- The Washington Times - Sunday, August 31, 2003

Doctors in the Washington area are facing a crisis, much like their counterparts throughout the nation.

Malpractice insurance rates and government restrictions on Medicare payments are making it tough to go about the day-to-day business of treating patients.

Some doctors are giving up high-risk practices completely, leaving their patients with fewer options for treatment. Would-be doctors are entering medical school only to change their career goals as they see the hard realities ahead.

“You have a situation where the viability of a physician’s practice is in great jeopardy,” said Dr. Donald Palmisano, president of the American Medical Association (AMA).

The AMA says the financial and liability difficulties of doctors in 19 states are bad enough that doctors are giving up high-risk procedures. Another 26 states are reaching the same point, including Maryland, Virginia and the District.

“The overall costs of practicing medicine are increasing while payments are decreasing,” Dr. Palmisano said.

Some doctors — both locally and nationally are doing what would have been unthinkable several decades ago: They are leaving the profession, either by retiring early or taking different jobs.

Sam Roberts will decide in December whether he will continue his obstetrics practice in Elkins, W.Va. That’s when his medical malpractice insurance company will tell him his premium rate for 2004.

If it rises above the $55,000 a year he currently pays, he will pull out of obstetrics completely, keeping only a family medical practice.

“I’m basically paying as much as I make in obstetrical practice,” Dr. Roberts said. “I’m doing it because I love it.”

If he leaves, he will end a two-generation obstetrical practice that has included deliveries of more than 9,000 West Virginia babies.

Backlash against Medicare

Michael Dodd, a Washington ophthalmologist who worries about the legal problems of his profession, has collected stories from colleagues whose careers have been damaged by Medicare or medical malpractice. None of them wanted to be named.

For example, Medicare investigators showed up at the door of one Maryland doctor for a surprise inspection of his files, Dr. Dodd said.

“They found that he was not signing his records,” Dr. Dodd said. “He said, ‘Look, I’m the only guy in this office.’ They fined him $50,000. He didn’t know what to do. Just to get rid of them, he paid it.”

Three-fourths of doctors spend more than five hours a week filling out forms for Medicare, the federal health insurance program for the elderly and disabled. One-third spend one hour filling out forms for every one to four hours of patient care.

The program is rampant with fraud by doctors claiming undeserved compensation. The doctors who do not commit fraud say they suffer the backlash by government regulators.

“That’s a bigger threat to medicine than medical malpractice,” Dr. Dodd said.

The Justice Department says its investigations are justified.

“Last year, we recovered in civil fraud claims nearly $1.2 billion,” said Justice Department spokesman Charles Miller. “Of that, health care fraud totaled $980 million. It’s obviously the overwhelming amount.”

The health care fraud prosecutions are expected to recover even more money this year.

“There are overbilling issues,” Mr. Miller said. “That is the primary thing, when we are charged for services not rendered.”

The bills of Medicare patients who choose their own doctors are paid according to a fee schedule set by the government. Last month, the federal Center for Medicare and Medicaid Services published a notice in the Federal Register saying Medicare fees would be cut by 4.2 percent in fiscal 2004.

The other option for patients covered by Medicare is to join a health maintenance organization (HMO) in which they go to doctors in their plan and pay a small co-pay for each visit.

Government Medicare payments fell 14 percent between 1991 and 2003 and continue to drop, according to the AMA.

The medical group wants Medicare to establish medical savings accounts in which the government makes a certain amount of medical reimbursement money available for each patient. The patient then would pay the fees of the doctors he or she chooses.

“It’s kind of like spending your own money,” said Jane Orient, executive director of the Association of American Physicians and Surgeons. “Patients are a lot more careful than they would be with other people’s money.”

The sky’s the limit

As much as they want Medicare reform, the doctors want caps set on malpractice lawsuits even more.

A survey of Maryland doctors last year gives a hint of a malpractice insurance dilemma creeping toward crisis.

Among doctors getting hammered the worst by medical malpractice insurance are neurosurgeons, emergency medicine doctors, obstetrician-gynecologists and orthopedic surgeons.

