Overuse of health care services, which is frequently cited as a major driver of uncontrolled health care spending, has received considerable attention by policy makers as they debate health care reform.1 There is a variety of causes for overuse of health care services, but few appear to inspire as much contention as the issue of malpractice. The pervasiveness of malpractice litigation is believed to lead to defensive medical practices, whereby physicians order tests or procedures in excess of their actual need to protect themselves from the risk of lawsuits.2 Malpractice concerns could have an impact on health care reform efforts to improve efficiency and quality in health care, such as the promotion of the use of comparative effectiveness data, if physicians believe that following comparative effectiveness-based guidelines leaves them vulnerable to malpractice suits. We conducted a national survey of physicians to better gauge the potential impact of malpractice concerns on clinical practice in the context of health care reform.
Data for this analysis were from a national survey of physicians on health care reform.3 From the American Medical Association (AMA) Physician Masterfile, we randomly sampled 1500 physicians from each of 4 specialty groups: primary care, nonsurgical (medical) specialists, surgical specialists, and other specialists. Half of this sample was then randomly selected to receive questions about malpractice (n = 3000). Physicians were asked to rate their level of agreement with 2 statements: “Doctors order more tests and procedures than patients need to protect themselves against malpractice suits” and “Unnecessary use of diagnostic tests will not decrease without protections for physicians against unwarranted malpractice suits.” Response options on a 5-point Likert scale ranged from strongly agree to strongly disagree. Additional questions assessed the amount of time spent in clinical activities, practice ownership (or potential for ownership), salary structure, and professional society affiliation. The survey was mailed to physicians in 3 waves beginning on June 25, 2009, and data collection was completed on October 31, 2009.
For our analytic sample, we excluded physicians in training and physicians from the US territories. We calculated the response rate using standard methods4 and compared the characteristics of respondents and nonrespondents using data in the AMA master file. Weights were used to adjust for the stratified sampling design, and all analyses were performed using the complex survey sampling procedures in Stata version 9 statistical software (StataCorp, College Station, Texas).
Of the 2416 eligible physicians who received the survey with malpractice questions, 1231 returned completed surveys, for a response rate of 50.9%. Survey respondents were slightly older than nonrespondents (52.0 vs 50.2 years; P < .001), but there were no significant differences by sex, geographic location (census region or division, or urban or rural setting), specialty category, or type of practice.
An overwhelming majority of respondents (91.0%) reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits (Table). These views were consistent across a range of physician characteristics, most notably across specialty groups, where 91.2% of generalists, 88.6% of medical specialists, 92.5% of surgeons, and 93.8% of other specialists agreed with the statement (P = .35). No significant differences were seen by geographic location, type of practice, or professional society affiliation. A statistically significant difference in responses to the question was only observed for sex: male physicians were more likely to agree than female physicians (92.6% vs 86.5%; P = .01). The majority of physicians also agreed that protections against unwarranted malpractice suits are needed to decrease the unnecessary use of diagnostic tests (90.7%). There were no significant differences across any of the physician characteristics for this question (data not shown).
We found that most physicians in this study believe that malpractice concerns result in unnecessary testing and procedures. They also believe that reforms should be instituted to protect physicians from medical liability. Physicians in typically lower liability-risk specialties, such as primary care, expressed as much concern about malpractice as physicians in high-risk surgical specialties. Our findings are consistent with research conducted in more limited geographic areas and among a narrower scope of physicians.5
This nearly universal fear may stem from the pervasiveness of malpractice suits. On average, 2 to 3 malpractice claims are paid for every 100 physicians annually.6 Physicians may also feel vulnerable to malpractice suits because malpractice claims often do not involve medical error or negligence7 and physicians have been sued despite practicing within the standard of care.8 Our findings indicate that physicians want protection from liability risk. Further, they suggest that proposals to promote cost-effective care, such as the promulgation of guidelines from a national comparative effectiveness center, could be limited by physicians' fears of malpractice unless such protections are ensured. Malpractice reform should focus on ways of offering assurance to physicians that they will have protection against malpractice if they competently practice the standard of care.
Some limitations to our study warrant discussion. First, the survey had a modest response rate, 50.9%, and nonresponse could have biased our findings. However, respondents and nonrespondents in our study only differed significantly by age. Second, we did not measure actual practice patterns to corroborate physicians' perceptions of practicing defensive medicine, and our findings may overstate the role of defensive medicine in practice.
The potential for malpractice reform to save health care dollars is unclear. Direct malpractice expenditures such as insurance premiums and awards account for a small fraction of health care spending.9 However, it is estimated that as much as $60 billion are spent annually on defensive medicine.10 Even if the true cost of defensive practices was only a fraction of this amount, it would still represent a significant source of cost savings. Policy makers should consider reforms that curb defensive medical practice as they work to identify strategies to reduce health care spending and promote efficient, high-quality health care.
Correspondence: Dr Keyhani, Department of Health Policy, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1077, New York, NY 10029 (firstname.lastname@example.org).
Author Contributions: Drs Bishop, Federman, and Keyhani had access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Bishop, Federman, and Keyhani. Acquisition of data: Federman and Keyhani. Analysis and interpretation of data: Bishop, Federman, and Keyhani. Drafting of the manuscript: Bishop, Federman, and Keyhani. Critical revision of the manuscript for important intellectual content: Bishop, Federman, and Keyhani. Statistical analysis: Bishop, Federman, and Keyhani. Obtained funding: Federman and Keyhani. Administrative, technical, and material support: Federman and Keyhani. Study supervision: Federman and Keyhani.
Financial Disclosure: None reported.
Funding/Support: This project was supported by a grant from the Robert Wood Johnson Foundation. Drs Federman and Keyhani are additionally supported by grants from the National Institute on Aging; the National Heart, Lung, and Blood Institute; and the Veterans Administration Health Services Research and Development Service.
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