What Crisis?
GAO: Malpractice Premium Spikes Don't Force Out Docs
By Sandra G. Boodman
Washington Post Staff Writer
Tuesday, September 16, 2003; Page HE01
The stories are legion: pregnant women unable to find
doctors to deliver their babies because disgruntled
obstetricians have closed their practices or retired in
droves; white-coated physicians hitting the picket lines
and threatening to shut down emergency rooms; desperate
patients forced to travel long distances to find a
specialist willing to perform lifesaving surgery.
The culprit, according to the American Medical Association
(AMA) and President Bush: multimillion-dollar jury awards
in malpractice cases that have resulted in insurance
premium increases so huge that they are forcing doctors out
of business and jeopardizing patients' access to health
care.
But a new study by the General Accounting Office (GAO), the
investigative arm of Congress, has reached a very different
conclusion about the effect of rising malpractice premiums
on consumers. Investigators who studied nine states found
instances of localized but not widespread problems of
access to health care mostly in "scattered, often rural,
areas" that have long-standing problems attracting doctors.
And many of those highly publicized accounts of doctors who
have retired or moved are, according to the GAO, either
"not substantiated," temporary or involved only a few
physicians.
In Pennsylvania and West Virginia, for example, two of 19
states designated by the AMA as being in a "full-blown
liability crisis," the number of doctors per capita has
actually increased in the past six years, according to the
GAO.
In Florida, where the state medical society told
congressional investigators that all the neurosurgeons in
Collier and Lee counties had stopped practicing, the GAO
found at least five such specialists at work in each
county. Although medical groups have repeatedly warned that
doctors are reluctant to come to Florida because of
escalating premiums, the GAO found that the number of new
medical licenses issued by the state has increased in the
past two years.
A study released last week about Maryland, where medical
groups have warned about a "crisis" caused by rising
malpractice premiums, reached similar conclusions.
Researchers from Public Citizen Health Research Group
analyzed government data and found that the number of
malpractice claims filed per physician declined
significantly between 1996 and 2002, as did the amount paid
by insurers to cover claims. And while some groups have
warned about an "exodus" of physicians, the number of
doctors in the state actually increased between 1996 and
2002, according to the advocacy group.
"Every 10 years we hear the same thing: that all the
doctors are leaving, that patients can't get care; it's
sort of a ritualized dance," said J. Robert Hunter, former
federal insurance administrator who is now director of
insurance for the Consumer Federation of America, a
Washington-based advocacy group.
"And the reason is always the same," added Hunter, who also
served as Texas insurance commissioner. "The AMA and
insurance companies blame the tort system." Previous
malpractice "crises," Hunter said, occurred in 1975 and the
mid-1980s and represent cyclical economic fluctuations; the
latest downturn was delayed by the sustained economic boom
of the 1990s.
"What the latest GAO report shows is that the threat about
access to health care is largely overblown," said Maryann
Napoli, deputy director of the New York-based Center for
Medical Consumers. "It's interesting that [organized
medicine] always zeroes in on pregnant women every time
there's a so-called crisis.
"To address the issue, the Bush administration, backed by
the AMA and other medical groups, is pushing legislation
that would limit the amount of money patients who prove
they were injured by substandard care could collect from
doctors and hospitals.
In a prepared statement, AMA president Donald J. Palmisano
said the report "confirms that America's medical liability
crisis is causing access to health care problems in
high-risk medical specialties" and noted that in five
states "identified by the AMA as liability crisis states,
the GAO found health care access problems."
John M. Gibbons, Jr., a Connecticut obstetrician who is
president of the American College of Obstetricians and
Gynecologists (ACOG), condemned the report as "a sorely
superficial analysis of access problems . . . that totally
misses the crisis in obstetrics and gynecology." ACOG
officials disputed the methodology GAO researchers used.
"I think you just can't discount all of the press reports
and information about OB-GYN departures that is coming
forward," one ACOG official said.
But anecdotal reports can be misleading, experts say.
Hunter, an actuary, said that he oversaw the production of
a study last year for a coalition of 100 consumer groups
that tracked 30 years of malpractice payments and insurance
premiums. The report concluded that there has been no
malpractice "explosion" during the past three decades and
that payments have been "extremely stable" since the
mid-1980s.
Premiums paid by doctors, Hunter's study found, "do not
correspond to increases or decreases in payouts," but "rise
and fall in concert with the state of the economy. . . .
Insurance companies raise rates when they are seeking ways
to make up for declining interest rates and market-based
investment losses."
That conclusion is similar to one reached by the GAO in a
report released last June. Among the causes of the latest
round of malpractice premium increases, the congressional
investigators found, were insurers' losses in their
investment portfolios, inadequate reserves to pay claims
and artificially low rates set during the 1990s when many
companies vied to attract policyholders.
Among states and specialties, insurance rates paid by
doctors vary tremendously. The GAO found that a large
insurance company in Minnesota charged a statewide base
rate of $3,803 for an internist and $17,431 for an
obstetrician-gynecologist in 2002, an increase of about 2
percent over its 1999 rates. By contrast, a large Florida
insurer charged an internist in Dade County a premium of
$56,153 and an obstetrician $201,376, increases of 98
percent and 43 percent, respectively, over 1999 rates.
Because reliable national data on malpractice do not exist,
congressional investigators studied five states the AMA has
deemed as being in the throes of a liability crisis:
Florida, Pennsylvania, Nevada, West Virginia and
Mississippi. For comparison, researchers also examined four
states without reported problems: California, Minnesota,
Colorado and Montana.
One GAO finding embraced by the AMA was that "limited
available data" indicate that the rise in premiums paid by
doctors and in malpractice payments to patients has been
slower in states that capped some types of damage awards, a
centerpiece of the Bush administration's tort reform
proposal. Premiums in states with caps of $250,000 in
noneconomic damages, typically known as "pain and
suffering," rose by 10 percent in three specialties
including obstetrics, compared with a 29 percent increase
in states without such laws. The GAO concluded it could not
tell whether this difference was "caused by tort reform
laws or other factors that influence such differences."
Palmisano pointed to the disparity as confirmation of "what
the AMA has long held to be true -- tort reform works."
But while doctors' groups often talk about how ruinous
malpractice lawsuits are for physicians, the cover story in
the May 23 issue of Medical Economics, a magazine widely
read by doctors, had a more reassuring message.
"The vast majority of malpractice claims are dropped by the
plaintiff, dismissed by the court for lack of merit, or
settled before trial for an amount within the defendant's
policy limits," senior editor Berkeley Rice noted. "Of
those cases that do go to trial, most end in victories for
the defense."
Nationally, studies have found that doctors and hospitals
win about 70 percent of cases that make it to a courtroom.
Multimillion-dollar awards by juries are often bigger than
the amount actually paid by an insurance company or doctor;
these awards can be reduced by a judge, overturned on
appeal or, more commonly, are the subject of negotiations
between lawyers for both sides that dramatically reduce the
amount a victim receives.
"What's often lost in this discussion is that there is much
more malpractice than there are malpractice suits," Napoli
noted. A 1991 study by Harvard University researchers,
still regarded as the most influential of its kind, found
that acts of medical negligence are eight to 10 times more
common than malpractice lawsuits.•
© 2003 The Washington Post Company |