One-third of the obstetricians surveyed by the Maryland chapter of the American College of Obstetrics and Gynecology said that if malpractice insurance rates increased 25 percent or more, they would leave the field.

Currently, the Maryland Insurance Administration is considering a petition by the Medical Mutual Liability Insurance Society of Maryland to raise its rates an average of 28 percent. The society is Maryland’s only medical malpractice insurer.

“For those specialties that can’t get coverage, it’s an absolute crisis,” said Dr. Michael Preston, executive director of the Maryland State Medical Society. “For those who can get coverage, it’s a looming crisis.”

The number of specialists probably would drop for some critically ill patients, such as emergency care patients.

Dr. Gina Sager, a Baltimore general surgeon, gave up her profession last year because of malpractice liability concerns.

“I had three malpractice cases filed in tandem in 1997,” she said.

One was dismissed, a second settled out of court. The third involved a woman who received surgery from other doctors, suffered complications, then sought Dr. Sager’s help. The woman eventually died and her family sued.

“I was in court for two weeks,” Dr. Sager said. “I was completely devastated by the whole thing. The jury found I was as negligent as everybody else.”

Her malpractice insurance rates jumped from $21,000 to $59,000 in one year. The policy included a $25,000 deductible fee before insurance would pay.

“I was absolutely unable to pay that,” Dr. Sager said.

Instead, she left the profession.

“At the moment, I’m still trying to figure out how I’m going to move back into the world,” said the 43-year-old surgeon who Baltimore Magazine named one of the city’s best breast surgeons in 2000. “I apparently have the dubious distinction of being the youngest physician in Maryland to retire.”

Insurance rates for internists, ob-gyns and general surgeons have posted double-digit increases for each of the last two years, the health care publication Medical Liability Monitor reports.

Most affected are rural doctors. They pay the same insurance rates as urban doctors but usually have fewer patients to help them cover their costs.

Their exodus from rural communities is forcing residents to travel long distances for health care or simply neglect it.

Eight years ago, a dozen insurance companies covered medical malpractice in Maryland. Now, there is only one large company, Medical Mutual Liability Insurance Society of Maryland. It was organized and is owned by the state’s doctors.

“All the others left,” Dr. Preston said.

The fact the company is owned by doctors is no buffer against high rates.

“It is driven by the growth in the size of the [lawsuit] awards,” Dr. Preston said. “The trend line is accelerating upward.”

Getting out of town

Ironically, medical malpractice insurance in Maryland and Virginia is a bargain compared with the District, and is luring many doctors into the suburbs.

The District has no caps on medical malpractice lawsuits, which has driven up insurance rates. Maryland and Virginia have caps, just not as low as doctors would like.

Maryland limits pain and suffering damages to $620,000 per case this year with an increase of $15,000 per year.

Virginia sets a total cap on any medical malpractice lawsuit at $1.7 million.

Some doctors have cut their rates almost in half by moving to the suburbs.

“Obviously, the rates can get more stable if you have caps,” said Edward Koch, a board member of the National Capital Reciprocal Insurance Co., which insures doctors in the Washington area.

Among doctors considering a move out of the District is Dr. John L. Lawson, president of the Medical Society of the District of Columbia.

“What I’ve done this year to scout out the waters is establish an office in Chevy Chase,” said Dr. Lawson, a 46-year-old rheumatologist who until now has operated his private practice at one downtown office in the District.

He will be able to pay Maryland insurance rates if he spends most of his time at the Chevy Chase office.

“I’ll pay half the malpractice premium I currently pay for just crossing Western Avenue,” Dr. Lawson said.

In May, Dr. Lawson debated with Frank Clemente, lobbyist for the consumer advocacy group Public Citizen, on WAMU’s Kojo Nnamdi Show. Public Citizen sponsored a study that said doctors in the District were trying to increase their profit margins by trying to win legislation that would limit their legal liability.

“Given the data, it’s clear that there is little — if any — malpractice insurance problem in the District,” Mr. Clemente said when the study’s results were announced. “Proposals to limit patients’ legal rights are simply an effort to curry favor with well-heeled special interest groups, not improve the quality of health care in Washington.”

