e. non-teabagger) arguments? Or are you spending that energy on blogs?

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It seems plausible that the overtesting described by brazzy and retired urologist could be a significant driver. Is there a way for the NBER to check? I have no idea how difficult it would be to access the necessary data, but it would seem what is necessary is a count of how many testing procedures were done and how many came up finding nothing. Remove the false positives, and you have your testing to diagonosis rate (or some more accurate title for the measure). Any medical system, be it completely state run or free market, would like to have this number be relatively high, while still maintaining a low undiagnosed to able to be diagnosed rate. It seems that these efficiency measures would need to be known first, before improvements in this area of health care could be made.

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