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Financial contractions

Caught between the cost of malpractice insurance and smaller fees from health-care providers, many obstetricians are fighting to stay in their specialty.

By SUSAN ASCHOFF, Times Staff Writer
© St. Petersburg Times
published October 29, 2002


Dr. Linda Tijerino, after 12 years of grueling training and $150,000 in debt, graduated this summer to do what she dreamed of: care for women and deliver their babies.

But her education is only beginning. She's now being schooled in the business of obstetrics.

"I like my job," says the 31-year-old doctor, who practices in St. Petersburg. "I just wish I didn't have all these lawyers hovering around."

In choosing one of the most frequently sued specialties, Tijerino is on the front line of a crisis in malpractice insurance costs for physicians. In the end, it is the patient who will suffer, they say. Doctors will flee the state, choose less risky areas of medicine or stop carrying insurance altogether.

At a hearing last week in Orlando, the first of several scheduled by the governor's task force on the issue, doctors, lawyers and insurance executives pointed fingers at each other.

The task force will suggest legislation or other fixes to the governor in January.

"Tort reform is the long-term goal, but something's got to happen before then that allows doctors to stay in practice and protect themselves and their patients," says Dr. Bob Yelverton, an OB-GYN in Tampa and president-elect of the Florida Obstetric and Gynecologic Society.

The state's physicians have been hit with premium increases of 25 to 400 percent over the past three years, the Florida Medical Association reports. About half of Florida's estimated 1,000 board-certified OB-GYNs are no longer delivering babies, says Dr. J.K. Williams of the University of South Florida School of Medicine.

"If you're new to the state, you can't get a policy," he says. "It needs to be looked at as a health-care availability issue, not an insurance issue."

Obstetrics and gynecology is the only specialty Dr. Kimberly Biss wanted to practice. "I like taking care of women," says Biss, who works with Tijerino at their Bayfront Plaza office. Biss sees 30 to 40 patients a day, about one-third for obstetrical care. She could do better financially if she lost the expectant mothers, she says.

"(People) have this image that we're all millionaires, and so our concerns are not taken seriously," Biss says. "We're not millionaires. And I think it's the consumers, bottom line, who suffer."

Area doctors are leaving the state or not delivering because they cannot afford insurance, she and others say. Florida had the highest average premiums for OB-GYNs in the nation in 2000, averaging $158,000 a year. The cost of Biss' malpractice insurance jumped almost 15 percent this year. Costs to operate and staff the office average $70,000 a month and are increasing, she says. Yet this month, when health-care provider Cigna sent its new fee schedule -- the charges doctors are permitted under health care plans -- "Surprise, surprise," Biss says. "Most of them have gone down."

The malpractice crisis is neither new nor limited to Florida. But in this round, physicians are grappling with increasing insurance costs while being squeezed on the income side by managed health care. In the spring, the American College of Obstetricians and Gynecologists issued a national "red alert" for the third time in as many decades as premiums soared.

The organization identified Florida as one of nine "hot states." Another seven states are listed as threatened.

Dr. Gilbert Shamas, an OB-GYN who has delivered "thousands of babies," dropped his obstetrics practice in 2001. He says insurance premiums were not to blame: He was ready to scale back. He was 55 years old and the oldest obstetrician in St. Petersburg. "Think about that," he says. "Many have retired early because of the liability and managed care issues."

He resents the wedge that he says today's health care system drives between doctor and patient.

"Every patient is a potential lawsuit," Biss says. "That's a shame."

Obstetricians are among a handful of specialists classified as "high risk" by insurers. They can expect to be sued two to three times over a career and pay more to defend against litigation than other doctors. They win most of the claims, according to a 1999 survey of members of the American College of Obstetricians and Gynecologists. Over half the lawsuits were dropped, dismissed or settled without payment. Seven out of 10 cases that went to court were decided in favor of the doctor.

But competence is no guarantee of coverage. Nine carriers in Florida stopped selling medical malpractice insurance over the past three years. During the 1990s, agencies flooded the market, and five companies were headquartered in the state. Now there is one, First Professionals Insurance Co. Inc.

Largo Medical Center's maternity ward will close by year-end after losing two busy obstetricians who could not find affordable insurance. In South Florida, many high-risk specialists are "going bare," or practicing without insurance and instead certifying they have a $250,000 bond or letter of credit in case of litigation. In the Tampa Bay area, only University Community Hospital in Tampa and Carrollwood permits that kind of coverage. Several other facilities are studying the option.

"The most popular seminars for doctors now are (on) asset protection," says Yelverton of Florida's OB-GYN society. Doctors do not want their patients unprotected, either, he says. Doctors make mistakes. But the system's apportionment of costs must be more equitable if the caregivers are to survive, he says.

California is often cited as a model state for insurance and tort reform. Two decades ago, it set upper limits on noneconomic damages, which curbed premiums and stopped an exodus of physicians from the state. Statistics show that an OB-GYN in California typically pays about one-fifth to one-10th as much for insurance as a physician in Florida.

"If I knew then what I know now, I would never have gone into medicine," Biss says. "It's a real kick below the belt."

"You feel like you're under the gun all the time," Tijerino says. "There's only so much you can ask of (doctors)." When they can no longer afford to practice, "who's going to take care of you?"

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