In 2009, there was concern that American health care costs were too high. Since the advent of the Affordable Care Act, there is now concern that costs are really too high, only it is not rich doctors and insurance companies being vilified, it is defensive medicine and doctors being willing to sign off on unnecessary things to keep patients happy which, along with lawsuits, was the problem the whole time.

A study in the American Journal of Managed Care finds that more than half of primary care providers reported that they made what they considered unnecessary referrals to a specialist because patients wanted it and many physicians gave into patient requests for brand-name drugs when cheaper generics were available.

Thirty percent of U.S. health care expenses each year are thought to be unnecessary. Now it is no longer an "it's between me and my doctor" world when insurance companies are not alone paying the bills, physicians are under real pressure to consider the costs of their treatment plans on financial system when making medical decisions - but then they are being rated by patients and criticized when reviews are negative. Balancing cost-saving expectations in the face of patient requests is daunting.

Specialty referral rates have more than doubled in the last decade, raising questions about what is driving this pattern. Much of it is likely defensive medicine and some of it will be doctors being taught to the protocol and not to use general knowledge. Surveys show that almost half of physicians report at least one patient request per week for what a doctor considers an unnecessary test or procedure.

Sapna Kaul. Credit: The University of Texas Medical Branch at Galveston

Researchers used data from a nationally representative survey of 840 primary care physicians in family practice, internal medicine and pediatrics.

In response to patient requests, 52 percent of the surveyed physicians reported making what they considered unnecessary referrals for a specialist and 39 percent prescribed brand-name drugs despite generic alternatives. Family physicians and internal medicine physicians were more likely than pediatricians to prescribe brand-name drugs and make unnecessary referrals. Other factors of giving into to patient demands included interactions with drug/device representatives, more years of clinical experience, seeing fewer under-insured patients and medical practices with only one or two physicians.