When Julie Burdin envisioned being a doctor, she saw herself practicing rural family medicine and delivering babies in communities like Macon.
“I am from a small town, and this has always been my dream,” said Burdin, a family practitioner and obstetrician at Total Family Health Care, a community clinic associated with Samaritan Hospital in Macon.
Medical malpractice insurance was not a great concern for Burdin when she opened her practice last year. Now the skyrocketing cost of malpractice insurance is a barricade between Burdin’s ability to deliver babies and her patient’s access to maternity care.
Come November, Burdin’s patients, who travel from all over Macon County for her care, will journey south to Columbia to deliver their babies. Some women must travel an hour, others more than two hours.
“We expect we will have a delivery or two somewhere along the highway,” Burdin said.
Burdin is one of two obstetricians in the rural county seat of about 5,500 people still practicing. She will perform her last deliveries next month. After that, Burdin said her patients will travel to University Hospital or Boone Hospital Center to give birth. Samaritan Hospital, the only hospital in Macon, will only provide prenatal care.
“We are turning women away now,” Burdin said. “After November, the number will be impossible to estimate.”
A doctor’s burden
Family doctors like Burdin who specialize in rural medicine are often among the hardest hit by rising insurance premiums. Eighty percent of Burdin’s obstetric patients are Medicaid recipients.
Burdin’s salary from Samaritan Hospital, therefore, is determined by what she collects from Medicaid reimbursements and patients minus her expenses, which include medical malpractice insurance. The hospital does cover her insurance, but it, in effect, is deducted from her salary as an extra expense.
“We don’t have the dollars to throw around,” said Linda Wyatt, administrative secretary at Samaritan Hospital.
Insurance companies consider obstetrics along with neurosurgery to be one of the most high-risk medical practices, and thus, one of the most expensive to insure.
“If I was not covered under the University umbrella, I would not be doing (obstetrics),” said Dr. Carin Reust of University Physicians in Hallsville, a group of doctors with the MU School of Medicine. Reust will deliver the babies of some of Burdin’s patients as part of a “shared maternity care” relationship between the two hospitals.
Burdin is only a year out of her residency and just beginning to pay malpractice insurance, but her veteran partners consider themselves among the casualties of the contentious medical malpractice debate in Jefferson City and Washington, D.C.
“I saw my premiums of $19,000 shoot up to $71,000 in one year,” said Julie Wood, a family practitioner and former partner of Burdin’s who said she could no longer afford to deliver babies in Macon. Wood, who also chairs the Missouri Academy of Family Physicians, moved to Kansas City where she could be assured that her insurance costs would be covered.
“The situation has come to the point where we are going to have to borrow money to see patients,” she said.
The blame game
Depending on who’s talking, the story of the Macon doctors is either an isolated situation or one representative of a medical crisis of potentially historic consequences.
“This is definitely not unique to Macon,” said Tom Holloway, director of government relations at the Missouri State Medical Association. “It is happening in every corner of the state.” Holloway, however, said he has not collected data to demonstrate a flight of doctors from rural towns, “but we literally get phone calls every day.”
Across the United States, insurance “sticker shock” has prompted frustrated health care providers to blame the rising costs of insurance on individual malpractice lawsuit awards.
Mobilized by the American Medical Association and other groups, doctors have arranged protests and information campaigns to plead their case that multi-million dollar jury awards — not weak insurance company investment returns — have raised the cost of medical malpractice insurance.
Other policymakers argue that irresponsible doctors and not punitive damages are to blame.
On Monday, Gov. Bob Holden named 17 members to the new Missouri Commission on Patient Safety, a group of doctors, trial lawyers and health care professionals with the mission to prevent “medical errors” by Missouri doctors in order to improve “the quality of health care and further reduce the number of medical malpractice claims in the state,” according to the governor’s office.
A report by the Missouri Department of Insurance shows that some malpractice insurance carriers have stopped taking new business from doctors, and four of the largest malpractice insurance providers in the state have increased their rates in the range of 28 to 97 percent.
Farmers Insurance Group on Wednesday stopped writing malpractice insurance for 18 states, including Missouri. In Columbia, two doctors were affected, said Dallas-based spokeswoman Michelle Levy.
A new study released in August by the U.S. General Accounting Office, the investigative arm of Congress, disagreed with the AMA, saying increased premiums have not created the widespread health care crisis that the group claims.
Nonpartisan investigators cited “localized health care access problems” that were not prevalent outside of rural areas.
The report examined nine states. Five of these states are considered by the AMA and other national health organizations to be malpractice “crisis” states based on the difficulty doctors have in obtaining malpractice insurance, the rate of providers denying coverage and the cost of malpractice premiums.
Missouri, although considered by the AMA to be one of the 18 states in “full-blown medical liability crisis,” was not studied by the GAO for the report, “Implications of Rising Premiums on Access to Health Care.”
Even with the GAO’s preliminary findings, Holloway said, “I think we are on the cusp of a serious access problem that will start with high-risk medicine (such as obstetrics and neurosurgery), and it is not going to stop there.”
Holloway would like to see a lower cap on punitive damages awarded for “pain and suffering.”
Holden has vetoed a bill that sought to lower the cap to $350,000. The current cap, passed in 1986, is adjusted annually for inflation. It now stands at $557,000.
Randy McConnell, a spokesman for the Missouri Department of Insurance, said the department has created a joint underwriting association to assist doctors experiencing difficulty finding or keeping malpractice insurance, but it will not go into effect until 2004.
But the joint underwriting association is “definitely not a substitute for tort reform,” said C.C. Swarens, executive vice president of the state’s medical association, adding that it would only affect 1 percent of Missouri physicians.
Regardless of the policy solutions proposed, for now, expectant mothers from Macon County are preparing to travel more than an hour to Columbia to give birth.
“I’m not real happy about it,” said Sandra Reger, 31, one of Burdin’s patients, who is expecting her second child. “I wanted Dr. Burdin to be the one to deliver, but she can’t.”