Feature: Tort reform may curb non-indicated imaging
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One factor contributing to the growth in the volume of imaging among Medicare beneficiaries may be defensive medicine, with physicians ordering non-indicated studies to assuage fears about lawsuits, posed Rebecca Smith-Bindman, MD, of the department of radiology and biomedical imaging at University of California, San Francisco. The idea has been discussed a lot, but previous studies have not quantified the indirect change in practice patterns resulting from the medical malpractice environment, Smith-Bindman said in an interview.
“In a 1992 Gallup poll, 84 percent of physicians said that the threat of medical liability suits cause them to order tests they might consider unnecessary,” wrote Smith-Bindman and colleagues. Yet, few studies have addressed the connection between specific tort reforms and defensive medical practices.
According to the U.S. Office of Technology Assessment, indirect costs such as those that stem from defensive medicine account for as much as 5 percent of healthcare costs, or $5 billion to $50 billion annually, Smith-Bindman pointed out.
The researchers reviewed defensive medical imaging ordering by studying the association between 10 states’ medical liability tort reforms and neurologic imaging rates for patients seen in the ED with head trauma. The study included 8,588 female Medicare beneficiaries, age 65 years or older, who presented to the ED with head injury between Jan. 1, 1992, and Dec. 31, 2001. The authors determined whether a CT or MRI scan was ordered within seven days of the visit.
Smith-Bindman and colleagues focused on four tort reforms: caps on monetary damages, mandated periodic award payments, collateral source offset rules and caps on attorney contingency fees. They also assessed the effect of the combined impact of several laws by summing the number of reforms in each state.
The researchers reported a substantial increase in imaging over the study period, increasing from 73 to 89 percent among patients with severe injury and from 38 percent to 68 percent among patients with a mild-moderate injury. Imaging was more likely in areas with a higher density of radiologists, shared Smith-Bindman, and twice as likely in suburban, urban and metropolitan areas as compared with rural areas.
The impact of tort reform on imaging rates is dramatic, stated Smith-Bindman. “Laws that capped monetary damages, mandated periodic award payments or specified collateral source offset rules were each associated with an approximately 40 percent reduction in the odds of imaging,” wrote Smith-Bindman. In contrast, limits on attorney’s fees were associated with increased imaging. After summing the number of tort reform laws, researchers found that the greater number of laws, the lower the odds of imaging.
The authors acknowledged that increased imaging might have improved patient outcomes and also that rapid triage enabled by imaging could reduce costs by leading to more efficient triage.
Results should be interpreted cautiously, opined Smith-Bindman, as the geographically limited study excluded men, younger patients and HMO members. However, she noted that if the “results are confirmed in larger studies, tort reform might mitigate defensive medical practices.”