I am always puzzled by doctors who believe that it is OK to practice defensive medicine.  Do they think that their rationale meets patients expectations especially when patients are paying a greater share of their healthcare expenses or that patients are willing to take the time to undergo extra tests or even undergo an intervention that is not in their interest?

Defensive medicine is medical practices designed to avert the future possibility of malpractice lawsuits. And defensive medicine is squarely blamed on the fear of medical malpractice litigation.

Gloria Steinem always said we need to name the problem and the problem is money.  Far too often conflicts of interest and payment models drive the over-prescribing and overuse that we see.  Components of the Affordable Care Act and healthcare reform will be driving change and physicians are insecure in their expectation of their futures. The reaction seems to be that they hold their beliefs more fervently rather than acknowledge the real problem: many of them have financial interests in keeping things the way they are.

Last summer I was a panelist at the annual meeting of the American Board of Radiology Foundation. National leaders discussed the dangers of overuse of CT imagining particularly with young children. At that two day meeting, I listened to the debate and I was puzzled that no one talked about financial interests.

• Physicians may own the equipment which has been shown to trigger more testing.
• Physicians may own a share of the entity that does the imaging which also drives testing
• Physicians are paid to read the tests

Overuse of testing will never end up in a court.  How would it be proven that the three CT scans that a seven year old soccer player had is now responsible for his or her brain cancer twenty five years later?  Doctors cannot keep saying that it is partially the parents fault for demanding tests.  It is not the patients' responsibility to understand the dangers.

Patients will be paying more for their healthcare.  As we pay more, we will demand greater transparency of the charges and many of those charges make absolutely no sense.  Steven Brill, in his Time Magazine article Bitter Pill: Why Medical Bills Are Killing Us has opened the door to ridicule.  Your vet and dentist will tell you the cost of a procedure but not your orthopedic surgeon and definitely not your hospital.

The All Payer Claim Data Base will be aggregating data from all payers.  For the first time in Connecticut's history, in just a few years we will be able to find the outliers: for instance, those obstetrical practices that routinely perform early deliveries or the internist who is ordering too many tests or prescribing too many antibiotics.  We will be able to see the surgeon whose infection rates are indefensible. 

CMS is also stepping up to the plate.  Their access to data, and their lethargy to use that data in the past has been discouraging.  Going forward, Medicare will be focusing on doctors with the highest Medicare billings because they may well  have received improper payments.  This scrutiny will be a signal to all physicians that the new willingness of CMS to use data in the patient's interest will increase accountability.

The Affordable Care Act is demanding greater transparency of the financial relationships between the pharmaceutical industry, the medical device industry and the physicians.

Martin Luther King talked about tranquilizing incrementalism.  There is no better example than in our attempts to reform the industries so ineffectively providing healthcare.  Healthcare has become about the industries and not about the patients.  Slowly we are now beginning to focus on the patient.  Unfortunately, 20% of our economy needs to shift and I fear that it will not be in my lifetime.

Jean