By Maureen Salamon
HealthDay Reporter

THURSDAY, Feb. 9 (HealthDay News) — A shocking new national survey suggests that nearly all orthopedic surgeons may order unnecessary tests, referrals or hospitalizations to avoid being sued, to the tune of $2 billion a year.

The report is the first of its kind to demonstrate that “defensive medicine” — practiced to help exonerate doctors from malpractice accusations but adding no benefits to patient care — is common among orthopedic surgeons across the United States, the study authors said.

“All across America, orthopedic surgeons are moving away from a standard of care and doing things out of fear of lawsuits,” said study co-author Dr. Manish Sethi, an assistant professor of orthopedic surgery at Vanderbilt University Medical Center in Nashville. “This is a major issue that costs a lot of money, and no one’s done anything about it.”

The research is scheduled to be presented Thursday at the American Academy of Orthopaedic Surgeons (AAOS) annual meeting, in San Francisco.

Of the 2,000 orthopedic surgeons chosen randomly from the AAOS registry to participate in the web-based survey, 61 percent responded. Of those 1,214 surgeons, 96 percent reported they had practiced defensive medicine by ordering scans, laboratory tests, specialist referrals or hospital admissions mainly to avoid possible malpractice claims. On average, 24 percent of all ordered tests were for defensive reasons.

Using the American Medical Association’s billing codes as a reference point for costs, researchers determined that orthopedic surgeons spent nearly $8,500 per month — nearly a quarter of their total practice costs — on defensive medicine, adding up to an average of nearly $102,000 per doctor each year. Given the 20,400 practicing orthopedic surgeons in the United States, this amounts to $173 million per month and $2 billion annually nationwide, the study said.

Typical scenarios resulting in unnecessary costs include patients with minor injuries who ask for MRIs after their doctors lay out a course of action that doesn’t require such a high-level diagnostic tool, physicians said. Depending on the region of the country, MRIs cost $1,000 or more per scan, Sethi said.

“It’s so ingrained in how we practice now,” said Dr. Douglas Lundy, an orthopedic surgeon in Atlanta and chair of the AAOS medical liability committee. “There’s so much faith in technology that not using it almost makes you look like you’re not doing all you can do. Also, the overall attitude of our culture is that we get everything we want pretty much when we want it.”

Researchers also found that between 70 percent and 84 percent of orthopedic surgeons who responded also practice “negative defensive medicine” by avoiding high-risk patients or procedures to limit liability. Other examples of defensive medicine include closing a practice to become a consultant, no longer seeing patients in the emergency room and not operating on patients with diabetes or heart problems.

Fixing the problem would require “massive medical liability reform at a federal level,” Lundy said, while Sethi suggested the implementation of clinical practice guidelines that would lay out treatment steps for different conditions and exonerate doctors from liability if patients develop problems outside the scope of those guidelines.

“I’m optimistic,” Sethi said. “I think physicians as a whole need to begin the steer the future of our country. I think we have to make this an issue and cut costs anywhere we can.”

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Nearly all small healthcare organizations and practices responding to a recent survey said they’ve suffered some sort of data breach in the past year, the Ponemon Institute announced this week. Overall, 91 percent of responding facilities with 250 employees or less said they had suffered at least one data breach, with 23 percent of respondents saying that their organizations experienced at least one patient medical identity theft in that time span.

What’s more, three-fourths of respondents said that organizations lacked sufficient funding to prevent such breaches; 48 percent, meanwhile, said that less than 10 percent of their organization’s annual budget was used on data security.

Major factors for such breaches included negligent employees and an inability to meet compliance requirements, according to the study’s authors. Mobile device use and social media activity were considered to be areas of particular vulnerability.

Ponemon Institute founder Larry Ponemon said that despite organizations indicating they were on the right track with regard to privacy, few in management at such facilities saw data security as a “top priority.”

“Suprisingly, only 30 percent [of respondents] agree that they have adequate resources to ensure that privacy and data security requirements are met,” he said.

