This one will get some “discussion” going. Health Affairs has an article showing that malpractice premiums are much lower as a share of physician practice revenues than they were 20 years ago!
This one will get some “discussion” going. Health Affairs has an article showing that malpractice premiums are much lower as a share of physician practice revenues than they were 20 years ago!
As far as cost of malpractice the average internal medicine doc in my area pays around 30 to 35k. The average internal medicine MD in my area makes around 175k. This percentage is similair for most specialties in my area which has one of the highest rates of claims in the country.
Defensive medicine has been estimated around 10 percent of the total cost of medical care. I believe that estimate to be low.
NO democracy is the world has a rate of lawsuits anywhere near the rate in the US.
This also applies to all forms of civil suits such that this country spends about 450 billion dollars/year on civil suits. When you have 100 to 1000 percent more lawyers per capita than anywhere else in the world and a congress that is dominated by attorneys( 30 percent)
and another 50 percent bought and payed for by the trial lawyers it is no wonder why torts have increased by 15 percent/year over the last 15 years.
About 7 to 8 percent of every dollar earned by all Americans goes to the lawyers in one form or another.
States have tried to reform tort laws but most have or will be overturned by the courts. The courts of course are headed by judges who used to be lawyers and depend on the trial lawyers for financial backing and political influence. The entire system is broken and will not be fixed because of the power of the largest unrecognized monopoly in the world THE TRIAL LAWYERS OF AMERICA.
“Entire counties in Arizona do not have a single obsetrician.”
Which ones? The same rural counties that have always had trouble retaining physicians of any kind?
“While a far less than perfect piecemeal approach, at least it provides the opportunity to assess real world experience with respect to access to care, medical outcomes, and malpractice insurance premiums, especially for high risk specialties, in states that have enacted sensible malpractice litigation reform legislation vs those that have not.”
Since malpractice is primarily a state level action, it only makes sense that the states would be the one to pass reforms, regardless of sensibility. Principles of federalism and all. The opportunity to experience these things has come and gone. This isn’t the first “crisis”, and nothing ever changes no matter how draconian the reforms. Healthcare costs go up, so the cost to insure those costs go up.
Pennsylvania’s problem is exacerbated mightily by two of its largest insurers going under due to what regulators called gross financial mismanagement. Essentially, they were looted.
“Maybe, but the most legitimate evidence shows that the current tort system does an incredibly poor job.”
Actually, the most legitimate evidence, particularly the Harvard study that came out last week, concludes exactly the opposite. The main complaint is the delay in payment and that people with smaller claims don’t get their cases heard. And no “reform” proposal that goes anywhere legislatively includes paying more people faster. They all consist of paying fewer people less. So while there may be criticisms of the current situation, so far no one has offered any alternatives designed to help patients.
Thanks Barry and Tom for the feedback.
Barry, I think Dentistry is not a good correlation as I would not think Veternary would be either. There the patient(well payer) has choices, althought not the best. In Dentistry it’s “pull it”, in Veterneary it’s kill it. Both cheap alternatives. And the Dentist schools do provide cheap care. Here in NC the Dentists have it pretty good. The school only admits a limited number and we have one of the lowest per pop. of any state. As for say a voucher/means test with fee for service, again I believe that can be done more efficiently through the present tax system. Look to the countries already doing this and make it better. As to sustainability of a government run system, I don’t think anything on this planet is sustainable least of all U.S. healthcare. And far as efficient government control, well if the present regime gets to do it watch out, we don’t need any more Iraq wars, Katrina, Dept.of Homeland Security, and MedD plans.
> So why aren’t docs lobbying against the insurers?
> Too tough, so get the government to go after
> malpractice? Or maybe it’s just an aggrevation
> issue not an income issue? “I don’t want anyone
> looking over my shoulder.”
Its all of the above. And docs do lobby against the insurers. You have heard me say here that managed care is mostly illegal now, and its because docs protested and got their patients to help them. The malpractice thing resonates with our cultural rejection of “ill-gotten gains” or something like that. We do not want “jackpot justice”, so the tort system becomes an easy target. Maybe we target MedMal because we want new technology and we don’t want to think nurses are overpaid, but we want everything for free even though we know it can’t be. Insurance companies are just a bunch of greedy financiers, and everyone knows you can’t fix pain and suffering with money, so let’s go after MedMal insurance and the tort system. I personally think MedMal is a distraction.
