Why are doctors vanishing? USA

Main Category: Pain / Anesthetics
Article Date: 27 Oct 2003 - 0:00 PDT

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From ABC News -
http://abcnews.go.com/sections/Business/Living/doctorshortage_031021-1.html

Dr. Bohn Allen practiced medicine for 42 years and had hoped to continue for a few more. Instead, the 67-year-old physician told his patients this past spring he would no longer be seeing them.

The reason? It wasn't his health, which he says is good. And it wasn't that the Arlington, Texas-based surgeon doesn't enjoy surgery, which he does.

It was because when Allen's malpractice insurance rose dramatically - his premium was $36,000 in 2003; a 177 percent jump from $13,000 in 2000 - he found he could simply no longer afford to keep his practice open.

'By the end of June it became apparent that I could not generate enough cash flow to pay my overhead,' says Allen, now retired and doing some consulting work, as well as serving as president-elect of the Texas Medical Association. 'For the past six months I've been paying my nurse out of my savings account.'

Allen is just one of many doctors across the country who have decided to retire early, stop providing certain high-risk services like obstetrics or neurosurgery or stop practicing medicine altogether because of what they say is the rising cost of medical malpractice insurance.

Some Patients Left Out

Chet Barnes, a 31-year-old firefighter who lives in Las Vegas, experienced the problem first hand when his wife became pregnant last year. As a result of rising insurance rates in the state, many obstetrician-gynecologists were not taking pregnant patients.

After a home pregnancy test came out positive, Barnes' wife went to her gynecologist, who told her she could not take her on as an obstetrical patient because of the high cost involved. Other doctors in Las Vegas gave them the same story.

Finally, the Barnes' found an ob-gyn who would see them - over two hours away in Bullhead City, Ariz.

Fortunately for the couple, the intense media attention that followed an appearance to tell their story at a medical conference in North Carolina proved fortuitous - once the couple returned from their trip a number of doctors offered to take them on as patients.

But Barnes says some of his friends were not so lucky. One couple he knows had to deliver their child almost two hours away in St. George, Utah.

'They had to drive all the way to St. George for their weekly appointments,' he says.

States in 'Crisis'

While it's hard to come by firm numbers on how many doctors are leaving the ranks, 19 states are considered by the American Medical Association to be 'in crisis' because of patients' limited access to health care, and another 25 states are showing problem signs.

The AMA says the rapidly rising costs of malpractice insurance is causing many doctors in these 'crisis' states to either leave the profession, move to another state with cheaper insurance rates or cut back on riskier types of services they provide.

The Chicago-based physicians advocacy group is pushing for caps on malpractice awards, among other moves, to help clamp down on the rising costs of malpractice insurance.

But that solution is controversial. Many consumer advocacy and trial lawyers' associations argue patients who suffer at the hands of malpractice should be allowed unlimited damages, especially for the patients' pain and suffering, known as non-economic damages.

'There is evidence that in states that have used caps, premiums didn't go up as fast,' says Uwe Reinhardt, health care economist at Princeton University. 'But you also pay a price in a sense that you have a cap on pain and suffering.'

A Limit on Suffering?

Twenty-one states currently have varying caps, or limits, on non-economic damages. Seven states have caps on total damages, that is, non-economic plus economic damages, or the amount of money a patient loses from lost wages or cost of medical treatment.

Proponents of such caps often cite California as a prime example of how medical malpractice limits can help to keep doctors' insurance premiums relatively low. That state enacted a cap of $250,000 on non-economic damages in 1975.

Physicians' medical liability insurance in California rose 167 percent between 1976 and 2000, compared to 505 percent in the rest of the United States, according to the National Association of Insurance Commissioners, the Kansas City-based organization of state insurance officials.

'There is a correlation between states with caps and greater insurance stability,' acknowledges Cheye Calvo, insurance policy specialist for the National Conference of State Legislatures, a Washington, D.C.-based association of state legislatures.