John Glaser, Ph.D., CEO of Siemens Health Services, pointed out in a Hospitals & Health Networks post this week that health IT is more accessible today than ever. “The costs of technologies are decreasing, and remote management visa high performance networks means it is possible for the rural and community hospital to take advantage of enterprise-level HIT for a reasonable cost,” Glaser said.

More than 700 practitioners participated in the Ponemon survey, which was sponsored by communications networking company MegaPath. A Ponemon survey released last fall determined that data security breaches cost the U.S. healthcare industry roughly $6.5 billion annually.

For more information:
- here’s an announcement on the study
- download the report
- read the Hospitals & Health Networks post

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by Kevin Pho, MD

Patient satisfaction is all the rage.

Medicare is beginning to tie patient satisfaction scores with hospital reimbursement, and doctors across the country are under pressure from administrative executives to raise patient satisfaction scores.

High scores are even used by hospitals as a powerful marketing tool.

But, in the end, are patient satisfaction scores hurting patients?

I wrote about the issue previously, saying that patient satisfaction scores reward rich hospitals, as well as a previous USA Today op-ed, warning that catering to patient demands may not be in their best interest:

Quality health care sometimes means saying “no” to patients, denying them habit-forming pain medications that can feed an underlying, destructive drug addiction, or refusing to order unneeded CT scans that can facilitate harmful radiation exposure.

But Edwin Leap, a nationally recognized physician columnist at Emergency Medicine News, notes that doctors “are constantly under the microscope to give patients what they want, since ‘giving people what they want,’ has been tragically, and falsely, equated with good medicine.”

So it comes as no surprise that a recent study from the Archives of Internal Medicine has confirmed most physicians’ fears.

According to the study,

compared to the least-satisfied patients, those who were most satisfied with their healthcare were on more prescription medications, made more doctor’s office visits and were more likely to have had one or more hospital stays, despite the fact they were in better overall physical and mental health. Also, despite the greater attention and all those prescription drugs they got, the highly satisfied were more likely to die in the few years after taking the survey than were those who pronounced themselves least satisfied with their physicians’ medical care.

As emergency physician WhiteCoat aptly puts it, “High satisfaction with a health care facility means that you’re more likely to be admitted, you’re more likely to pay more for your care, and you’re more likely to be discharged in a body bag.”

Not only are satisfied patients more likely to die, they cost more:

Overall, the most satisfied patients incurred 8.8% more healthcare expenditures than did the least satisfied and spent some 9.1% more on prescription drugs than did the least satisfied.

Our health system provides overwhelming incentives to “do more.”  The flawed fee-for-service payment system gives a financial carrot to order more tests.  The emphasis on patient satisfaction pressures doctors to acquiesce to demands for medications.  And finally, the malpractice system punishes doctors for not ordering, or not referring, enough, never for overuse of medical resources.

We need are more incentives to do less.  Reward doctors for sticking to evidence-based clinical guidelines.  Back them up for saying “no” to patients, at the risk of lower satisfaction scores.  Educate the public that more tests can, in fact, be harmful.

And now, patients need to know that a hospital with a high patient satisfaction score isn’t necessarily a good thing.

The Archives study shows that patient satisfaction raises health costs and kills patients.  How much more data do we need before realizing that patient care and patient satisfaction cannot be mixed?

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

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by Kevin Pho, MD

As the cost of health insurance rises, patient deductibles are getting bigger.

More doctors are reporting that patients are coming in less frequently for chronic care followups, skipping medication refills, or balking at the out of pocket costs for various tests.

Sometimes, however, this can get physicians into trouble.

I was reading through a copy of Massachusetts Medical Law Report, and saw this story of a primary care physician who was sued for not offering colon cancer screening:

A 65-year-old man was belatedly diagnosed with cancer of the sigmoid colon, which caused his premature death.

From 2002 through 2006, he was a patient of the defendant. It was undisputed that during this time, the defendant neither offered nor performed a complete physical exam, including but not limited to colon rectal cancer screening.