Peter, a couple of things. First, Medicare and Medicaid are already, in effect, single payer systems for the large populations that they serve. While they have continually squeezed reimbursement rates for both doctors and hospitals over the last 15 years, their overall costs continue to grow far faster than general inflation. Why is this? I don’t know, but I’m sure there are numerous factors at work such as an aging population, new expensive technologies (including biotech cancer drugs), longer life expectancy, etc.
I do find it interesting that an area like dentistry, including relatively expensive procedures like root canal and oral surgery, has not experienced anywhere near the same degree of cost growth because most people have to pay out of pocket, and, even when they have insurance, the consumer still pays plenty including the premium for the dental coverage.
My personal preference in health care is the fee for service model (as opposed to an HMO or capitation model) with a meaningful but manageable deductible and out of pocket maximum coupled with good information with respect to pricing transparency, outcomes and cost effectiveness among providers and plenty of choice among competing insurance plans. For very low income people who can pass a means test, vouchers could be provided to offset much of the out of pocket exposure just as we currently provide free or reduced rate school lunches to poor children while the middle class and upper middle class pays its own way.
I will not repeat my prior ideas and proposals to reduce utilization which is where I think the most potential lies for getting control of costs. Finally, regarding malpractice insurance, believe it or not, I am not a big proponent of caps on non-economic damages, but I do think specialized health courts without juries could do a better, fairer, more objective and more consistent job across the system in rendering judgment in medical disputes.
The report does give where they got their figures from;
National Association of Insurance
“According to the federal government’s Medicare program”
So I guess we’d have to root through their data. Would be nice to agree on some numnbers. I don’t think Nader/Citzen is down on docs, just the medical lobby. The following statement is also in the report,
· Reduced fees—not insurance rates—are the biggest financial burden on doctors. Doctors across the country have seen their fees slashed in recent years as managed
care companies tried to increase profits, and government programs, such as Medicare and Medicaid, tried to cut costs. Medicare reimbursement rates no longer come close to keeping pace with increases in doctors’ practice expenses. The American Medical Association (AMA)estimates that since 1991 physician practice costs have risen by 35 percent, but Medicare
payments have risen only 10 percent. That means practice costs have risen two-and-a-half times the rate of Medicare payments.
I know from recent experience that Insurance companies do engage in doc take-aways. Recently my wife’s work offed a PPO plan. Rates were slightly less than the old plan. The insurer got the savings from the docs reimbursements, she’s a nurse, that’s how I know. So why aren’t docs lobbying against the insurers? Too tough, so get the government to go after malpractice? Or maybe it’s just an aggrevation issue not an income issue? “I don’t want anyone looking over my shoulder.”
As to over expectations from patients I do understand that. Everyone wants the perfect baby. But mistakes are made, even normal, honest, human mistakes. But who should get to pay for that? The Hospital/docs insurance company, or the patient? If an OD was accidentally given, who should pay for the harm done? Mistakes happen every day. When docs get in a car accident they sure want to establish blame and collect damages. If there is physical harm they sure want to collect, if there’s lost income they sure want to get that back. I still believe that if we had a single pay government run system where everyone is insured then the med costs would be taken off the table and everyone would save money.
Dr. Borboroglu asks:
> Am I interpreting these numbers wrong?
Well, not the numbers so much as the qualifiers. The average physician isn’t in a surgical specialty, and MedMal rates vary by about a factor of four among specialties and geographical regions. Averages aren’t very useful. I think I posted some figures on this a month or so ago. Surgical specialties spend more like 10% of the gross on MedMal insurance, and the ObGyns can spend more than that in some places. It is highly variable, but let’s use “10%” as an average for “surgeon, anywhere but Southern Illinois, USA”
So, on average a surgeon who pays $75K for MedMal “ought” to be billing around $750K per year. His practice overheads “ought” to run somewhere just north of 50% if he’s managing his practice well. Which leaves him with $375K or so to regard as something like a “salary”. But he’s got expenses out of that most people don’t have (self-employment tax, medical insurance, maybe continuing education, pension/401K match, stuff like this).
Of course, this is all very back-of-the-envelope, and a really screwy way to estimate physician income, but does this sound more like it?
[LEVEL3] Rethinking MedMal
Malpractice insurance is cheaper.
