@MontereyJack,
One main effect of high malpractice insurance premiums is to decrease the amount of income a physician is able to pocket. As a group, physicians in the United States are accustomed to enjoying a high standard of living. As the costs of practicing medicine increase, physicians will increase their fees accordingly, simply to maintain a high level of income. If malpractice premiums increase in one geographic area, physicians may opt to move to another part of the country where the cost of such premiums is significantly lower. Or, they may opt to go into a medical specialty where the cost of malpractice insurance is much lower. Again, these decisions would be motivated by a desire to maintain a higher level of income. Ultimately, these choices by physicians can affect availability of medical care in certain geographic areas, but there is no reason to assume that they affect the overall quality of medical care which is actually delivered.
The 2007 Merrit-Hawkins salary survey determined that the average salary for a neurosurgeon is about $520,000. Those with experience, who own a private practice, can make $700, 000 to a million dollars a year. Even if the neurosurgeon pays $200,000 a year in malpractice premiums, that physician is still going to have a quite substantial profit margin.
As long as we regard physicians as being innately entitled to make large sums of money, a big chunk of the costs of medical care will go toward funding physicians very comfortable lifestyles, including expensive travel and vacations, vacation homes, expensive recreational pursuits, private schools for their children, and on and on. But the length or cost of the graduate training in most areas of medicine is often no longer than it is in many other professions, professions which do not command salaries anywhere near as high as those of physicians. Because we, as a society, have decided to reward our doctors handsomely, we get left holding some pretty hefty bills. Physicians as a group are a very privileged class of people. I do not bemoan the high cost of their malpractice premiums, it simply comes with the territory of being a doctor, and that territory often comes with a lot of other perks (including all kinds of lucrative entanglements with pharmaceutical companies). If high malpractice premiums drive some out of the practice of medicine, perhaps others will be attracted to medicine for reasons other than the desire to make a great deal of money. Perhaps we will ultimately wind up with better doctors. Perhaps we will learn to demand better doctors--doctors who actually take some time with their patients, who really listen to their patients, and who take the time to clearly explain things and answer questions. Informed patients, who are fully aware of the risks of treatments and medications beforehand, and who agree to take those risks, are much less likely to sue for malpractice later, or to prevail if they do bring a suit or charge.
I would suggest that really good doctors don't need to practice defensive medicine, by ordering unnecessary tests. Really good doctors know when a test is necessary to assure proper diagnosis or treatment. If another test or procedure wouldn't alter the diagnosis or treatment of a patient, a really good doctor won't order it. I say this based on my experience with some really good doctors. These same doctors don't write prescriptions for essentially unnecessary medications, their patients tend to be on the smallest number of medications possible, in the lowest possible dosages. Not only does this reduce the number of possible side-effects, it also helps to protect the functioning of their patient's liver and kidneys and heart--all of which can be adversely affected by medications, even common medications. They therefore help to protect their patient's long term health, which can substantially reduce the costs of later medical care.
In my experience, really good doctors are decidedly in the minority. Far too many people go to doctors who hand them prescriptions for every minor complaint, prescriptions the patient does not medically need and which may have no effectiveness, but which are faster and easier for the doctor than actually talking to the patient about lifestyle changes, or behavioral treatments, or even alternative therapies. Patients not only willingly gobble down these pills, because that's easier for them, they also willingly go for all sorts of unnecessary tests, as long as they don't have to pay for them out-of-pocket. Perhaps if doctors had to medically justify every prescription they write, and every test they ordered, to either the patient or the insurance carrier, we'd see an immediate reduction in these practices. But then we'd also need more savvy patients, patients who could practice defensive consumerism about their medical care.
Medicine is not a profession which polices itself well. Doctors often look the other way when colleagues practice sloppy medicine, do unnecessary procedures, prescribe unnecessary medications, and even when there is suspicion of alcohol or drug abuse on the part of a colleague. Doctors do not have to be board certified in a medical specialty to call themselves a cardiologist, psychiatrist, plastic surgeon, or just about any other medical specialist you can think of. Any licensed physician can claim to be a specialist in a particular area, and it's the consumer beware. Why does the medical profession allow this? Why do consumers accept it? Thank goodness there are now state websites where you can check on whether your physician is board certified in a particular medical specialty--but that's not thanks to the medical profession, which tends to not inform consumers about such things. These same websites also often provide info on whether a doctor has been disciplined or had a large malpractice payout. Again, no thanks to the medical profession.
Doctors just aren't demanding a high enough standard of patient care from their colleagues, and sometimes even from themselves. If they did that more often, we'd see a drop in malpractice claims and payouts. Unfortunately, malpractice claims may be the most effective way to root out some of the really bad doctors, given the present state of affairs. But many, many, other mediocre or poor doctors just fly below the malpractice radar because they haven't significantly injured anyone--yet. We won't really reform health care until we start demanding that the medical profession starts policing itself better and requiring a higher standard of patient care and a higher standard of continuing medical education for all doctors. We should also demand that some ethical controls be placed on the often unholy alliance between big pharma and the medical profession.
So while we consider caps on malpractice awards, or tort reform, or the high costs of medical care, I'd also suggest we look at the way medicine is practiced in this country, the actual quality of the medical care we receive, and what we, as consumers should be demanding from physicians. We took the first step toward providing everyone with some sort of medical coverage. Now we have to start looking at the quality of medical care that people will be getting for their money.
