Record Low Autopsy Rates in the US: Why It Matters and What It Reveals

A surgeon holds a metal scalpel. (Shutterstock)

The autopsy rate in 2020 reached a record low of 7.4 percent, marking the lowest rate between 1972 and 2020, according to a recently released report by the National Center for Health Statistics (NCHS), a subagency under the Centers for Disease Control and Prevention (pdf). In 1972, the autopsy rate stood at 19.1 percent, but it has since experienced a steady decline.

The decline in autopsy rates hampers diagnostic accuracy, limits medical research and public health understanding, impairs legal and forensic investigations, hinders quality assurance and education, and deprives grieving families of closure about their loved one’s cause of death, experts say.

Autopsy rate trend from 1972 to 2020. (Donna L. Hoyert, National Center for Health Statistics)

The report distinguishes between two types of autopsies: hospital/clinical autopsies requested by families or doctors to determine the cause of death, and medicolegal autopsies ordered by legal officials to investigate death circumstances.

It notes the stability of autopsy rates from the 1950s to the early 1970s.

Between 1972 and 2020, hospital autopsies declined, while medicolegal autopsies remained stable or increased. Notably, in deaths caused by external factors such as drug overdose, homicide, or suicide, the autopsy rate rose from about 19 percent in 1972 to 60 percent in 2020.

In an email to The Epoch Times, the NCHS noted that the distinction between medicolegal autopsies and autopsies for deaths from external causes is not clear, suggesting that the increase in autopsies for external causes may reflect the rise of medicolegal autopsies, while “hospital autopsies” may refer to autopsies for deaths resulting from diseases.

Possible Reasons for the Decline

The report attributed the decline in autopsy rates to the removal in 1971 of the 20 percent to 25 percent autopsy rate requirement in hospitals set by the Joint Commission on Accreditation of Hospitals.

Two other possible reasons are doctors’ reluctance to order autopsies because they fear potential lawsuits (pdf) if errors are discovered—despite such occurrences being relatively rare—and a perception that autopsies as less valuable (pdf) than they were in the past because of advancements in medical technology, as described in a perspective by Dr. Lee Goldman published in Circulation in 2018. The cost of autopsies and the fear of lawsuits need to be addressed, it warns.

“Our collective inability to address the financial and medicolegal disincentives to higher autopsy rates is a societal shortcoming, undoubtedly reinforced by overconfidence in modern diagnostic technology," wrote Goldman, then dean of the faculties of health sciences and medicine at Columbia University Irving Medical Center.

A lack of insurance reimbursement and diminishing academic importance are two other primary reasons for the consistent decline over the past 50 years, Dr. Harry Sanchez, director of autopsy services in the pathology department at the Yale School of Medicine, told The Epoch Times.

Lack of Reimbursement

Sanchez said that shortly after Medicare and Medicaid were created in 1965, pathologists could no longer bill an autopsy to the patient or the insurance company because it was no longer considered an individual procedure.

Autopsies are considered part of the hospital’s administrative and quality assurance work, covered by Medicare. “You get the same payment whether you do one autopsy or 100 autopsies,” Sanchez said. “So there’s really no financial incentive for the hospital to do more autopsies.

“For pathologists, you can’t bill for the autopsy. So there’s no reimbursement to the pathologist who does the autopsy.”

Before the implementation of Medicare, autopsies were typically billed as a fixed proportion of the total medical bill, according to a 1980 report.

Autopsies involve significant work, with a routine adult autopsy taking a few hours. However, pathologists do not receive direct reimbursement for their efforts, including examining slides and generating reports.

Lack of Career Incentives

The declining academic importance of autopsies has been influenced by significantly increased federal funding for medical research since the 1950s. As grant money has become the primary measure of academic success, pathologists have shown less interest in autopsies and have focused more on research. “There was increasingly less incentive to engage in things like quality assurance and teaching,” Sanchez said. “That continues to be true today.”

The federal budget for medical research rose from $3 million to $76 million between 1941 and 1951.

In the 1940s and 1950s, approximately half of all hospital deaths were autopsied. By the mid-1960s, it had declined to about 25 percent to 35 percent.

“Very few pathologists want to do autopsies,” Sanchez said. “The incentives are just not there for them to change their minds ... economically and professionally.”

Why Autopsies Remain Indispensable

Autopsies have long been regarded as the gold standard for investigating a cause of death, accurately determining the cause and manner in most cases.

Even with today’s advanced medical technologies, Sanchez said that autopsies remain “the gold standard for seeing whether or not you made the right diagnosis.”

They hold immense importance for families, settling disputes when questions or doubts arise regarding a loved one’s death. Autopsies also play a crucial role in medical education and quality assurance within hospitals, Sanchez added.

Widely cited studies from 1960 to 2010 cited by Goldman in his commentary in Circulation have shown that autopsies uncovered Class 1 errors in approximately 10 percent of cases. These errors involve crucial causes of death that were initially missed by clinicians and where appropriate treatment could have impacted survival.

Sanchez also said that autopsies had proven particularly important from a public health standpoint. Cases involving the severe acute respiratory syndrome (SARS) caused by a coronavirus first reported in Asia in 2003, as well as cases involving the 2015 Zika virus epidemic and its association with microcephaly (when a baby’s head is much smaller than expected), have demonstrated the continued importance of autopsies.

How the COVID-19 Pandemic Impacted Autopsy Rates

According to the NCHS report, the COVID-19 pandemic led to a significant decrease in autopsy rates, particularly for COVID-19 deaths. The autopsy rate for COVID-19 deaths in 2020 was 0.9 percent.

Many autopsy services were “essentially shut down” in early 2020, Dr. John Sinard, vice chair and director of clinical operations of the pathology department at the Yale School of Medicine, told The Epoch Times.

One reason was the “initial uncertainty about the mechanisms of transmission and, thus, the risk an autopsy might pose to staff performing the autopsy,” Sinard said.

Another reason was the shortage of personal protective equipment (PPE) for health care workers. “Many places elected to save PPE for live patient care,” he said.

Experts, including Sanchez, acknowledged the importance of conducting more autopsies during the pandemic to gather crucial information about COVID-19, its effects on organs, and the causes of death. They said they believe that autopsies could have played a vital role in improving patient care and developing effective treatment strategies.

“It was really important to do autopsies in those cases so that people could find those things out [and] come up with rational therapies and stop doing things that didn’t work,” Sanchez said.