“Malpractice insurance costs comprise 3.9 percent of a physician’s practice income. Doctors allocate 13 times more of their practice income for their own salaries than they pay in malpractice premiums. According to the federal government’s Medicare program, doctors nationally spend an average of 52.5 percent of their practice incomes on their own Executive Summary pay, about 31 percent on such overhead expenses as office payroll and rent, and only 3.9 percent on malpractice insurance.”
I may be interpreting this wrong, but if these numbers are correct then an OBGYN that spends $150k on malprac insurance should be also taking home over $2mil in salary?? I should have been an OBGYN!
Even the average surgeon that pays $75k on malprac insurance should by these numbers be taking home $975k in salary!
Am I interpreting these numbers wrong?
All good questions. Starting with the lawyers, the “stars” at the top of the field do only take the very strongest cases. I skimmed the Public Citizen study that you referenced in your last comment. As you can imagine, I am not a big Ralph Nader fan (founder of Public Citizen). The part of the study that referenced relatively subdued trends in malpractice payouts, did not really speak to the high costs that insurers spend defending (and generally winning) non-meritorious claims. Many of these might be cases of bad outcomes that were not due to malpractice.
The defensive medicine issue is a tough one. In a response to one of my posts last month, Dr. Hinson went into this in some detail. I would summarize his comments as follows: (1) the magnitude and cost is very hard to quantify, (2) the CYA and defensive medicine mentality is strong, and a whole generation of physicians has been trained in it, (3) the doc will generally tell the patient that all tests ordered are necessary, (4) in the doctors’ lounge at the end of the day, they will talk among themselves about all of the CYA tests they ordered. Whether the extra tests add to the doctor’s income or not depends on whether doctor owned equipment is being used or is he just referring you to a hospital or independent lab to have the test or procedure done. This is also an area where differences in practice patterns can be material even within the same geography but especially across geographies.
One other issue that Public Citizen didn’t speak to is that in order for doctors to maintain their income in the face of high malpractice premiums, they have to charge considerably more for their services as compared to doctors either in lower risk specialties or doctors within the same specialty but in a lower cost state with stricter rules covering litigation and damages.
Barry, if the significant costs to healthcare of malpractice are the defensive medicine costs then how do we track that? Will docs admit to procedures as only defensive, not medical needs for the patient? Or are the so called defensive costs actually bill padding? If docs do defensive medicine how much of that adds to their incomes in order to offset the insurance costs? And if there is so much defensive medicine going on why are there so many stated malpractice lawsuits? If as you say the majority of claims that go to trial are in favor of the defendant would that not deflate all those who try to make malpractice the demon in healthcare? And why would lawyers, who you say lose so much, not take only worthy cases, not frivolous ones, as the cost of contingency is so high to the lawyer? So far I believe the points made by citizen.org and have no sympathy to docs or insurers.
Wow, where to start. First, with respect to drug spending being 10% of healthcare costs, it was actually Tom that originally made that point a couple of times, and I just repeated it or referred to it.
More to the point, regarding malpractice insurance premiums being only 1% or so of total healthcare costs, that does not include all of the defensive and CYA medicine that is routinely practiced systemwide to try to protect against lawsuits, at least to some extent. Perhaps Tom has some data on this, but it wouldn’t surprise me if defensive medicine, solely attributable to the fear of litigation, adds 10% to our system costs vs other countries with a much less litigious culture, and, at least in the case of the UK, a loser pays (litigation costs) rule.
Third, as to the percentage of physician practice revenue consumed by malpractice premiums, this probably varies enormously by specialty and, even within a specialty, there is probably significant variance from state to state. Back to the point I made in my very first comment on this thread, the system is not working for the high risk specialties, though it may be at least tolerable for the lower risk specialties and PCP’s.
Finally, my understanding is that a significant majority of malpractice claims that go to trial are decided in favor of the defendant — doctor, hospital, etc.
Barry, every time someone complains about the high cost of drugs you counter by saying it’s only 10% of the overall healthcare bill; forget it, no big deal on a macro view.
I found these two statements on
http://www.citizen.org/documents/MedMalBriefingBook08-09-04.pdf The whole thing’s worth a read.
1. Medical malpractice expenditures comprise less than 1 percent of overall health costs. In 2002 health care expenditures rose 9.3 percent to $1.553 trillion. Yet
expenditures on all malpractice premiums reported to the National Association of Insurance
Commissioners (NAIC) that year were only $9.6 billion – making malpractice costs about .62
percent of national health care expenditures.
