Oh, It’s a Trap Alright… by Pat Conrad MD


The latest issue of Medical Economics had an article about “Defensive medicine versus value-based care.”

The article notes the “waste and inefficiency” of defensive medicine costs whose estimates range from $46 – $178 billion per year, depending on your source. The author correctly notes, “doctors will increasingly be forced to choose between limiting their utilization of health care services to augment income and exposing themselves to legal risk.” In 2019, CMS will replace meaningful use, the Physician Quality Reporting System, and the Value-Based Payment Modifier with the all-unifying Merit-Based Incentive Payment System (MIPS).

MIPS will reimburse physicians based on 1) Quality; 2) Efficiency (cost-controls); 3) meaningful electronic use; 4) “clinical practice improvement activities”, whatever the hell that means. If you score well, you get a little more money. If you don’t, you’ll be penalized.

The article recognizes that the “meager incentives that third-party payers offer to doctors who keep costs down just aren’t enough to offset liability risks.” An average 1% loss of reimbursement isn’t bad enough to give up practicing defensively. Not when “the average physician spends an estimated 11% of an assumed 40-year career with an unresolved, open malpractice claim.”

  • A 2015 multi-university study found that higher-spending physicians face fewer malpractice suits. Higher C-section rates correlated with fewer malpractice claims. Defensive medicine is as valid as it is predictable. A cited 2014 RAND Corp. study found in several states that tort reforms raising the negligence threshold did not reduce defensive spending costs.

The article turns to Richard Roberts, MD, JD, and professor at the Wisconsin School of Medicine and Public Health (Shields Up!!). A former attorney, Roberts advocates using the Ottawa rules to evaluate the need for lower extremity x-rays, saying that outside the guidelines the “probability [of] a fracture is virtually zero.” Uh-huh. I choose to rely on the “Pat” scale: when a patient points to an extremity and says “Ow!” I x-ray it.

President-elect of the AAFP John Meigs, MD stays that family docs will have more success eliminating “non-valued adding practices” than the payers will in coming up with new incentives. If that was a subtle way of throwing us under the bus again, then at least Meigs is staying true to his organization’s vision. He suggests that a patient-centered approach will inject more reason into the diagnostic process. Uh-huh.

And now the trap is coming into focus, and I’m embarrassed I didn’t grasp it more quickly.

Meigs urges that moving to value-based care can actually reduce defensive medicine, and here is his shiny, idiotic patient-centered foolishness as the perfect getaway vehicle to flee the lawyers. Meigs tells M.E. that physicians should deal with patients who demand more health care services by communicating more effectively. Really? The first notice of a malpractice lawsuit that I received was extremely effective communication. Dr. Roberts calls down from his public health balcony that “we have to be partners with our patients.” He adds, “You don’t have to be afraid of your patients. If you’re trying to practice medicine by looking over your shoulder all the time, you’re going to hit the wall ahead of you.” Brave words from someone inside the walls of sovereign immunity. As long as I know a patient can sue me for a bad outcome, I will not trust them and will continue to see each of them as a potential adversary. That is corrosive to the soul, but I have to pay the bills like everyone else.

Our bankrupt government will continue to pander to greedy, envious, ignorant voters by squeezing docs to find savings. This will delight patients right up until their doc closes up shop. Private payers will follow suit along HMO/ACO/group savings lines. The trap is that the payers know physicians will keep practicing defensively, thereby allowing them to hand out annual penalties and pay us less. Big Insurance and Big Government will use the malpractice threat as an opportunity to fleece docs even more. The collaborators over at the AAFP will see this ongoing threat as a perfect way to advance the idiocy of quality and PCMH goals, and will keep silent as their non-conformist colleagues have their money stolen.

We thought we were starting to turn the tide against the malpractice industry, but in fact it is gaining new allies eager to pursue their own agendas. The one potential remedy is to go Direct Primary Care, telling the government and other payers to stuff their insulting bonuses and penalties. Free from those burdens, the DPC doc can practice as they and their patients please (and maybe refuse to carry malpractice insurance?).

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  9 comments for “Oh, It’s a Trap Alright… by Pat Conrad MD

  1. mamadoc
    April 7, 2016 at 10:08 pm

    Just get sued, even once, and you won’t ever fully trust a patient either.

  2. Steve O'
    April 4, 2016 at 8:39 am

    Umm…whuh? I don’t think that Doug or Pat show a bias against patients. Read the fortune cookie. The article offers Richard Roberts’ perspective that if you want to walk across the freeway, smiling and waving will get you there. Now try it twenty times a day.
    The “opiate crisis” and the “defensive medicine crisis” are logical mirror images. In spite of what you see, you should have no individual discretion to give opiates, or withhold opiates, or test under suspicion, or NOT test under suspicion. The current mindset seems to be…
    #1) Healthcare would be a lot better off without doctors. Doctors are seen as the source of all the problems in healthcare.
    #2) Pre-existing bureaucratic laws will improve the quality of healthcare.
    These two rules will produce a clumsy and inefficient system that does not measure outcomes, like normal humans do intuitively; it will measure performance objectives, which do not measure the delivery of actual service, but merely the speed at which the gears turn.
    “The operation was a success; but the patient died.” I want that on the gravestone of America’s Retail Health Service.
    Plus, if you set up the doctor-patient relationship to favor an adversarial struggle, you will get adversarial struggles. Those benefit neither doctors nor patients; only those who hold the puppet strings.

  3. Avery
    April 4, 2016 at 6:42 am

    Harsh, Dr. Doug. Harsh. And you know what? I don’t believe it. I’ll bet your relationships with most of your patients are productive, supportive and close and you wrote this on a bad day. If you truly viewed your patients through slitted eyes, you think they wouldn’t pick up the vibes and jump ship sooner or later?

    • Pat
      April 4, 2016 at 6:55 am

      Don’t blame King Doug for this, he’s just kind enough to allow me to rant here. Pat C.

      • Avery
        April 4, 2016 at 6:56 am

        Then I’ll say the same for you. You do see patients, yes?

    • Doug Farrago
      April 4, 2016 at 9:46 am

      Avery, that was from Pat Conrad MD. He is giving his opinion, which deserves to be heard. My practice is totally different. I have never been this happy. I just came in after my birthday dinner with my wife on Saturday and sewed up a patient’s head. And it was no problem. DPC made ALL the difference with me. I love them and they love me. I think seeing what Pat is going through is a great contrast.

      • Avery
        April 4, 2016 at 9:50 am

        Read and registered.

        That’s what happens when someone (myself) reads too quickly and misattributes an opinion or sentiment. Apologies to both Doug and Pat. But I’d still like to know whether Pat still see patients, and if so whether he thinks they know how he feels about them.

        • Doug Farrago
          April 4, 2016 at 10:24 am

          Besides, Avery, you should know me by now

        • Pat
          April 4, 2016 at 11:09 am

          Avery, I see patients frequently working full-time in rural ER’s. I certainly don’t share my views during patient encounters, and whether they perceive my mistrust, I cannot say. My perceptions and instincts have been formed by hard, bitter experiences which, however tempting to share, might detract from the larger points I’m trying to make (I will tell you that once a patient in my clinic was very happy when I told him that he didn’t presently need a heart catheterization, but only a treadmill stress test. He said, “That’s great news! I have an attorney friend I asked about what I needed, and he said I needed a heart cath.” Incredulous, blood gone cold, I said, “You asked an attorney for medical advice?” The smiling patient laughed, saying “Well yeah, he does a lot of malpractice work, so he should know.” I fired that patient the second he walked out).

          Defensive medicine is very real and necessary for many of us who feel thusly threatened.

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