Media, politicians and special interest groups often claim that the high cost of health care is related to doctors performing “defensive medicine” out of fear of being sued by a personal injury medical malpractice attorney. Basically what they are saying is that doctors are purposefully performing unnecessary tests and procedures, billing insurance companies and Medicare for those unnecessary tests and procedures, and getting paid to perform those unnecessary tests and procedures. If that is true, then those doctors are readily admitting to engaging in insurance fraud. For those doctors engaging in this type of practice, the question is whether the real motivation is “defensive medicine” out of fear of being sued by a personal injury lawyer or whether the real motivation is simply to make a lot of money. The fact that the doctors involved in such practices keep the money should shed some light on the answer to that question.
For example, Luis Fabregas of the Pittsburgh Tribune Review reports that two cardiologists at Pittsburgh’s Forbes regional hospital are being investigated for unnecessarily implanting 141 patients with coronary stents. Stents are used to open arteries to the heart that are clogged with plaque; however regrowth of tissue can reclog up to 40% of the stents. Most Physicians recommend that a stent be used only if the artery is at least 70% clogged. These doctors placed stents n patients with as little as 10% blockages. Most of the patients who received the stents were covered by Medicare. The article did not clarify how much money the physicians made for each of these procedures. However, the procedures are performed in hospitals. The hospitals receive anywhere from $10,000 to $18,000 from Medicare for each stent implant.
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The American College of Cardiology reports that Medicare paid $3.4 billion in 2008, just for coronary stents. Most doctors are practicing medicine for the right reasons. They are not engaged in fraudulent practices. However, the fact that these two doctors alone may have implanted 141 unnecessary coronary stents, makes one wonder how much Medicare is paying for unnecessary stent procedures performed by doctors that are simply trying to line their own pockets. Furthermore, it also makes one wonder how much of the high cost of healthcare is caused by this type of fraudulent conduct. As Amy Murphy, a spokesperson for the college said: “You’re not paid for the quality of care; you’re paid for the procedure,” she said. “It’s a flawed system, based on the number of procedures.”