I submitted an op-ed to the Enid News-Eagle last month in response to a story on medical malpractice and obstetrician-gynecologists.
While I hope the newspaper sees fit to publish my response, I wanted to share it here as well.
I don’t fault the media for presenting the doctors’ views without scrutiny. Space and time constraints make a well-balanced story increasingly a rarity, and there’s criticism no matter what’s written.
It’s a shame, though, that decades of one-sided coverage have given the medical, insurance and business lobbies a free pass when it comes to getting their viewpoint out.
Part of my job at the Oklahoma Foundation for Consumer & Patient Rights is to let people know that there is another side to the story, and it’s just as compelling cataloging as the doctors’ woes.
Here is the News-Eagle story. My response follows.
OB services no longer a problem for Enid health care market
By Cindy Allen Managing Editor
August 20, 2008 01:02 am
Four years ago, Enid made national news because the community suddenly found itself with only two practicing obstetricians to take care of a market area that includes around 70,000 people.
In the summer of 2004, physicians received a malpractice rate increase from Physicians Liability Insurance that caused many practicing obstetricians and gynecologists (OB-GYN) to call a halt to delivering babies.
Even though high malpractice insurance rates continue to be a problem for physicians, the picture is much brighter today after a concerted effort by both Enid hospitals to recruit more obstetricians to Enid.
Today, there are six OB-GYNs practicing at Integris Bass Baptist Health Center and St. Mary’s Regional Medical Center, as well as a number of family physicians who deliver babies. And, the baby business is good, hospital officials report.
In July, Integris Bass Women’s Service Center reported a second month of record-breaking numbers at 105 for babies delivered. In December 2006, they recorded their second-highest number at 96.
Neither Jeff Tarrant, president of Integris Bass, nor Rick Wallace, CEO of St. Mary’s, was here at the time of the 2004 crisis, but they both say their staffs have worked diligently to recruit OB-GYN physicians to Enid, and their efforts have paid off.
In crisis mode
Dr. David Weaver had just been recruited to Integris Bass in Enid when the local malpractice insurance crisis hit. Ironically, he had just left Las Vegas due to a similar malpractice insurance crisis there in 2002.
“About 55 OBs left Vegas,” said Weaver. “We had been there 14 years.”
Weaver was drawn to Enid by a recruiter who really pushed the job opportunity here. He and his wife made a visit, and their first impression was positive.
“I interviewed here that weekend,” he said. “I loved the church we went to. I met several important people here in the state. The following weekend we sold our house. I bought a house over the phone and was here the following week.”
Weaver’s practice was going along fine until 2004, when Enid OBs got their new malpractice insurance premium bill. One by one, physicians began announcing they were closing the obstetrician part of their practices.
Weaver suddenly was only one of two OBs in practice here for a few months.
It was pretty crazy, he remembers. At one point, he was on call for six weeks with no on-call relief.
State Sen. Patrick Anderson, R-Enid, recalled how legislators and local officials were concerned about the lack of practicing full-time obstetricians.
Typically, the birth rate in Garfield County is higher than the state average, and one reason for that is families stationed at Vance Air Force Base are in their child-bearing years.
“We were right in the middle of the BRAC rounds,” Anderson said, so there was a political, as well as a medical, concern for the shortage.
Both hospitals actively recruit physicians year-round. Recruiting physicians sometimes is done by a corporate office, but a lot of the work is done locally by staff members in charge of development and recruitment of physicians.
At Integris Bass, the hospital has gone to an employment model in which physicians become employees in the Integris system.
That’s how Integris recruited Weaver, as well as Dr. Michelle Bergner and Dr. David Keuchel in obstetrics and gynecology. Bergner and Keuchel came to Enid in 2004, following the crisis.
“I grew up in Guymon and was a resident in Little Rock (Ark.),” Bergner said. “I was trying to get closer to home.”
At the time Bergner also was expecting her first child, which was another motivation to get back to northwest Oklahoma.