2. Malpractice insurance costs comprise 3.9 percent of a physician’s practice income. Doctors allocate 13 times more of their practice income for their own salaries than they pay in malpractice premiums. According to the federal government’s Medicare program, doctors nationally spend an average of 52.5 percent of their practice incomes on their own Executive Summary pay, about 31 percent on such overhead expenses as office payroll and rent, and only 3.9 percent on malpractice insurance.
So I guess what needs to done is agree on these two statements. If they are relevent facts then is the present discussion about the harm malpractice suits do to healthcare much ado about nothing? I always get amused when the doc loser in a malpractice suit always complains that the other lawyer did a better job at convincing the jury there was actual harm done by the doctors actions or lack of. Get a better lawyer! It’s always the evil lawyers when it’s a lawyer the insurance company or docs turn to when they want to plead their case.
In general I Hate lawyers, usually because they legally keep themselves as the only gatekeepers you are allowed to go through to get legal help, when much of the time it’s just paper filing. But I think the main problem is there are way too many lawyers trying to get access to a limited number of financial resources, law suits. You then create a situation of taking any suit that crosses your desk because you need to pay the rent. Ever looked in the yellow pages under lawyers, wow, how do they all make a living?
Your point about licensing boards not acting aggressively enough to weed out bad doctors by revoking their license could well be a significant part of the problem.
It seems to me that an issue like this lends itself very nicely to representatives from the boards in each state getting together to share and spread best practices and/or develop common criteria under which medical licenses would be revoked. If, in fact, a fairly small percentage of doctors account for a disproportionate share of malpractice suits, the profession’s self-interest should be to weed them out and not protect them behind a white wall of silence.
I’m also going to start posting under “Matt S.” from now on to avoid confusion.
Firstly, premiums are cyclical, even if they are gradually moving in one direction over the long run. They rise and fall, fall and rise. Everyone should know that.
This is all a symptom of a larger problem. And it’s really, really easy to pick an easy answer to this problem. Simple answers add little. The link below isn’t perfect, but it is _definitely_ in the right direction.
One chess move further, why, oh dear heavens why, are doctors not paid strictly on merit? We bitch and bitch about it, and yet there is little correlation between effectiveness as a doctor and compensation. There are few incentives for this. We do the same for public schools…and yet, teachers are paid based on seniority, not ability.
…this is why “word of mouth” metrics like “would you recommened this doc to your friends/family” drive physician choice and utilization. Again, (and again, and again, and again) we have a problem of information.
Barry, I didn’t say that those doctors were bad doctors. I said that Pennsylvania doesn’t take away the licenses of the truly horrific doctors. So, the horrific doctors drive up the rates for those good ones, like the OB/GYN you citedwho moved to New York.
As yesterday’s Senate vote indicates, the trial lawyers still seem to have the Senate democrats bought and paid for when it comes to malpractice litigation reform. Fortunately, there are some good things happening at the state level. While a far less than perfect piecemeal approach, at least it provides the opportunity to assess real world experience with respect to access to care, medical outcomes, and malpractice insurance premiums, especially for high risk specialties, in states that have enacted sensible malpractice litigation reform legislation vs those that have not.
The timing of this ‘study’, as seems to happen whenever the national attention gets turned to tort reform is suspicious in and of itself. The data presented simply does not reflect the realiy on the ground.
“the figure in PA ($170,000 per doc per yr) is hard to believe.”
I even understated what he told me. He actually said that the range within his group was $170,000 to $300,000 per doc. He further said that there were no longer any OB/GYN’s in private practice in Philadelphia. All now work for hospitals or in hospital owned groups, as that is the only was they can get their malpractice insurance paid for (by the hospital) and earn a reasonable income.
This particular individual has practiced for over 30 years. For someone like this to take the radical step of voting with his feet to relocate to New York after all that time suggests the situation is serious.
The malpractices are a combination of insurance, health care and also the aggressive sales of drugs. Doctors have their favorite drugs that generate more income. Anyway, the figure in PA ($170,000 per doc per yr) is hard to believe.
