AMA: 21 states in crisis’ from closing practices

Tennessee, Guam newest on list; Texas removed John Ameen, one of only two practicing obstetrician/gynecologists in rural Monroe County, TN, is considering abandoning the obstetrics arm of his practice because the cost of medical liability insurance has become more than he can afford.

The Tennessee Medical Association (TMA) cites Ameen as a prime example of why the American Medical Association (AMA) has added Tennessee to its list of "in-crisis" states, where the high cost of patient care and medical liability insurance is driving doctors to close or move their practices, cutting patients’ access to medical care.

As of March 2006, the AMA listed 21 states as being in crisis.

From 1995 to 2005, Tennessee physicians have seen liability premium increases as high as 127% to 212%, according to AMA figures. The TMA says Ameen’s experience is, unfortunately, all too common. Ameen, in a letter to the association, says his insurance cost $26,000 when he moved to the state in the 1990s, but had more than doubled — to $59,000 — by 2005. He said he was forced to borrow money to make his quarterly premium at the end of the year.

While premium costs have increased, reimbursements from TennCare — the state’s health care program — have dwindled, and now average only 25% of billed charges.

Phyllis Miller, MD, president of the TMA, described the situation in that state as "a perfect storm" of financial factors that alone make practicing medicine in Tennessee difficult, but together make it impossible for more and more practitioners.

Miller says the costs are causing some physicians in her state to close their practices or relocate to other states, leaving fewer doctors for the patients left behind.

"Doctors have to pay their bills and pay their employees, just like everyone else, or they cannot keep their doors open," says AMA President J. Edward Hill, MD.

AMA data from 2004 show that of the state’s 95 counties, 81 have no residing neurosurgeon in patient care, 49 have no residing orthopedic surgeon in patient care, 47 counties have no residing emergency physician in patient care, and 42 have no residing obstetrician/gynecologist in patient care.

Doctors, lawyers differ on solutions

While physician groups support legislating caps on damages that juries may award, opponents of medical malpractice reform, including the national Trial Lawyer Association, say capping non-economic damages (so-called "pain and suffering" awards) would do nothing to reduce high insurance rates.

In a prepared statement, the American Bar Association (ABA) takes a stand against reform that would cap non-economic damages, saying, "Supporters of this approach . . . argue that placing caps on these awards will lead to reductions in doctors’ malpractice insurance premiums. The ABA strongly refutes any such contention because neither empirical data nor experience with tort reform efforts within the states in the past have shown any established link between limiting non-economic damages and affordability of malpractice insurance policies."

For the fourth consecutive year, malpractice reform legislation is being considered by the Tennessee general assembly. The legislation’s main points seek a cap of $250,000 on non-economic rewards, a sliding scale for attorney fees to ensure that more money goes to the injured patient, and requirements that each lawsuit contains an affidavit from a medical expert certifying a specific malpractice occurrence.

Sponsors say passage of such a bill will require supporters of the reforms to produce new, compelling data showing that the changes have worked elsewhere and could work in Tennessee.

In addition to Tennessee, the AMA’s in-crisis list includes Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Massachusetts, Mississippi, Missouri, New Jersey, Nevada, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Washington, West Virginia, and Wyoming.

The AMA points to medical liability reforms that include a reasonable limit on non-economic damages as proven ways to protect patients and preserve access to medical care. A medical liability crisis in Texas resulted in sweeping reforms enacted in 2003, and voters passed a constitutional amendment to head off potential court challenges. Since then, the AMA reports, access to care has been increasing, claims are down, physician recruitment and retention are up, and new insurers are entering the increasingly competitive Texas medical liability market, creating more choices for physicians. As a consequence, last year the AMA removed Texas from the list of crisis states.

The AMA in March also added the territory of Guam to the medical liability crisis map as an area showing signs of trouble, with a limited number of physicians practicing some specialties, no physicians available in others, and the closest alternative about eight hours away in Hawaii. Guam has only one civilian hospital serving a largely rural population of 160,000. A number of physicians have left the territory, and local doctors cite the medical liability environment as the key challenge to attracting and retaining physicians to meet existing needs.