For Keuchel, he previously had been in practice in Enid but left in 2001 to take a position at the medical school in Tulsa.
“(Integris Bass) built the new women’s center, and I just couldn’t stay away from it,” he said.
Both physicians had been contacted by recruiters to come to Enid.
What also attracted them to Integris was the model of an employee-hospital relationship.
“A systematic response (to the malpractice insurance crisis) through Integris was to self-insure – to develop our own liability product and make it available to Integris physicians,” Tarrant said. “That’s the product these three are insured under.”
By being an employee, the Integris Bass physicians have their insurance paid for, but they also receive a salary. The business aspect of their practices are managed through the Integris system. The physicians also are rewarded for growing their practices, which all three have done, Tarrant said.
Weaver, Keuchel and Bergner say they like the employee model because it allows them to focus on their medical practice and not on the financial side of running a business.
“My main reason (for joining Integris) was the insurance,” Weaver said. He also likes that Integris doesn’t “settle” lawsuits unless it is at fault.
Bergner said the biggest benefit for her is not having to worry about management of the business.
“Medical schools don’t offer business courses,” she said. “I don’t want to know how to run a business, I want to take care of my patients and not have to worry about all the aspects of a business.”
St. Mary’s Regional Medical Center also worked to recruit three new OB-GYN physicians to Enid; however, St. Mary’s uses a guaranteed income model that does not bind the physicians to be employed by the hospital.
Dr. David Parker arrived in Enid in 2004 just before Wallace took over as administrator at the hospital. Dr. David Ferguson arrived in 2006, and Dr. Dennis McFadden arrived in January this year.
St. Mary’s promises the physicians a guaranteed in-come for a set period of time, and that includes enough money to start up a new business and pay for the malpractice premiums. The physicians also are rewarded for growing their practices, but they eventually take over their own business.
Both Ferguson and McFad-den were recruited in their last year of residency and were on contract with St. Mary’s prior to arriving at the hospital.
Ferguson also was drawn to the Enid area because of family ties.
“My family made the land run near Alva,” he said. “I had been coming up and around this area my whole life. I went to Northwestern. When it came time to be done with my residency, I was looking for a small town, and it happened Enid was in need of a physician.”
He said the St. Mary’s guaranteed income program helped him overcome fears of starting his own practice.
“The hospital made sure we had an income guarantee” he said. “As for building a practice, they make sure your family and practice have a stable mode of income until you can be on your own.”
Ferguson said the agreement provides enough income to cover office rental and malpractice insurance and provides a personal income.
Ferguson said most hospitals offer these kinds of benefits to new physicians.
“There is always some kind of guarantee,” he said. “Almost all doctors need 12 to 24 months of help. The average billing cycle can take up to 90 days.”
Ferguson said he prefers being in charge of his own practice.
“I really wanted to have control over everything from who I hire to how the office is going to look and be located at,” he said. “This is kind of like a dream.”
Wallace likens the St. Mary’s program to an incubator process in which physicians receive support and assistance until they can establish their practice.
“I think physicians want their own solo business model,” he said. “This still provides them the security they need, at least in the initial practice period.”
Ferguson said it took him 24 months to establish his practice, but now he is on his own. He said business is good, and he’s hoping to expand.
Taking care of the market
While the hospitals are competitive with each other, Wallace said the main objective of the health care community as a whole is to make available the resources for patients to have choices.
Enid and Garfield County aren’t the only market for the local hospitals.
“The total market area is looking beyond Garfield County,” he said. “We look at Fairview, Okeene, Seiling, Alva, even Woodward.”
A lot of smaller hospitals don’t have obstetrics services, and many of those patients choose Enid as a place to deliver their babies. Tarrant said obstetrics is not a high-margin business, but it does have a fairly high expense.