“The fiction that poor, dumb plaintiffs are convincing poor, dumb juries to just add zeroes, with greedy trial lawyers as their enablers is about as empty as the notion that poor, dumb Medicaid recipients are the ones dreaming up the fraud schemes that are eviscerating state Medicaid systems.”
Maybe, but the most legitimate evidence shows that the current tort system does an incredibly poor job. Even if you don’t believe that malpractice premiums are increasing due to payments to plantiffs, the current system is indefensible, and the suggestions for change that physicians advocate are solutions for a bigger problem.
Even slightly dated, and despite attempts to poke holes in it the Studdert Colorado/Utah study and the older Harvard Medical Practice study are, and should be, considered the gold standard of legitimate research into negligence’s relationship to malpractice suits.
There is little of one.
The people who are actually injured due to negligence don’t sue at what anyone should consider acceptable rates and those who do sue often have failed to suffer negligence. Jury verdicts as well seem unrelated to negligence.
Almost 80% of all claims made in the absence of negligence. 97% of actual negligent events not leading to claims.
These are the most thorough, objective, sound (although they certainly have their detractors) studies on the subject.
Verdict numbers are just as bad. Even with less data on the subject, it seems impossible that settlements aren’t as bad or worse as insurers fear what juries will do or figure a payment is better than the investment in trial. But even that choice by the insurance company is indefensible. If you’re going to have a system dedicated to finding the truth, then that is what it needs to do; insurance companies settling non-negligent claims is a failure of the entire judicial process, because the forces influencing the insurer’s decisions are located there.
Even if you don’t believe that malpractice premiums have outstripped income growth, I’m not sure it matters. The necessity of tort reform remains the same, simply because the current system sucks. Medical courts are preferable but until that day caps will do to partially right the wrongs.
I will end with an anecdote, cause I just love this quote from the first Vioxx trial. I know this quote has been beaten to death, but it just illustrates so well the complete failure of lay juries in complex cases:
“Whenever Merck was up there, it was like wah, wah, wah,” one juror told the Wall Street Journal [making the sound of the teacher from Charlie Brown]. “We didn’t know what the heck they were talking about.”
I know, it proves nothing but its just funny. I wouldn’t trust myself to decide if a plane crash was a manufacturer’s fault and I don’t trust a mechanic to sit in judgement of my future medical decisions.
Data released today:
During the 2003-04 federal election cycle, lawyers contributed $182 million to Congress. During this same time period, trial lawyers received more than $18 billion via medical malpractice lawsuits.
who is the small guy and who is the big guy?
In Mass, the state is considering a law to require that attorneys actually (gasp) tell their clients when they receive money in a settlement due to the amount of fraud where attorneys do not bother to tell the clients that money is available.
who is the small guy and who is the big guy?
75% of emergency rooms have severe problems with specialist coverage, leaving patients to longer waits and transfers to receive care.
Entire counties in Arizona do not have a single obsetrician.
And yet, amazingly enough women still get pregnant in Philadelphia and deliver healthy babies, even high risk pregnancies. On top of that, there has been no spike in bad outcomes.
The doctor I referred to in my “anecdote” headed an 11 doctor practice in Philadelphia which was THE referral practice for high risk pregnancies in the entire city. Of the 11 doctors in the group, only one still operates in Philadelphia. The others have all been driven away by the intolerable malpractice situation. I would bet a considerable amount of money that these were NOT bad doctors. Numerous contacts in Philadelphia all say that the malpractice situation is horrible for many specialties because people are so quick to sue when they have a bad outcome even when they were non-compliant with doctors instructions. I doubt that Philadelphia is unique.
Pennsylvania seems to be a special case, though. I’ve heard that the Pennsylvania Medical Board (or whatever it’s called) is really bad about taking away licenses from terribly negligent and incompetent doctors. ALl the good doctors have to pay higher premiums, because there are a bunch of bad ones who screw up a lot.
So, the message I take from your post is that all malpractice claims are meritorious, all trial lawyers are honest and just trying to make sure the “little guy” gets his day in court, and all those insurers are big business crooks. Get real! Insurance is a highly competitive business subject to significant regulation in most states. They set their premiums to cover expected claims, administrative costs, and, yes, a profit. Most of those profits come from investing their premium dollars in the capital markets (stocks and bonds) until the money is needed for claims payments and other costs. Like any business, it takes capital to sustain, and investors don’t invest capital without expecting to earn a reasonable return on their money. If this were such a wonderful and lucrative business, don’t you think insurers would be falling all over themselves to write more of it?
