Medical Professional Liability and the Delivery of Obstetrical Care Volume II, An Interdisciplinary Review (1989) / Chapter Skim
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Medical Professional Liability and Access to Obstetrical Care: Is there a Crisis?
Medical Professional Liability and Access to Obstetrical Care: Is there a Crisis?
Pages 78-96
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From page 78... ...
Residents of rural areas are also likely to encounter difficulty in obtaining care: a single physician's decision to stop practicing obstetrics can result in impaired access for women who have trouble reaching distant providers. In this chapter I examine the relationship of professional liability issues and access to obstetrical care for low-income women and women 78
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From page 79... ...
Various pieces of information from numerous sources must be drawn together to obtain a picture, or at least an outline, of the situation. For this report, I reviewed 30 state studies, principally from state and national medical associations,3 and nine national studies.4 The available literature highlights the impact of professional liability concerns on physician decisions to provide obstetrical care; only a few studies examine access to care directly.
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From page 80... ...
reported that, by the end of 1985, 23.3 percent of its member~twice the proportion reported by the ACO~had stopped practicing obstetrics because of malpractice concerns. The state studies reported that from 8 to 75 percent of family practitioners had dropped obstetrics over the past five years.
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From page 81... ...
Are These Changes Occurring Because of Professional Liability Concerns? Physicians consistently report that they are reducing or eliminating their obstetrical practice because of the cost of malpractice insurance or
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From page 82... ...
In Illinois, 57 percent cited malpractice insurance costs and 44 percent cited the risk of being sued. In Kentucky, 78 percent of family physicians stopping obstetrics and 38 percent of those reducing their caseloads cited malpractice concerns.
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From page 83... ...
· Only 45 percent of Kentucky physicians serve Medicaid obstetrical patients. Three-quarters ofthe physicians who have reduced their provision of obstetrical care cite malpractice issues as a reason for nonparticipation in Medicaid.
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From page 84... ...
According to the administrators of public programs, malpractice issues are reducing significantly the number of participating providers, and some areas of their states are experiencing major problems in access to care.6 · More than 60 percent of Medicaid programs and almost 90 percent of Maternal and Child Health programs are experiencing significant difficulty in finding providers who are willing to render maternity care. Nine out of ten programs say that rising malpractice insurance costs have contributed to this problem.
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From page 85... ...
One-fifth considered malpractice insurance costs the most important reason. Access to Care In Rural Areas Family practitioners have traditionally been key providers of obstetrical care in rural areas.
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From page 86... ...
· A 1985 survey of small and rural California hospitals reported that 30 of 56 respondents providing obstetrical care had family physicians on their staff who were planning to drop obstetrics. Thirty-six of the hospitals (64 percent)
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From page 87... ...
This trend creates a vicious circle, wherein physicians who continue to accept Medicaid patients experience greater pressures on their time—possibly to the point where they need to begin restricting their Medicaid practice. With fewer physicians providing obstetrical care, the low-income patient or Medicaid recipient, who may be perceived as less financially, socially, or medically desirable, can end up competing with a middle-class patient for the physician's time.
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From page 88... ...
It is important to understand that how much a provider must charge to meet all expenses, including malpractice insurance, is difficult to ascertain and depends to some extent on the net income desired by the practitioner. The ACOG reported that in 1986 malpractice premiums represented 20 percent ofthe average ob-gyn's overhead; the ACOG also reported that premiums represented 10.3 percent of gross income in 1986, compared with 9.7 percent in 1984.7 Thus, although malpractice premiums rose 46.7 percent in the two years, the proportion of gross income devoted to malpractice insurance rose by only 6.2 percent.
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From page 89... ...
Insurance premiums do not vary with caseload; therefore, one could reasonably argue that service to Medicaid patients is a marginal cost and payments that do not reflect the full cost of coverage are not necessarily unreasonable. If Medicaid reimbursement policies were revised to assume part of the cost of malpractice insurance directly, should these costs include only the obstetrical portion of the premium?
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From page 90... ...
Indeed, such data are at the heart of the Medicaid expansions recently established by Congress and are the focus of such groups as the National Commission on Infant Mortality Prevention. Yet it is precisely this information that may underlie a physician's sense that service to low-income and Medicaid patients increases the risk of malpractice litigation.
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From page 91... ...
The study found no significant correlation between Medicaid participation and threatened or actual malpractice litigation.~5 · Two surveys of providers found higher rates of litigation among Medicaid patients. Respondents in the 1986 Washington State survey of
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From page 92... ...
Hospitals reported that Medicaid patients represented 17.1 percent of deliveries but initiated 24.8 percent of malpractice claims (this finding was not statistically significant. The data that are currently available neither substantiate nor disprove the belief that "the poor sue more." All of the studies suffer from methodological problems that may be inherent in any analysis of this issue.
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From page 93... ...
Although the causal relationships between professional liability concerns and service to Medicaid patients are not fully established, Medicaid reimbursement rates and fear of suit appear to be primary factors. The empirical evidence suggesting that physicians who serve Medicaid patients are at greater risk of malpractice litigation is inconclusive at best; yet the perception may have assumed its own reality.
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From page 94... ...
For example, one state Medicaid program has provided funds to help a local health department in recruiting physicians for health department and Medicaid programs. Other approaches might be to increase reimbursement rates for physicians with large Medicaid practices (to compensate for their rising malpractice insurance costs)
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From page 95... ...
1987. Changes in Availability of Obstetrical Services in Illinois; Iowa Medical Society and Iowa Academy of Family Physicians.
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From page 96... ...
Hospital admission data were provided by the Maryland Health Services Cost Review Commission.
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