“Not a lot of (smaller) hospitals have the luxury of maintaining (obstetrics) services,” he said. “You hear a lot about people leaving Enid to go to Oklahoma City” to deliver babies, but “you don’t hear so much about patients coming here” from nearby rural towns.
Anytime an expectant mother has to drive 70 miles or more to deliver a baby, it’s a concern, Tarrant said.
Integris Bass built a women’s center in 2003 that includes a large number of services women need. The center has birthing suites, a special care nursery, a lactation consultant – all geared toward expectant mothers.
St. Mary’s also has been upgrading its obstetrics services and facilities, but Wallace concedes a majority of the births are going to Integris Bass.
“We’re getting our fair share,” he said. “The goal we should be looking at is not taking births away, but we need to be looking at being able to insure that all potential births come to this market as opposed to other alternatives.”
Wallace and Tarrant agree Enid has an adequate number of OB-GYN specialists serving the market area – for now.
“Anything could change that,” Tarrant said.
“We’re a fairly young population, and we seem to be fairly prolific. Normally a decent economy leads to more babies, and we’ve been blessed with a nice economy.”
A nagging issue
Even though Enid’s crisis has been abated, high malpractice insurance for specialties like obstetrics still causes problems for hospitals and physicians.
“It’s an issue that as a state we’ve never effectively addressed as far as meaningful tort reform,” Tarrant said.
The Legislature actually approved a tort reform package two years ago most local officials agreed with, but Gov. Brad Henry vetoed it.
“It was not a perfect bill but would have put in place meaningful caps on awards of non-economic damages,” Tarrant said. “That’s the one piece we don’t have – we’re surrounded by states that do.”
Anderson said there is enough support in the Legilature to get a meaningful tort reform package passed by both houses, but he doubts anything will be done until Henry, a Democrat, is out of office.
In the meantime, both Integris Bass and St. Mary’s believe they’ve found a way to appeal to just about any physician wanting to practice OB-GYN in Enid or any other specialty.
“We’re proud to say that every physician we’ve coached through the process has been successful,” Wallace said.
And here’s my two bits:
When will someone finally demand doctors explain themselves?
While the Oklahoma Foundation for Consumer & Patient Rights appreciates Cindy Allen’s efforts to inform readers about the availability of obstetrics in the Enid (see “OB services no longer a problem for Enid health care market,” The Enid News & Eagle, Aug. 20), we suggest she look beyond the medical community’s rote call for tort reform.
What began as the familiar attack on malpractice insurance rates and a legal system run amok later revealed how several obstetrician-gynecologists who relocated to Enid did so because of local hospitals’ financial amenities.
Any professional would benefit from being under a large umbrella, with the advantages, economies of scale, resources and state-of-the-art facilities such affiliation brings. Doctors are no different.
In the end, the physicians’ reasons for coming to Oklahoma had little to do with insurance and lawsuits. They instead chose to make Enid their home because of its quality of life and the opportunity to concentrate on practicing medicine rather than worrying about making payroll.
The Journal Record has taken on the question of whether the state is losing doctors.
In 1997, the newspaper found, 276 medical doctors in the state practiced obstetrics, gynecology or both, including related surgical specialties. By 2007, 395 were in the fields. Among osteopathic physicians, 25 practiced obstetrics, gynecology or both, including related surgical specialties, in 1997. By 2007, 58 were in the fields.
Insurance rates, the bugaboo of so many doctors, aren’t as they seem, either.
Surveys of physician salaries in Medical Economics magazine do little to engender sympathy for one of the nation’s best-compensated professional classes.
The magazine’s 2003 salary survey noted obstetrician-gynecologists in 2002 outpaced their primary care colleagues in both practice revenue ($500,000) and total compensation ($220,000). As a percentage of practice revenue, obstetrician-gynecologists’ expenses were in line with those of their primary care colleagues.
When doctors move beyond demonizing the legal system and look instead at their own shortcomings, we’ll have real tort reform.
Oklahoma Foundation for Consumer & Patient Rights