Other Reasons for Insurance Hike

But others maintain the cost of jury awards is not the only contributor to rising malpractice premiums. The congressional Government Accounting Office recently found while losses on malpractice claims are the primary driver of medical malpractice rates in the long run, other factors, such as rising reinsurance costs and losses in insurance companies' investment portfolios, have also contributed to the increase.

For example, the GAO found malpractice insurers experienced a decrease in their investment income between 1998 and 2001 as interest rates fell on bonds, which make up around 80 percent of insurers' investments.

Further, a competitive marketplace for insurance in the 1990s forced many companies to lower their prices to levels that did not cover their costs, the GAO found, ultimately forcing many companies out of the business altogether. With fewer insurers and less competition in the marketplace, doctors often find themselves paying even higher rates for malpractice insurance, say industry watchers.

The number of insurers offering malpractice coverage in the state of Florida, for example, has shrunk to four companies from 66 in 2000, says Florida Medical Association spokeswoman Lisette Gonzalez Mariner.

Indeed, the GAO found the largest underwriter of medical malpractice insurance in Florida raised its premium rates for general surgeons in Dade County by about 75 percent from 1999 to 2002, while the largest insurer in Minnesota raised its premium rates only 2 percent during the same period.

Minnesota does not have any caps on its medical malpractice awards, while Florida recently enacted limits to a doctor's liability for non-economic damages in most medical malpractice cases to $500,000.

'We found ourselves in a situation where we had insurance companies pulling out of the state,' says Gonzalez Mariner. 'They have basically the option of going without insurance, or, trying to find a company where they could afford the rates or having to weigh whether or not they were going to buy new equipment or lay off their staff.'

Is There Really a Crisis?

Others who are on the side of unlimited awards and deny doctors are in a state of crisis were recently emboldened by another report. In the report, the GAO concluded that in five states reporting problems in patients' access to health care the problems were not substantiated or did not affect health care on a widespread basis.

'Although some physicians reported reducing certain services they consider to be high risk in terms of potential litigation, such as spinal surgeries and mammograms, GAO did not find access to these services widely affected,' the report concluded.

'According to the GAO, the non-partisan research arm of congress, there is no crisis,' says Carlton Carl, director of media relations for the American Trial Lawyers Association, which opposes medical malpractice caps. 'There aren't doctors leaving the profession.'

For its part, the AMA says the GAO needs to look at a wider sample of states before concluding patients' access to health care services is not being compromised.

'You might have an area where there is only one obstetrician,' says AMA president Donald Palmisano. 'If that obstetrician no longer delivers babies, that area is in a crisis.'

Still, advocates for patients' rights argue capping insurance is not the answer. Washington, D.C.-based consumer advocacy group Public Citizen maintains the doctor shortage, especially in rural areas, predates the rise in medical malpractice insurance premiums and argues state medical boards should work harder to crack down on allegedly negligent doctors.

Another solution the group advocates are different insurance rates for different doctors, based on the number of claims made against them, much like the auto insurance industry works.

'Ideally you would hope that the rates would go so high that they would simply find another line of work,' says Jackson Williams, legislative representative for Public Citizen.

Survivor's Story

Survivors of medical malpractice are also opposed to the caps, saying that there is not one monetary solution to quantify the pain and suffering that victims go through.

Deborah Surlas, who was left blind in her left eye and only now has partial vision in her right due to one doctor's misdiagnosis in 1990, was awarded $4.5 million in non-economic damages when her case went to court.

Surlas, who paid her lawyers one-third of her award, says she thinks malpractice caps would discourage lawyers from taking on cases like hers, especially since it cost her legal team $100,000 to fight her case.

'If you've got a cap of $250,000 and it's going to $100,000 just for the court case, what lawyer is going to take that on?' she asks.

She adds that although her award was for pain and suffering, it has helped her with her medical expenses since she's had to give up her job working as a clinical nurse and later as a medical consultant because of her difficulties seeing. She says she is fortunate enough to have her husband to help support her, but says not being able to do things like read, watch television or drive herself around has really dealt a blow to her quality of life.

'Nobody hit the lottery,' she says of her malpractice award. 'We would all give it back to have our lives back. There is no lottery here. It's adequate in a financial way, but no, not in my life it's not.'