Rising professional liability insurance costs in Florida have had a major impact on the availability of health care services in rural areas

Rising professional liability insurance costs in Florida have had a major impact on the availability of health care services in rural areas, according to an article in the November 8 issue of The Archives of Internal Medicine, one of the JAMA/Archives journals.

According to the article, almost half of the states, including Florida, face serious problems with professional liability insurance (PLI). In these states, huge increases in insurance premiums, physicians leaving these states, and the closing of health care facilities including emergency departments, are reported frequently. Particularly vulnerable to these changes are the 60 million people who live in rural America, the article states.

Robert G. Brooks, M.D., of Florida State University, Tallahassee, and colleagues surveyed physicians practicing in rural Florida in 2003. Physicians were asked about changes in health care delivery by service type and specialty, and about changes in PLI premiums and the effect of these changes on delivery of services and their own satisfaction in their practice.

Of the 781 physicians surveyed, 411 (52.6 percent) decreased or eliminated health care services during the past year. The researchers found that overall:

• 73 (61.3 percent) of 119 decreased or eliminated vaginal deliveries
• 60 (52.6 percent) of 114 eliminated cesarean sections
• 186 (51.7 percent) of 360 eliminated hospital-based surgical procedures
• 209 (46.4 percent) of 450 eliminated emergency department coverage
• 103 (41.7 percent) of 247 eliminated endoscopic procedures
• 187 (40.9 percent) of 457 eliminated office-based surgical procedures
• 105 (34.5 percent) of 304 eliminated mental health services

Elimination of procedures and/or services was found to be highest among general surgeons (78.4 percent), surgical specialists (73.6 percent), and obstetricians/gynecologists (70.2 percent).

The researchers also found that premiums for PLI in Florida rose an average of 93.5 percent, and they write, “Difficulty finding or paying for PLI was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next two years.”

The authors state that, “The current crisis in medical PLI in Florida has a major impact on the availability and delivery of health care services to rural areas. Given the number of states that are experiencing similar insurance market upheavals, adverse effects on access to care are likely occurring nationwide.”

“One of the most concerning findings in this study is the decrease and elimination of vaginal deliveries and cesarean sections by obstetricians/gynecologists and family physicians. Rural women have traditionally been shown to have increased rates of infant mortality and maternal complications, problems that may be accentuated by the decreasing availability of local delivery and cesarean section services,” the authors write.

In an accompanying editorial, James Schroeder, M.D., of the Northwestern Medical Faculty Foundation, Chicago, writes, “Brooks and colleagues make clear that, as a result of the liability crisis, access to care is declining significantly, and that effect is marked, especially in vulnerable populations where access is already problematic.”

“Identifying a solution to the crisis is not difficult, because we have states in which PLI costs are not excessive. The common factor in states in crisis is the failure to cap noneconomic damages. Overall, states that cap noneconomic damages have lower PLI premiums than those that do not have caps,” Dr. Schroeder writes.

“Beginning with the capping of noneconomic damage awards is critical to stabilize the system, but ultimately other reforms are needed if we are to ‘bridge the quality chasm,’ as the Institute of Medicine proposed,” writes Dr. Schroeder.

Among Dr. Schroeder’s recommendations are the following:

• cap all noneconomic damages (pain and suffering, mental anguish) at $250,000
• eliminate the rule that prohibits juries from knowing about payments that plaintiffs already received from other sources
• require a reasonable statute of limitations on claims
• establish a sliding scale for attorney’s fees
• limit punitive damages to $250,000 or twice compensatory damages (the total of economic damages plus noneconomic losses), whichever is greater
• Make grants available to states to develop Alternative Dispute Resolution programs