In June 2006, the patient presented to the hospital with complaints of abdominal pain for the past several hours and no bowel movement for several days. An abdominal pelvic ultrasound showed free air, while a CT scan confirmed free intraperitoneal air consistent with a perforated bowel.

The patient was taken to the operating room emergently and underwent exploratory surgery, which detected the stage IIIB colon cancer. The disease was later found to have spread to his lungs. His condition deteriorated and he died in April 2007.

A tragic case, for sure.

But further down the article revealed the reasons why the physician didn’t offer screening:

[The physician] claimed that the patient was only seeing him for blood pressure checks, and did not want a “full PCP.” He was a private-pay patient and had declined any further medical services.

The case settled prior to trial for $1.5 million.

Unfortunately, this scenario is sure to rise as both the cost of health insurance and the unemployment rate rises. More patients may be willing to put off that colonoscopy if it’s not covered by insurance.

Doctors need to explain the risks of skipping these tests, and follow through on whether they’ve been performed, or not.

Just as important, if the patient declines age-appropriate screening tests, that needs to be documented in the chart, along with whether the patient understands the medical ramifications of their decision.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.

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by Robert Sadaty, MD

A recent article in the Wall Street Journal reviewed the emerging role of email in healthcare, arguing that doctors should more aggressively offer their patients the option to communicate with each other through email. Unlike other professionals in the United States, doctors have generally resisted the adoption of email into their practices. But according to the WSJ article, email can result in many benefits to both the doctor and patient. With email capability, patients have more immediate access to the office staff and can potentially get their problems and concerns addressed more quickly. They can also maximize their cost savings by minimizing office visits and reducing lost time from work. The author further elaborates that although doctors are not permitted to submit a charge to Medicare for email communication, they can benefit by delivering better medical care which results from the ability to monitor their patients’ conditions more closely through email.

Although these points are all valid, some areas of concern remain. In my own medical practice, I formerly used email with patients for about two years. But I eventually abandoned email and don’t ever envision going back. For sure, most patients loved using email. The option to report any symptom or concern at any time of the day without having to bother with telephone menu prompts or dealing with the hassles of making appointments proved to be tremendously convenient. And for those questions that were straightforward and consisted of hardly two sentences at most, email at times was a definite time saver.

Not infrequently, however, email could create a fair amount of inefficiency and confusion. Mostly everyone has either sent or received an email in which the content somehow did not fully convey the point intended. Despite reading, and rereading the message, the intent of the email was never fully apparent. I often felt that my responses were clear and concise, only later to learn that further clarification was required. On several occasions, I recall dispensing advice under the assumption that a patient was already taking a certain medication when in fact, they were not – all leading to confusion and the inevitable thread of emails that seemed endless. In the end, the potential back and forth that can occur with email often resulted in the need for an office visit in order to clarify the mess that was created from the original email.

Most worrisome to me, however, was the very real possibility that a diagnosis could be missed whenever an office visit was replaced by an email communication. There is an aspect of the doctor-patient interaction that that cannot be duplicated through the email process. Since the beginning of modern medicine, the face-to-face doctor-patient interaction has always been regarded as paramount to all successful medical decision making. It is only through the office visit that one can observe body language and identify other physical cues that assist in making the right diagnosis. Simply put, without this interaction you potentially miss the boat on what the patient needs.

Those on the side of more email use would counter-argue that it would only be medical issues of a “minor” degree that would be relegated to email status. That is fine, but in everyday life it is pretty much impossible for most patients to know what is a “minor” issue that is email appropriate and what is more serious and in need of a visit or immediate phone call. Seemingly trivial medical symptoms can often represent a serious condition. For patients to rely on an immediate email response or for the physician to sift through the nuances of an email to determine whether something is emergent or not becomes a gargantuan task.

I have concluded that email communication can work in a safe and efficient manner only if certain restrictions and systems are in place:

1. Security. Email should require logging into a secure system, which often requires several steps, such as entering in a medical record number and password. This would prevent any aspect of your conversation with the doctor from getting stolen. I think that it would be safe to say that many would prefer that their hemorrhoids remain a private matter and not circulating freely in cyberspace.

