system might alter these behaviors. The assessment was first requested by Congressman Bill Archer, Ranking Republican Member of the Committee on Ways and Means, and Senator Orrin Hatch, a member of OTA’s Technology Assessment Board. Other members of OTA's Technology Assessment Board also requested that OTA examine these issues, including Senator Edward M. Kennedy, Chairman of the Committee on Labor and Human Resources: Congressman John D. Dingell, Chairman of the Committee on Energy and Commerce: and Senators Charles E. Grassley and Dave Durenberger. OTA addressed the following questions: Chapter 1 Findings and Policy Options | 13 What is defensive medicine and how can it be measured? What are the causes of defensive medicine? How widespread is defensive medicine today? What effect will current proposals for malpractice reform have on the practice of defensive medicine? What are the implications of other aspects of health care reform for the practice of defensive medicine? OTA also published a background paper in September 1993, Impact of Legal Reforms on Medical Malpractice Costs, which summarizes the current status of malpractice law reforms in the 50 states and evaluates the best available evidence on the effect of malpractice system reforms on physicians’ malpractice insurance premiums. DEFINING DEFENSIVE MEDICINE OTA defines defensive medicine as follows: Defensive medicine occurs when doctors order tests, procedures, or visits, or avoid high-risk patients or procedures, primarily (but not necessarily soley) to reduce their exposure to mal - practice liability. When physicians do extra tests or procedures primarily to reduce malpractice liability, they are practicing positive defensive medicine. When they avoid certain patients or procedures, they are practicing negative defensive medicine. Under this definition, a medical practice is defensive even if it is done for other reasons (such as belief in a procedure effectiveness, desire to reduce medical uncertainty, or financial incentives), provided that the primary motive is to avoid malpractice risk. Also, the motive need not be conscious. Over time some medical practices may become so ingrained in customary practice that physicians are unaware that liability concerns originally motivated their use. Most importantly, defensive medicine is not always bad for patients. Although political or media references to defensive medicine almost always imply unnecessary and costly procedures, OTA’s definition does not exclude practices that may benefit patients. Rather, OTA concluded that a high percentage of defensive medical procedures are ordered to minimize the risk of being wrong when the medical consequences of being wrong are severe: OTA asked panels of experts in three medical specialties-cardiology, obstetrics/gynecology (OB/GYN), and surgery-to identify clinical scenarios in which they would expect the threat of a malpractice suit to play a major role in their own or their colleagues’ clinical decisions. The groups identified over 75 scenarios, all of which involved a patient presenting with a probable minor condition but with a small chance for a potentially very serious or fatal condition. Thus, concern about malpractice liability pushes physicians’ tolerance for uncertainty about medical outcomes to very low levels. Stated another way, concerns about liability drive doctors to order tests, procedures, and specialist consultations whose expected benefits are very low. Using such medical technologies and services to reduce risk to the lowest possible level is likely to be very costly even when the price of the procedure is low, because for every case where its performance makes the life-or-death difference, there will be many additional cases where its performance is clinically inconsequential. THE EXTENT OF DEFENSIVE MEDICINE OTA searched for evidence of defensive medicine in the existing literature and also conducted and contracted for new analyses where feasibility and Physicians may stop performing certain tests or procedures if by doing so they can ellminatc the need for costly or hard-to-find malpractice insurance to cover these activities, The most frequently citcd examples of negative defensive medicine are decisions by family practitioners and even some obstetrlcim-gynecologists to stop providing obstetric services. These decisions may be a result of higher malpractice insurance premiums for physicians who deliver babies. 4 | Defensive Medicine and Medical Malpractice costs permitted. One conclusion from these efforts is that accurate measurement of the extent of this phenomenon is virtually impossible. There are only two possible approaches to estimating how often doctors do (or do not do) procedures for defensive reasons: ask them directly in surveys, or link differences in their actual procedure utilization rates to differences in their risk of liability. Both of these approaches have serious limitations. If physicians are asked how often they practice defensive medicine in survey questionnaires, they may be inclined to respond with the answer most likely to elicit a favorable political response and thus exaggerate their true level of concern about malpractice. Even when physicians are asked in a more neutral instrument what they would do in certain clinical situations and why, they might be prompted if one of the potential listed reasons relates to