Access to Medical Care Have Been Reduced by Higher Price
Public access to medical care at a reasonable price is the second major public interest. There is good evidence that higher malpractice premiums cause higher prices for physicians’ services (Sloan 1982). Indeed, physicians seem not merely to pass through the full cost of insurance increases to patients but also to raise prices even further. A given rise in premiums seems to raise fees by about twice that amount. However, since premiums remain a very small component of physician expenses on average, even with a double effect of fees, the contribution of premium increases to physician fee inflation has been minor. The most plausible explanation for the double pass-through is that physicians provide more care per service—better record keeping, more time talking with patients, and the like—which raises their costs of service. Whether presumably higher levels of service are worth their price is not obvious in the heavily subsidized medical services market; the issue has not been analyzed in systematic fashion.
Frequent statements by physicians suggest that the extra care is not worthwhile. Extra tests and procedures are said to be done more for potential legal defense than for value in health care. Very high estimates exist of this cost—up to $15 billion annually in 1985 dollars. This defensive padding of services is widely believed to occur, but its extent is very hard to document, for factors other than malpractice fears also promote service-intensive care—including patient demand and physician profit seeking.
Effects on access to medical services are potentially even more troubling than those on the cost of care, and some physicians may have withdrawn certain medical insurance policy services in response to malpractice fears. One of the defining features of the mid-1970s was the threat and occasional reality of a near strike by concerned physicians, especially in hospital-based and emergency practice. There are also many reports of physicians who have left practice early, have reduced their practices by eliminating riskier procedures, or have practiced “negative” defensive medicine by refusing to treat certain patients or certain conditions deemed at too great a risk of malpractice claim. (”Positive” defensive medicine, described above, consists of providing too many services— more than medically indicated.) Here again, the evidence is largely anecdotal and occurs against a backdrop of rapidly rising numbers of physicians seeking to practice.
Obstetricians are often said to be most affected. The American College of Obstetricians and Gynecologists (ACOG) has published results from national surveys of its membership in 1983, 198 and 1987, indicating that many physicians have indeed reportedly made changes. Among respondents, 27 percent had decreased their volume of high-risk obstetrical managed care plans and 12 percent no longer practiced obstetrics. One should recall that theACOG data were self-reported in an atmosphere of crisis and political mobilization. Moreover, although a physician who curtails his or her practice clearly loses access to certain patients, it is less clear that his or her former patients lose access to care. Virtually nothing reliable is known about impacts on patient access to care. It seems improbable, for example, that the birth rate has declined in many areas where obstetricians report cutbacks or that many babies have been delivered at home other than by the choice of the parents involved. There are stories, however, of patients having to travel long distances for long term care insurance or being dumped in public facilities. Another physician response is to “go bare,” or refuse to buy formal liability coverage, thus withdrawing on the demand side, just as insurance companies withdrew on the supply side. A small percentage seem to go bare, but documentation of this phenomenon is not good.
