machine501

I frequently read a blog about IT in health care because I’m interested in HCI in medical settings and the blog’s author usually makes good posts that sometimes shed light on the organization impact of introducing software and hardware into a healthcare setting. But the last post was a piece in which he praised and agreed with an opinion piece on the Wall Street Journal titled “Why Doctors are Heading for Texas“. This opinion piece is just a rehash of the story “More Doctors in Texas After Malpractice Caps” on the New York Times posted last October about the same subject. The gist of the NYT article and the WSJ opinion piece is that more doctors are moving their practice to Texas because of a series of tort reforms passed in 2003 and 2005 in the same state that essentially capped malpractice payments at 250k.

One [of the reforms] capped medical malpractice awards for noneconomic damages at $250,000, changed the burden of proof for claiming injury for emergency room care from simple negligence to “willful and wanton neglect,” and required that an independent medical expert file a report in support of the claimant.

The other reform had to do with asbestos litigation.

Let’s stop to think about this for a few minutes.

First, it offers no comparison numbers to the increase in physicians nationwide and the output from medical schools. So maybe Texas is siphoning off doctors from other states, maybe it’s just part of a national trend. I went to the Texas Medical Board’s website and loaded up the numbers onto a spreadsheet from 1997 to 2008 to give myself a sense of any trend. The articles don’t compare the increase in doctors to population growth either.

Second, it ties the increase in Texas, without any proof, to a single cause: the reforms. One should consider a host of other factors like quality of life, programs that lighten the burden of medical school expenses for doctors willing to practice in underserved areas, wages, and many others. After determining the impact of other possibilities on the decision for a physician to practice in Texas, then can we compare the actual overall effect of tort reform on their decision. It may be significant, it may not.

Third, in other states in which med malpractice caps have been declared unconstitutional the effect of this change has had little if any effect on the # of active doctors. For example, in Oregon, in which a $500k cap in medical damages was declared unconstitutional, the number of active doctors increased at the same rate during the four years before and after the damage cap were overruled, according to the Oregon Board of Medical Examiners. “The number of active doctors in Oregon rose 11.9 percent from 2000 to 2004, compared to 12 percent from 1995 to 1999,” the years when the cap was in place. “There were 8,388 physicians practicing in Oregon in 2000 and 9,382 in 2004—an increase of 994, or 11.9 percent. By comparison, the number of physicians practicing in Oregon grew from 7,517 in 1995 to 8,416 in 1999, an increase of 899, or 12 percent.” In fact, the rate of increase in some of the specialties that are considered more at risk of malpractice litigation, like ob/gyn and trauma care, had a steady or dramatic increase in the years after the rule was overturned. It would be unwise to say that the change is the cause for this increase.

Further, as the data in the TMB site show, wealthier counties are getting more doctors than rural, poorer counties. The WSJ piece tries to appeal to our moral sense by mentioning that frivolous lawsuits impact the uninsured, the poor, the underserved. Yet, if you look at the numbers, physicians are moving to wealthier counties, and poorer counties have had little to nill increases of physicians in any specialty. Anyway, liability is a high cost in some specialties (ob/gyn) and in trauma, for example, but in rural areas the driver is reimbursement.

The NYT piece’s title is misleading because it implies causality. The two events could be completely unrelated, yet because the writer chose to focus on the tort reforms and because there was an increase in doctors coming into the state then the headline and story seem to imply that one caused the other. Both the WSJ and the NYT pieces use anecdotal evidence, quotes from doctors who did move because they thought liability premiums made it difficult to practice in their states, to back up their stories.

Is there a story in the TMB numbers? Maybe figure out why doctors practice in more affluent urban areas than in rural areas. But I suspect that’s not an exciting story. It’s obvious, doctors are just like the rest of us; we gravitate towards places with good paying jobs and things to do. And I suspect that story’s been written about before.

I’m not for litigation, and there are many cases where people who are actually victims of malpractice do not sue for malpractice.  There are some cases where people who have not been harmed or have no claim to medical malpractice nevertheless file one.  There are also many greedy lawyers who see this as an opportunity to make a lot of cash. But it really nags me when newspapers are happy to overlook a most basic rule taught in college, that “correlation does not imply causation,” to get you to read a story. And it’s even a weak example of correlation since the opposite “effect” can be seen in other states, like the Oregon case.  Bleh. Go back to school!