An internet television program that explores the intersection of medicine and the law.

Physician Spending, Patient Outcomes and Future Research

By Anupam B. Jena, MD, PhD to Defensive Medicine


Physician Spending, Patient Outcomes and Future Research

Our guest on Healthcare Matters is Anupam B. Jena, MD, PhD, one of the authors of the study Physician spending and subsequent risks of malpractice claims: an observational study, which was published in The BMJ in November 2015. Dr. Jena sat down with Healthcare Matters to discuss the study's results, methods and limitations as well as its implications for research on defensive medicine and healthcare spending. Dr. Jena details how the study shows a correlation between increases in physician spending and a lower likelihood for that physician to be subsequently sued for malpractice. Though the study has several limitations which are addressed during the interview, it helps to shed light on important aspects of healthcare spending, the doctor-patient relationship and the difference between appropriate healthcare spending and defensive medicine. In Part V of our interview, we discuss the relationship between physician spending and patient outcomes with Dr. Jena. Dr. Jena also outlines several lines of future research that are needed to fully explore these topics. This is the fifth part of our interview with Dr. Jena. To see the full interview, click here. To view each portion of the interview separately, please use the links below.

  1. Does Defensive Medicine "Work"?
  2. Greater use of Resources vs. Defensive Medicine: What's the Difference?
  3. The Link between Physician Spending and Medical Malpractice Claims
  4. Medical Malpractice Claims and the Doctor-Patient Relationship
  5. Physician Spending, Patient Outcomes and Future Research
  6. How can we differentiate between defensive medicine and “good” medicine?
  7. Fee-for-Service vs. Outcome-Based Models and the Effect on Healthcare Costs
  8. Could Defensive Medicine Actually Lower Medical Malpractice Claims?
This interview is brought to you by Cunningham Group, the Medical Malpractice Insurance Specialists.


Mike Matray: If this is an empirical data-driven study, what were the limitations of the data that you collected?

Dr. Jena: We have a few limitations. So the first is that we can’t really ascertain whether or not this relationship is a cause and effect relationship. And on top of that, even if it were a cause and effect relationship, we couldn’t say whether it’s because of good medicine that is leading to better outcomes and patients suing less often, or whether it really is truly defensive medicine, in which case doctors are spending more, outcomes aren’t changing and patients are suing less often because they believe that more was done. So in a sense, patients are more convinced. And the reason that is a problem is because there are far cheaper ways to reassure patients that the best possible care was delivered, then ordering a CT scan, or MRI, or an additional consultation. That’s just not the way to do it I think, from a cost perspective.

And I think the second limitation was that our analysis, although it’s the first analysis of its kind, was restricted to data from Florida. Florida is a different state than other states in its malpractice environments, and I think people who have read the paper would recognize that. But none the less, what was needed to do the study was two pieces of information. We needed to know what kinds of patients a doctor treats, and what the outcomes of those patients were, and we needed to know whether or not a physician had been sued before. And data on those two facts are generally very difficult to find in isolation, much less linked together. And Florida provided a unique case study where we could actually put those two pieces of data together. And so it really is a first of its kind analysis, but it does have limitations.

Mike Matray: Obviously, the biggest event in healthcare recently has been The Affordable Care Act of 2010, and one of the drivers of the legislation is that the healthcare delivery system is too expensive. If we’re trying to get a more efficient, less expensive system, and your study indicates there could be a correlation between defensive medicine or a greater use of resources per patient, how do we get physicians to be more cost effective in their practice and medicine?

Dr. Jena: That’s a terrific question, and my sense is that malpractice has been one of those issues that is preliminary on the mind of physicians. It seems to come up in almost every single election. And part of the reason could be that physicians are reluctant to constraint-spending because of these malpractice concerns. There are a number of reasons why physicians would be reluctant to constraint-spending, one of which is because spending is what actually drives their incomes, and could imagine that would be a sticking point. But aside from that, I think our study suggests at least it’s a possibility.

It’s at least a possibility that as we start to ask physicians to reduce spending, there could be unintended consequences. And again, I want to be careful to say that our study isn’t definitive evidence of it, but it does at least suggest that this is something that we should be monitoring for, something that we should watch out for and hopefully it won’t be a result of healthcare reform. I certainly don’t want it to be. But none the less, that’s the purpose of the science is to try to give us insights into what we should be watching out for.