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Small Cost Benefit for Tort Reform, More Primary Care

Sep 14, 2010

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True or False:

-- Medical malpractice suits are driving physicians to practice unnecessary defensive medicine.

-- A shortage of primary care physicians leads to uncoordinated and duplicative care.

Both statements are true. Both are frequently cited as major problems that must be addressed to end the upward spiral of health care costs. The former is cited by politicians on the right, the latter by those on the left.

And both, according to studies released last week, are vastly overrated as approaches to lowering costs.

A new study published in Health Affairs showed that medical malpractice suits led physicians to order unnecessary tests, give duplicative exams and perform dubious procedures (so-called defensive medicine) to avoid later claims that they missed a diagnosis through poor performance. But it pegged the total cost at just $55.6 billion a year or about 2.4 percent of health care costs.

“Medical liability reform is unlikely to bend the health care cost curve significantly,” said Michelle Mello, an attorney-researcher at the Harvard School of Public Health. “Reforms to the health care delivery system, such as alternations to the fee-for-service reimbursement system and the incentives it provides for overuse, probably provide greater opportunities for savings.”

However, one of the “big ideas” on the reform agenda for curbing the misplaced incentives of fee-for-service medicine came in for its own comeuppance last week. A new study from researchers at Dartmouth, whose renowned “Atlas of Health” documents geographic patterns of overutilization across the U.S., showed that an increased emphasis on coordinating care delivery through primary care physicians may not improve the quality of care or achieve lower costs.

Using Medicare data, the researchers compared the distribution of primary care physicians to the use of proven preventive health care services like annual blood sugar tests and eye exams for diabetics. Primary care physicians use such tests to make sure their patients are controlling a condition that, if left unattended, ultimately leads to complications like blindness, leg amputations and kidney failure, whose costs are huge.

They found that in many areas, though the supply of primary care physicians was high, the use of those preventive services remained low. And in other areas, the use of preventive services was high despite a dearth of primary care physicians.

“Primary care alone – having access – does not guarantee quality care nor does it guarantee better outcomes,” said Shannon Brownlee, author of Overtreated and one of the authors of the Dartmouth report. “Primary care has to be embedded in a system that is organized and functions as a system.”

The recently enacted health care reform law took a step toward embedding primary care in a system when it asked the Centers for Medicare and Medicaid Services to create pilot “accountable care organizations” or ACOs.  In targeted areas across the country, CMS will make a single global payment for each Medicare beneficiary, who will belong to an ACO made up of affiliated physician groups and hospitals that use primary care physicians as coordinators of care.

But as former New England Journal of Medicine editor Arnold Relman points out in the latest New York Review of Books, the ACO model has already run into problems in Massachusetts, which has been the forerunner of just about everything in the federal reform law. The state legislature recently delayed implementation of its ACO program.

Although many experts in Massachusetts agree that fee-for-service is a major impediment to the control of costs, the current payment system is so profitable for most medical providers that they are not inclined to change it,” he wrote. “National conversion to such a system would require a major change in the attitude of providers and in the political climate.”

In the absence of such changes, politicians turn to the politically expedient. Conservatives complain about out-of-control trial lawyers, who give Democrats most of their campaign contributions. Liberals demand more primary care docs.

Adopting either strategy — or both — might shave a few percentage points off health care cost growth down the road. While that’s nothing to sneeze at, it’s not the best way to pay for or deliver health care.

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