The fact is that insurance of all sorts, is, at best, an average return on capital business over an economic cycle. If you check with doctors in high risk specialties, I’m sure you will find wide differences from one state to another in both the availability of malpractice insurance and its cost for a given specialty.
Normally I’m with you regarding the evils of insurance companies, but HALF of all malpractice carriers are NONPROFITS RUN BY DOCTORS. Why would they screw themselves over with inflated prices?
If the malpractice market was 100% for profit run by the same suspects that run other insurance rackets, then I would agree with you. But the malpractice market is substantially different.
I look at the first comment, and it’s obvious where the disconnect happens. The writer gives an anecdote (Why talk about the facts? I’ve got anecdotes! Anecdotes!! Do you hear!?!) that is a parable against high malpractice insurance rates. Then by ignoring any evidence-based science, concludes that malpractice rates are high because of people’s propensity to sue, and the power of trial lawyers to keep legislation against it from happening.
This writer must have had a mother in the insurance business because he assumes the virtue and good intentions of the malpractice insurers. Cue the chorus of angels and let’s hear the one about how they only set rates at the bare minimum possible to cover their claims. Are we that naive?
I’ve got a better story, and this one has trails of dollars you can actually follow if you want to look at the campaign finance watchdogs’ websites. The insurers are keeping legislation from passing — whether in Harrisburg or any other capitol — that would provide oversight and accountability of malpractice insurers and how they set their rates.
The fiction that poor, dumb plaintiffs are convincing poor, dumb juries to just add zeroes, with greedy trial lawyers as their enablers is about as empty as the notion that poor, dumb Medicaid recipients are the ones dreaming up the fraud schemes that are eviscerating state Medicaid systems. Wake up and smell the french roast! In Medicaid, I’ll just use Missouri as an example. Over the last five years, the attorney general identified $39 million in Medicaid fraud by PROVIDERS, and a total of $109,000 in fraud by BENEFICIARIES. Get the picture yet?
In malpractice claims, the same didactic is at work. The big guys (the insurers, the providers) are the problem, not the little guys (the plaintiffs, their attorneys).
It’s a very simple rule, that you should have learned in Kindergarten. The big kids always eat the little kids’ lunch. The worst ones get the teacher to believe it’s the little kids’ own fault.
The press release reports on data from 1970-2000. Then, look what it says:
“Following the AMA’s halt to its surveys in 2000, the much-cited Medical Liability Monitor Report (MLMR) indicated that malpractice premiums increased by 10-20 percent per year from 2000 to 2002, and by more than 20 percent in 2003.”
So, from 1986-2000 premiums essentially stayed the same, but if you consider 1986-2003, premiums rose substantially. Since this is 2006, they may risen even more. This press release actually CONFIRMS the fact that malpractice premiums are rising.
This press release doesn’t even substantiate its own claims.
Since it is not feasible to have a different set of malpractice rules for high risk specialties, I think the issue really needs to be analyzed within the context of malpractice premiums for high risk specialties — OB/GYN’s neurosurgeons, etc. Furthermore, even within these specialties, I suspect there is cosiderable variance among states which have different rules, especially regarding non-economic damage caps. Finally, even within a state, my sense is that people living in or near large cities may have a higher propensity to sue than people living in more exurban and rural parts of the state.
By chance, I recently met an OB/GYN who recently left a high risk pregnancy practice in Philadelphia for a similar position at a major teaching hospital in New York City. In New York, malpractice premiums are considerably lower while reimbursement rates for his services are materially higher. He said the malpractice premiums in Philadelphia for the doctors in his practice were $170,000 per doctor per year! Obviously, the system is broken in Pennsylvania, and nothing is happening legislatively in Harrisburg because of the power and opposition of trial lawyers.
For patients who need but cannot get (or have a lot of trouble finding) access to these high risk specialty doctors, the problem is real despite what statistics covering a broad population of doctors across the country may show.
There are states like California, and, more recently, Texas that have enacted meaningful malpractice reforms. Why not compare premiums within a given specialty with outcome data in these states vs pemiums and outcomes data in states with no caps on non-economic damages? Also, to what extent do practice patterns vary as a result of the perceived need (or lack thereof) to practice defensive medicine and maintain a CYA mentality at all times?