Dr. Lawson said Public Citizen was wrong in asserting that the District’s medical malpractice crisis is fabricated.

Obstetricians often pay $105,000 a year for malpractice insurance in the District, he said.

“If I have the choice between continuing to have an office on K Street and moving my office to Chevy Chase and saving 50 percent on my malpractice premium … why will I stay on K Street?” Dr. Lawson said on the show.

Mayor Anthony A. Williams’ pledge to seek legislative relief for the doctors is angering Public Citizen and other patient advocates.

Mr. Williams is trying to build support on the D.C. Council before introducing legislation to set caps on pain and suffering damages. He also is trying to build safeguards into the legislation to ensure “accountability by providing increased licensing and safety regulation for the public,” spokesman Tony Bullock said.

Political hot potato

The Senate, led by Democratic opponents, fueled the malpractice insurance flames in July when it blocked a proposal that included a limit on “noneconomic” damages, which generally means pain and suffering.

Democrats used a procedural vote to kill the bill, championed by President Bush and approved by the House earlier this year. The Democrats said arbitrary caps on pain and suffering might help insurers and the pharmaceutical industry but would do little for patients.

The bill would allow awards for economic damages, such as lost wages or medical costs. However, it would cap “noneconomic damages” at $250,000 and curtail punitive damages.

Republicans who support the caps hope to work out a compromise to revive them.

“This is about access to care,” said Sen. John Ensign, Nevada Republican and a lead sponsor of the medical liability reform bill.

The bill has taken on more political potency in recent months amid unusual protests and work stoppages by doctors in several states.

Doctors in Boston, Chicago, Las Vegas, Philadelphia, Salt Lake City, Tallahassee and elsewhere have staged public protests. In West Virginia and New Jersey earlier this year, some protesting doctors delayed non-emergency medical care of hospital patients.

The insurance companies say high premiums are not their fault. In 2001, medical malpractice insurers paid out $1.35 for every $1 they took in from receipts, according to the American Academy of Actuaries.

Part of the fault lies with the rising cost of litigation. Lawsuit defense expenses have risen 14 percent since 1991 and 47 percent since 1975, according to the U.S. Bureau of Labor Statistics.

A weak stock market the last three years has added to the problems. The insurance industry invests a large part of its cash reserves in stocks. When the stock market stumbles, insurance companies have less money available for payouts. As a result, they raise their premiums to make up the difference.

The association said the best solution would have been the $250,000 cap on noneconomic damages. The AMA also wants damages and lawyers’ fees to be paid according to a schedule, rather than being up to judges and juries.

Medical school loses its luster

Despite a growing need for health care as the population ages, medical schools are graduating fewer doctors than the number who retire each year.

Unless more people choose to be doctors soon, the Association of American Medical Colleges is warning of a shortage of specialists, such as neurosurgeons and ob-gyns.

Medical schools nationwide graduated 15,652 doctors in 2002, compared with 15,355 a decade earlier.

In the same decade, the nation’s population grew 13 percent, many of them among the elderly population that requires the most health care service.

The elderly population is growing steadily as the Baby Boom generation ages, making further demands on the health care system, according to an August report from the Centers for Disease Control and Prevention.

“For the past six years, admission to medical schools has been down,” the AMA’s Dr. Palmisano said. Students “see a system that is so tangled up in red tape and a broken liability system that they believe they can best utilize their talents in other professions,” he said.

The Association of American Medical Colleges last year acknowledged a shortage bad enough to justify establishing new medical schools, hopefully creating an incentive for more people to become doctors. The number of medical schools in the United States — 126 — hasn’t changed since 1980, the association reports.

Contributing to the shortage of doctors is a shortage of nurses. Nurses who depart because of poor pay and working conditions leave doctors without the support staff they need.

“A lot of doctors say it’s impossible for me to do surgery because I have to retrain nurses every time,” said Kurt Mosley, vice president of business development at MHA Group, a Dallas health-care professional search firm. “They’re frustrated with the lack of nurses on the floor.”

The AMA says any relief for the medical profession will be determined when Congress reconsiders reform legislation, which it hopes will be later this year.

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