2. Receipt confirmation. Email sent to the Doctor should have a receipt confirmation in the form of an autoreply. In this way, the patient will know right away if their message arrived safely.

3. Word limitation. Email messages should be limited to 140 characters, similar to Twitter. Word limiations prevent patients from posing questions that are too complicated to answer by way of email. Likewise, doctor responses should be limited to the same extent. If it can’t be done in 140 characters, then the issue requires a call.

4. Word scanning. Medical email software should have a built in review process in place that scans each email created by the patient and clears it before allowing it to be sent. It would screen for “alarm” words in the email, such as “chest pain”, “stroke”, “gun-shot wound” or “suicidal”. If such words are in any way contained within the email message, then the message does not get sent and the patient gets a reply – “based on the content of your email please call the office immediately.”

5. Email delivery. It should be understood that email is read only once per day and each email sent will have only one reply. This prevents the back and forth that can happen with email use.

So patients can do all of that, and maybe get an accurate answer from the doctor. Or dare they pick up the phone and punch in 7 keys to speak with a live person, make an appointment, and have their best chance of getting the right treatment? You make the call.

Robert Sadaty is an internal medicine physician who blogs at Doc Chat.

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by Mandy Huggins, MD

“I wouldn’t hesitate to sue you.”

I’m sorry, what?

That is what I heard from the mother of one of my patients. I was evaluating a high school athlete who had recurrent stingers (nerve injury that affects an upper limb, usually resolves with time) and a possible episode of transient quadriparesis (affecting all limbs this time). I wasn’t on the sidelines for these injuries, so I had to go on the reports given to me by the athlete and the school’s athletic trainer.

However, with that information, I did not want to clear this player to return to football until I could be certain he didn’t have any cervical stenosis or any other abnormality that might put him at risk for permanent damage if he suffered another neck injury. I told the athlete and his mother that I needed to get an MRI of his cervical spine (neck) in order to determine this. The athlete was understandably upset with my decision, but his mother supported my decision to proceed with caution. She explained to me that if her son played again, sustained another injury, and something “bad” happened, she would be more than happy to take legal action against me. Fantastic.

First of all, I can’t say that I would blame her for being angry (at the very least) if I screwed up. But to tell me in my office, to my face, that she’s already thinking about suing me? I found that ridiculous. I must be in the minority, however.

If you Google “how to sue a doctor,” an abundance of information follows. There’s an “eHow” on the subject, and even CNN offers an opinion.

I’m sure many can offer some anecdote about how a physician did this or that wrong, and I agree that there are some bad apples out there. That’s not the point of this post. The point is, way too many people are looking, just waiting, for something to happen to they can “get theirs.” It’s disappointing, and quite frankly, very scary. I didn’t go through a lifetime of education and training to doubt everything I do for fear of a law suit. I’m lucky; my specialty is non-surgical and rarely deals with critical health issues. But I’m hardly in the clear.

A 2011 study in the New England Journal of Medicine estimated that by the age of 65, “75% of physicians in low-risk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties.” So I have a 75% chance, give or take, that I’ll be named in at least one claim during my career. Of course, not all of these claims go to court or end up with the plaintiff being awarded, but you can see how frequently patients are quick to take action if they think they’ve been wronged.

I’ll continue to do what I’ve been trained to do – practice good, evidence-based medicine, communicate well with my patients, and document the you-know-what out of everything. But at the end of the day, the fear of a malpractice claim, valid or not, will always be in the back of my mind.

Mandy Huggins is a sports medicine physician who blogs on her self-titled site, Dr. Mandy Huggins.

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The results of a recent survey of more than 200 healthcare leaders by Jarrard, Phillips, Cate and Hancock published in the firm’s Inside Baseball newsletter suggests that joint venturing with physicians is the most popular current physician alignment strategy (49.8 percent of respondents indicated using this strategy), compared to aggressively acquiring practices (26.3 percent), traditional credentialing and medical staff relations (15.1 percent) and “keeping [physicians] at bay” (8.8 percent).

