The ‘Michigan Model’ for Malpractice Reform

By Allen Kachalia and Sanjay Saint Michigan, News Source

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  • May 10, 2015

Doctors have many tests and procedures to choose from when treating you. But is it possible to have too much of a good thing?

It is. Overuse and waste in medical care—which include ordering more tests and treatment than scientific evidence supports—make up as much as 30% of health-care spending according to a 2013 Institute of Medicine report. That’s approximately $750 billion a year, which we all pay for in premiums and taxes to support Medicare and other insurance programs.

A massive new effort to eliminate wasteful spending has begun. This year the Department of Health and Human Services announced plans to pay doctors and hospitals more for quality, not quantity. Private insurers are likely to follow suit.

We recently published findings in the Annals of Internal Medicine from a national survey of hospitalists—physicians who primarily treat patients in the hospital setting—that sheds some light on how medical tests and treatments are overused, and how often.

We asked hospital doctors to imagine two common patient scenarios—a cardiac evaluation before surgery and a patient who suddenly loses consciousness—and asked what they thought most of their colleagues in their hospital would do. Evidence-based guidelines exist for both scenarios.

More often than not, the hospital doctors said that their colleagues would choose the option that meant overuse of testing—not because of a lack of awareness of the guidelines, but to reassure themselves or their patients. This unwarranted testing and treatment can lead to medical complications.

For example, an unnecessary cardiac stress test in a patient may return with a false positive finding leading to an unneeded and risky cardiac catheterization. Similarly, a patient being treated with an antibiotic for a viral infection may develop serious side effects from the unnecessary medication.

Financial incentives are part of the reason why unnecessary tests and treatments are ordered. Defensive medicine—ordering unnecessary tests or treatment to reduce legal risk—is another.

Physicians should not feel compelled to order more testing or procedures to shield themselves from malpractice lawsuits brought by patients who may feel that their doctors did not do “everything possible.” Unfortunately, many medical malpractice reforms—such as limiting financial awards for “pain and suffering” damages or creating pretrial screening panels—have not uniformly lowered defensive practices.

We see potential in creating “safe harbors” that protect physicians from liability if they follow approved guidelines or evidence. Another option: Remove medical malpractice lawsuits from ordinary civil courts and resolve them administratively (or in special health courts) that do not require the adversarial litigation process that can generate tremendous legal anxiety and cost.

Hospitals and health systems also may wish to implement communication and resolution programs that provide full disclosure of medical errors and offers of compensation. These programs are designed to treat patients fairly by a speedy resolution of medical errors while avoiding costly litigation. The programs also vigorously defend claims in cases where physicians have properly followed the evidence.

The University of Michigan Health System implemented a communication and resolution program for its outpatients and inpatients in 2001. Malpractice claims dropped by 36% through 2007, while attorney and patient compensation costs dropped by 59%.

UMHS surveyed its health-care providers and found that they approved of the approach. This suggests that these programs may go a long way in addressing legal fears that physicians have. The Michigan Model, as it’s called, is being tried at many other hospitals, including at Stanford University and at Beth Israel Deaconess Medical Center in Boston.

Finally, hospitals could employ more shared decision-making models. These models would provide user-friendly decision aids to help patients and families understand particular procedures and conditions. Patients can then ask physicians more specific questions and make more informed decisions.

Studies have shown that shared decision-making can reduce unnecessary care, causing patients to be more likely to choose conservative treatment instead of major elective surgery.

There is likely no magic bullet to reduce defensive medicine, but we need to keep searching for solutions. The coming tide of value-based payment for health care demands it. More important, our patients, and society, deserve it.