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Purpose. Defensive medicine, broadly defined as medical practices that protect physicians from malpractice lawsuits without providing benefits to patients, can lead to wasteful use of health care resources and higher cost. Although physicians cite malpractice liability as an important factor driving their decisions to order imaging tests, little research has been done to examine the systematic impact of liability pressure on overall imaging. The authors examined the extent to which radiography use is influenced by malpractice liability pressure among office-based physicians.

Methods. Using National Ambulatory Medical Care Survey data from 1999 to 2010, the authors used multivariate difference-in-difference logistic regression to examine the effects of different types of state tort reforms on the probability of radiography orders by primary care physicians (PCPs) and specialists.

Results. The probability that a PCP ordered radiography decreased when states enacted permanent caps on noneconomic damages (−1.0%, P < .01), periodic payment reforms (−1.6%, P < .05), and the total number of tort reforms (−0.5%, P < .05). Specialist physicians were responsive to two reforms: caps on punitive damages (−6.1%, P < .01) and the total number of medical tort laws (−1.2%, P < .01). The passage of new indirect reforms was found to reduce radiography orders for PCPs (−1.8%, P < .05), and the repeal of indirect reforms was found to increase radiography orders for specialists (+3.4%, P < .01).

Conclusions. State tort reform seems to reduce physicians’ ordering of radiography. This analysis also suggests that reforms that make it harder to sue physicians have a stronger impact than reforms that directly reduce physicians’ malpractice claim payments.