In terms of how healthcare organizations are facing reform, 42.8 percent of respondents reported “becoming strange bedfellows with…competitors” through ACO or joint venture development. Additionally, just over 20 percent of respondents reported they plan to wait until after the presidential election to embrace reform, 11.2 percent plan to orchestrate or sale or purchase, and 10.2 percent plan to start a new managed care business.

In regard to the election’s impact on reform, the majority (53.5 percent) say it’s “unstoppable” and market-driven, while 42.5 percent believe if President Obama loses the election, the intensity and direction of healthcare reform will dramatically change.

To view the full survey results, click here.

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According to recent American Hospital Association statistics, 25% of all active physicians are employed by a hospital, a 34% increase from 2000 to 2010.  As an employee, a physician no longer has the ability to make decisions regarding management of their practice expenses.  As the employer, a hospital could decide to settle a case against a physician, or combine their defense with the defense of the hospital or other employees in a lawsuit.

We have successfully helped practices maintain their own liability coverage in an employment contract negotiation while providing solutions, risk management services, and expense control for the hospital.  There are many key questions for a physician when considering hospital employment, these are just a few:

• Who is responsible for purchasing the tail coverage from my existing carrier?
• How is the premium determined and does it compare favorably with my current premium?
• Will I have a roll/say in how my defense is handled?

This is a preview of information regarding this topic in our White Paper discussing how your medical professional liability coverage might change if you become a hospital employee, what this change would mean to you, and advises some points for you to consider and potentially address in the negotiation process.

Click here to download a complimentary copy of the White Paper

We would love to hear from you regarding questions and comments about Hospital Employment!

The government corrected $75 million in Medicare overpayments and $16.9 million in underpayments in fiscal year 2010, according to the first Centers for Medicare & Medicaid Services (CMS) report on the National Recovery Audit program to Congress.

With nearly 1 billion claims each year submitted by more than a million providers (hospitals, skilled nursing facilities, labs, ambulance companies, etc.), CMS recognizes that “it is impossible to prevent all improper payments due to the large volume of claims,” according to the report. To correct the payment errors, CMS launched the Recovery Audit program nationwide in January 2010, which was based on the previous, successful regional Recovery Audit demonstration launched in 2005. Medicare contractors identify and correct areas to ensure Medicare compliance.

Healthcare organizations need to “serve as their own watchdog” to increase security and decrease data breaches, a new report from IT security audit firm Redspin concludes. The increase in “bring your own device” policies at various hospitals, in addition to the continued implementation of electronic health record systems, are too much for government alone to regulate, the report’s authors say.

The report digs into the latest major data breach figures–those breaches impacting 500 or more individuals–released by the U.S. Department of Health & Human Services’ Office for Civil Rights. With the addition last week of the 2011 Sutter Health breach, which impacted 4.2 million patients, the number of major healthcare information breaches now sits at 385 since 2009.

“The Federal government is unlikely to mandate that all portable devices that store [electronic personal health information] be encrypted, but it’s an obvious and sensible policy for a healthcare organization to adopt,” the authors say. “Taking it further, why not require that all mobile devices in the healthcare workplace be encrypted, even if ePHI is not allowed on them?”

According to the report, nearly 40 percent of all major PHI breaches occurred on a laptop or other portable media device, a problem the authors say isn’t likely to go away anytime soon. “Portability is here to stay,” the write. “The BYOD revolution is well underway, yet 50 percent of respondents in a recent healthcare IT poll say nothing is being done to protect data on those devices.”

In the last year alone, data breaches stemming from employees losing unencrypted devices spiked a whopping 525 percent, according to the report. Total records breached in that same span nearly doubled (97 percent), increasing the average number of patient records per breach from nearly 27,000 to more than 49,000.

“[I]t is strikingly clear that woefully inadequate security risk analysis [if any] took place prior to the occurrence of these incidents,” the report’s authors write. They add that a “proper risk-based assessment” could have triggered an evaluation of security controls in place at the time, given the large amount of PHI involved.

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