Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care-treatment for newly arising health problems -are made to patients' personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.

Physicians contend that the threat of malpractice lawsuits forces them to practice defensive medicine, which in turn raises the cost of health care. This argument underlies efforts to change malpractice laws through legislative tort reform. We evaluated physicians' perceptions about malpractice claims in states where more objective indicators of malpractice risk, such as malpractice premiums, varied considerably. We found high levels of malpractice concern among both generalists and specialists in states where objective measures of malpractice risk were low. We also found relatively modest differences in physicians' concerns across states with and without common tort reforms. These results suggest that many policies aimed at controlling malpractice costs may have a limited effect on physicians' malpractice concerns.A lthough analysts disagree about the scope and cost of defensive medicine, 1 physicians consistently report that they often engage in defensive practices and that they feel intense pressure to do so out of fear of becoming the subject of a malpractice lawsuit. 2Fear of being sued may compromise physicians' ability to communicate effectively with patients, particularly in disclosing medical errors.3 Physicians with high malpractice insurance premiums, which reflect a risky liability environment, have lower career satisfaction and report more adversarial relationships with patients than do physicians with lower premiums. 4 Physicians with high premiums are also more likely to order diagnostic testing and hospitalize low-risk patients in some settings. 5Federal health reform has heightened concerns about defensive medicine for two reasons. First, the financial and organizational changes wrought by health reform have introduced new sources of stress for health care providers, sharpening their demands for liability reform in exchange for their support on other health reform measures. Second, because it leads to defensive medicine, liability risk is an obstacle to health reform's ambition of moving physicians toward more cost-effective care. 6 In this article we report findings concerning perceptions of malpractice risk among a nationally representative sample of physicians. Our objectives were to assess levels of physician concern about malpractice, examine associations between level of concern and physician practice characteristics, and relate these concerns to objective measures of malpractice risk, including state medical malpractice reform laws.We found that individual physicians' concerns about their own malpractice risk are pervasive, vary across specialties in ways that are likely to reflect underlying malpractice risk, and reflect objective measures of risk across states to a limited degree. Our results suggest that many popular tort reforms are only modestly associated with the level of physicians' malpractice concern and their practice of defensive medicine. The results raise the possibility that physicians' level of concern reflects a common tendency to overestimate the likelihood of "...

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