In recent national discussions about healthcare, much was made about the practice of defensive medicine, especially its cost. Let’s add defensive bureaucracy to our list of grievances.
The practice of defensive medicine occurs when a provider does things to make the record look better, specifically more defensible from lawsuits and more acceptable to regulators. Practicing defensive medicine includes three behaviors.
1) The doctor can order medically unnecessary tests that are usually harmless but sometimes can cause injury. All add unnecessary cost. 2) The doctor can avoid medical procedures that involve risk or refuse to accept high-risk patients. 3) The doctor can take the standard, accepted approach when something different would be better for the patient.
Doctors practice defensive medicine in order to avoid lawsuits or anything else that might put their privileges in jeopardy. In essence, they are simply trying to protect their jobs.
There is a paucity of solid evidence on the cost of defensive medicine. Virtually all the “data” are estimates and guesswork. One study reported that doctors admit that 18-28% of tests ordered and consultations requested are due to defensive posturing. Other studies report costs ranging from $2.4b to more than $200b (yes, that is “b” for billion) per year.
Defensive bureaucracy is the same behavior by bureaucrats as described above for doctors. The bureaucrat does things that do not help or may actually harm the general public in order to protect his or her job. Example: the regulator in healthcare.
By promulgating a large number of regulations, then monitoring them and finding people out-of-compliance, the regulator provides for job security and expansion of the bureaucracy.
But wait you cry, We need regulations to protect us. Do we?! Regrettably, there is NO DATA showing that regulations protect us. Defenders of the regulatory machine have no evidence and invariably offer logic as a substitute. As David Webber the science fiction author wisely observes, “Logic is a way to err with confidence.”
Not only is there no evidence that regulations protect us, there is an equal lack of data about how much these useless-even-harmful regulations cost. Start with the easy stuff: the hassle and inefficiency.
I recently reported that for a 30-minute patient visit, I had to spend 7-9 minutes doing repetitious, redundant paperwork. I wrote my name five times, various diagnoses four times, filled out three separate forms each with a host of boxes to check. The waste of time and therefore dollars is significant. The much greater cost is in frustration. Nurses and doctors hate (I do not use that term lightly) the amount of bureaucratic nonsense and B.S. that dominates their lives, and that is driving them…away.
Regulatory compliance costs hundreds of billions of dollars each year. We–the Public– get virtually nothing for this expense, except more bureaucrats and fewer providers. The opportunity cost of useless regulations may be even higher than the dollar outlay.
The Joint Commission on Accreditation of Hospitals could be helping studies of best practices for long-term outcome as well as studies of optimal care-delivery-for-dollar-expended. They could be disseminating proven best practices, like checklists before surgery. Instead, they inspect for prohibited doorstops and surge protectors, and write out-of-compliance notices for writing µg instead of [the approved] mcg and for Cardiology keeping separate patient files. This is no exaggeration.
Incentives are just as perverse in healthcare bureaucracy as they are in medical practice. The system rewards the negative and then wonders why it keeps getting the negative. If we pay for sickness care, we get more sickness. If we pay regulators to find non-compliance, guess what they will find. Imagine if we paid doctors, managers and regulators for the positive outcomes we want: good health and longevity.
Defensive bureaucracy is even more harmful to patients than defensive medicine: it wastes more money and produces worse consequences.