A study finds high malpractice premiums cause some rural doctors to leave the state.
By LISA GREENE
Published November 9, 2004
Thirteen years ago, Dr. Manuel Alvarado chose Leesburg as the place he would deliver babies. He liked its quiet streets and small-town charm.
He was one of 10 obstetricians in the area. Now there are just five.
The departed include Alvarado's recent partner, who left because he couldn't afford malpractice insurance. Alvarado can't either. He's practicing without, sending high-risk patients to other cities and wondering whether he should leave, too.
So the study published in a national journal Monday was no surprise to him. A survey of 781 doctors in rural Florida found that more than half have cut back on procedures vital to every town, from delivering babies to staffing emergency rooms. Most of them cited rising malpractice premiums as a key reason for the cutbacks.
The 2003 survey appears to be the first scientific data backing a hotly contested claim made by state doctors during the last two years of malpractice wars. State medical lobbyists have said doctors were being forced to make cutbacks, but had few hard numbers to support their claims.
"Their (malpractice insurance) rates go up doing that, so they decide it's not worth it, so they quit," said Dr. Dennis Agliano, a Tampa surgeon who is president of the Florida Medical Association. "The things that have higher risk, they're going to eliminate."
Officials with a state advocacy group for Florida trial lawyers, who often are on the other side of the malpractice debate, declined to comment Monday.
In the survey, childbirth was the procedure most likely to be reduced or stopped entirely. More than 61 percent of the doctors who responded said they had cut back on normal deliveries, and almost 53 percent reported cutbacks on Caesarean sections.
More than 51 percent reported limiting their hospital surgeries, and almost 47 percent cut back on emergency room duties.
"We're disconcerted at the level of cutbacks in services to these vulnerable populations in rural areas," said Dr. Bob Brooks, associate dean for health affairs at Florida State University's College of Medicine and lead author of the study, which was published in Archives of Internal Medicine.
The study didn't look at whether urban doctors are making the same choices, or at how patients are being affected. Broader studies are under way, said Brooks, a former secretary of the Florida Department of Health.
But in rural Florida, even if no more doctors are cutting services than those in large cities, there are fewer doctors to take their place.
"The crisis that these changes precipitate is going to be more pronounced in rural areas," Brooks said.
In Zephyrhills, obstetrician/gynecologist Shiela Bahn already is seeing the impact. Because doctors in surrounding areas have stopped delivering babies, some of her patients drive in from towns 45 minutes away.
And she, in turn, sends her high-risk patients on to Tampa. Women who have such conditions as severe gestational diabetes must go to a specialist.
"We definitely do not do high-risk," Bahn said. "And I was trained to do all that. I know how to do it."
The chance of being sued is too high, she said.
"Bad things are going to happen to (some) patients with complications," she said. "It's very hard for people to understand, when they're expecting a normal healthy baby, when something goes awry. There's a lot of, "If something's wrong, it's somebody's fault.' "
Doctors in other fields also are reluctant to take risky cases, said Bahn, chief of obstetrics/gynecology and of surgery at East Pasco Medical Center. When she has a patient with gallstones or some other problem, it can be hard to find a specialist.
"A lot of doctors don't want to see a pregnant patient," she said. "Everybody is so scared."
That fear is reflected in Brooks' survey. More than 51 percent of respondents said finding or paying for insurance had "a lot" of impact in deciding to cut services, and almost 40 percent said it had "some" impact.
The surveyed doctors reported a mean increase of 93.5 percent in malpractice premiums over the past year.
In small towns, rural family doctors often perform procedures only specialists do in larger cities, Agliano said. By cutting those, family practitioners can cut insurance premiums. But patients must travel farther and wait longer.
At a meeting last week, FMA officials talked about getting doctors who retire to Florida more involved in caring for patients in need, including those without insurance and in rural areas, Agliano said. The sticking point: malpractice premiums.
"You're knocking out doctors to help people," he said.
Alvarado might become one of them. He has thought about no longer delivering babies. Or he might move. Indiana, maybe. Or Nebraska. Rates are supposed to be low there.
So far, pragmatic concerns - his house, his practice, his children's college bills - have kept him going. But that could change.
"We have been very happy here," Alvarado said. "But right now, I don't know."