UMHS study finds premium rates affect where ob/gyns choose to practice

The high cost of malpractice insurance for some medical specialties affects not only how many doctors are entering the field of obstetrics and gynecology, but also where they offer their widely needed obstetric, prenatal and gynecological care, according to new University of Michigan Health System research.

Their study, published in the June issue of the journal Obstetrics & Gynecology, gives a foreboding prognosis for the supply of doctors specializing in the field because of the rising costs of malpractice premiums.

"The high cost of malpractice premiums is beginning to lead providers to drop or reduce obstetrical services. Our study presented evidence that high malpractice premiums affect where new obstetricians are locating and it may affect the supply in the future," says Scott B. Ransom, D.O., M.B.A., M.P.H., associate professor of obstetrics and gynecology at the U-M Medical School and of health management and policy at the U-M School of Public Health, and the senior author of the paper.

"Our study shows that there is legitimate reason for concern about patients' access to obstetric care and prenatal care in the future," he says.

Some of the potential problem areas include states with the highest malpractice premiums, including Florida, Nevada, Michigan, New York, and the District of Columbia. Researchers also found signs for problematic future supply of obstetricians in several counties containing populous cities, such as Dade County, Fla., Wayne County, Mich., and Cook County, Ill., which all have high costs of malpractice insurance.

Ransom says he hopes that this study and others dealing with similar issues can inspire policy changes and tort reform that help reign in the cost of liability insurance for obstetrics/gynecology and other fields.

"Something has to be done about the skyrocketing cost of malpractice premiums in our field," says Ransom, also the director of women's health and gynecology at the Ann Arbor VA Healthcare Center and director of the U-M Program for Healthcare Improvement and Leadership Development. "We are going to lose some of the best and brightest young doctors who otherwise might enter this field, and we are going to face shortages in many areas of the country if something isn't done."

The researchers compared the rates of births per fellow and junior fellow members of the American College of Obstetricians and Gynecologists (ACOG) in states that have the highest cost of malpractice insurance and states at the other end of the spectrum.

They found that the rate of increase in births-per-junior fellow in the 10 highest-premium states was far greater (a median of 28.5 percent) than the rate of increase in the 10 lowest-premium states (a median of 5 percent) from 1995 to 2002. That indicates that the supply of obstetricians is not keeping up with the need for doctors in this specialty in the highest-premium states, says lead author Pamela Robinson, M.B.A., a student at the U-M Medical School.

The researchers also found that in general, most counties in the United States experienced decreases in the number of births per ob/gyn, indicating an improvement in the supply of doctors in the field. But they also found that the six highest-premium counties had a slightly lower rate of decrease in births per ob-gyn than the other counties in the nation. While not statistically significant, this result could hint at a worse situation in meeting the ob/gyn needs in these areas.

Malpractice insurance premiums vary widely from state to state. Florida is the highest-premium state, with an average 2004 premium of more than $195,000, followed by Nevada, Michigan, the District of Columbia, Ohio, Massachusetts, West Virginia, Connecticut, Illinois and New York.

The 10 lowest-premium states are Oklahoma, at about $17,000 on average, and Nebraska, South Dakota, Minnesota, Indiana, Idaho, North Dakota, Wisconsin, Arkansas and South Carolina.

Many areas of the country, especially around major metropolitan areas, are experiencing large increases in the average costs of premiums. Between 2003 and 2004, Dade County in Florida, which includes the city of Miami, went from $249,000 to $277,000, an increase of about 11 percent.

In that same period, Cook County in Illinois, which includes Chicago, jumped about 67 percent from $138,000 to more than $230,000. Wayne County in Michigan, which includes Detroit, went up 18 percent, from almost $164,000 to nearly $194,000.

The issue of how rising malpractice rates are impacting the obstetrics and gynecology profession has been a topic of national concern in recent years. It has received widespread attention both in the media and in the discussions and writings of health care professionals.

The reasons for the rising costs in this specialty are myriad, but Ransom notes that a partial explanation is that "everybody wants and expects a perfect baby," leading many people to sue when the reality doesn't match their expectation.

Another facet of the discussion relates to patient safety. This was the subject of an editorial in Obstetrics & Gynecology in May, written by Mark D. Pearlman, M.D., professor and vice chair in the Department of Obstetrics and Gynecology and professor of surgery at the U-M Medical School; and Paul A. Gluck, M.D., of the University of Miami School of Medicine.

Pearlman and Gluck wrote about the threat to the supply of ob/gyns, and said that doctors in the specialty should focus on increasing patient safety.

"As a specialty, we are threatened. Rising malpractice premiums, lower job satisfaction, intrusion of policy makers and insurance companies demanding better service and access while providing fewer resources, and decreased interest in obstetrics and gynecology among senior medical students pose formidable challenges," Pearlman and Gluck wrote.

"Our specialty should position itself among the leaders of the patient safety movement. Engaging ourselves fully in this effort is not only our moral imperative, it will bring us back to what motivated us to go into obstetrics and gynecology--to help women get well and stay well."