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OB/GYN Editorial May 2002
The Disgruntled Patient
Leslie Trope, MD, FACIP, FACMQ
In the county where I practice Obstetrics and Gynecology, malpractice
insurance premiums, driven by both the numbers and sums of judgments,
are rising at extraordinary rates. The discipline of Obstetrics
again retains the unpleasant distinction of leadership in this trend.
Physicians who have not already concluded that they cannot afford
to continue practicing obstetrics will have to consider whether
premium increases of approximately 15% every 6 to 12 months in the
face of stable or diminishing reimbursement are compatible with
their personal and career objectives. The situation for hospitals,
which can anticipate annual premium increases of 400% to 500%, is
even worse. Those who cannot afford to pay upwards of $25 million
per year for policies with per-case deductibles of $5 million or
more or who cannot secure insurance at any price, will either close
down or plan on handing over the keys to their creditors on the
occasion of their next big case.
Like most short-sighted practices, our existing tort system is
both unwise and unjust. While a small number of individuals (patients
and their attorneys) are enriched by huge awards and settlements,
enormous numbers of patients will be deprived of necessary health
care. Patients should be compensated for damages resulting from
medical malpractice, but as William Wordsworth said, "getting and
spending, we lay waste our powers." I believe in the free market
as it applies to the legal system and in the American meritocracy
of "to each according to his ability, from each according to his
means." Yet every system needs rules, and in too many jurisdictions
there seem to be too few rules with which to strive for justice
on a societal level.
What will be the long-term outcomes of our short-sighted medical
malpractice system? Here are some projections:
- Doctors and hospitals will cease to conduct business in nonprofitable
(read: low-income) areas or in high-risk specialties first, diminishing
access to quality health care and increasing the burden to society
of untoward outcomes and reliance on emergency room services.
- Midwives and other nonphysicians will pick up the slack. Such
a development might in fact be sensible policy. Properly trained
and supervised midwives can manage low-risk deliveries as well
as (and more cheaply) than obstetricians. It is doubtful, however,
that a majority of American women will accept this alternative,
especially if the midwives involved are not providing "deluxe"
services, but rather no-nonsense management of labor and delivery
suites. Further, the number of trainees in OB/GYN residencies
would have to be reduced dramatically, another unlikely development.
- Some other revolution in the practice of Obstetrics will occur,
such as tracking of obstetricians into office-based practices
with low malpractice premiums and hospital-based practices with
higher premiums.
- Tort reform capable of passing constitutional muster will be
forced upon the public and their legislatures if and when they
come to the realization that reactive policies are spectacularly
more expensive than sensible proactive ones, or when they face
a collapsing health care system.
- It may very well be that the outcomes of this external pressure
will at least in part improve our health care system, which continues
to be inefficient and wasteful despite a couple of decades of
managed care and increased regulation. Be that as it may, something's
gotta give, and we would be wise to work through our professional
associations to try and influence the point and magnitude of the
rupture.
Emmet Hirsch, MD
Advisory Board Member
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