The Effect of Malpractice Reform on Emergency Department Care — NEJM

"Defensive medicine" that drives up the costs of medical care is a battle cry of "tort reformers".  It has had a big effect.  Even President Obama has endorsed "medical malpractice reform" as a cost-saver. Like other "serious people" he has been untroubled by the lack of evidence - because it is "common sense" (which is what we think before we study).  Made shamelessly, the argument is odd. It is, essentially, that doctors violate their oath to do no harm. They spend other peoples money and subject their patients to great expense and inconvenience for no good medical reason.  Just out of fear that if they don't do it they could be subjected to a groundless claim.

It is really just interest group bargaining - physicians hoping to reduce their insurance premiums - at the expense of their patients.  They did that in three states in the single-party democracy of the south.  The Rand Corporation studied it.  The result: no change in medical practice - but patients injured through carelessness had no remedy. - gwc

The Effect of Malpractice Reform on Emergency Department Care — NEJM

Daniel A. Waxman, M.D., Ph.D., Michael D. Greenberg, J.D., Ph.D., M. Susan Ridgely, J.D., Arthur L. Kellermann, M.D., M.P.H., and Paul Heaton, Ph.D.
N Engl J Med 2014; 371:1518-1525October 16, 2014DOI: 10.1056/NEJM



BACKGROUND
Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice.

METHODS
Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions.

RESULTS
For eight of the nine state–outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges.

CONCLUSIONS
Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates.

(Funded by the Veterans Affairs Office of Academic Affiliations and others.)"



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