Does malpractice reform affect defensive medicine practices?

Physicians and health policy experts have long assumed that doctors are driven to practice defensive medicine because they fear being sued for malpractice. But a recent study of what happened in states that made it more difficult to sue some physicians casts doubt on that assumption.

The study examines the impact of changes in the behavior of emergency department (ED) physicians following the reform of malpractice laws in in three states: Texas, which in 2003 changed its malpractice standard for emergency care to “willful and wanton negligence;” and Georgia and South Carolina, which changed their standards to “gross negligence” in 2005.“From a legal standpoint, these two standards are considered synonymous and are widely considered to be a very high bar for plaintiffs,” the study’s authors write.

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The researchers looked at the numbers of computed tomography and magnetic resonance imaging procedures and inpatient admissions ED physicians ordered for a random sample of Medicare fee-for-service patients in the three states between 1997 and 2011. They focused on the imaging procedures because ED physicians frequently self-report them as examples of defensive medicine practices. Researchers also studied per-visit charges as a proxy for the intensity of the level of services provided to the patients.

The authors then compared patient-level outcomes before and after passage of malpractice reform both among the three reform states and in surrounding states, with the goal of isolating the specific impact of the reform legislation from other trends and from patient characteristics. The goal was to arrive at what the authors term “policy-attributable changes” in ED physician behavior.

After subjecting the data to regression analysis, the researchers found no decrease in rates of CT or MRI use or hospital admission in any of the three reform states, and no reduction in per-visit charges in Texas or South Carolina. Georgia experienced a 3.6% reduction in per-visit charges.

The authors note that ED physicians frequently cite the use of advanced imaging as example of a defensive medicine practice. “Our results challenge the validity of these assertions, or at least suggest that the use of emergency department imaging is unlikely to be affected by malpractice reform alone,” they write.

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Although the study focused on ED physicians, the results have wider implications for the debate over shielding doctors from malpractice suits would reduce defensive medicine practices, and thereby reduce the nation’s overall medical costs, says Daniel Waxman, MD, PhD, the lead author and an adjunct natural scientist at the RAND Corporation. “People have said over and over that malpractice reform is an important way to save money, and I think the interesting part of this study suggests that’s a blind alley,” Waxman says.

The study, “The Effect of Malpractice Reform on Emergency Department Care,” appears in the October 16 issue of the New England Journal of Medicine.