By now, every U.S. neurosurgeon surely must be aware of the extent to which the medical liability crisis is affecting access to healthcare in our country. Skeptics might wonder just how serious the problem really is.
In Missouri it was serious enough that with tremendous support of the Missouri State Medical Association, legislators from both sides of the aisle overwhelmingly passed significant tort reform. So why is Missouri still in deep trouble? In July the governor vetoed the bill; thus the ongoing concern.
True verifiable data is a powerful weapon that can be used in championing a cause. So, with the help of neurosurgeon John Krettek of St. Louis, earlier this year I embarked on an effort to gather data on rising professional liability insurance (PLI) premiums-a well-known symptom of the medical liability crisis-in Missouri. The hope is that our effort, detailed in this article, will serve as a template neurosurgeons across the country can use for gathering verifiable data that can reveal the extent of the crisis locally.
Methodology In order to obtain all the names of current practicing neurosurgeons in the state, a list was compiled from three different sources: the 2002 AANS/CNS Membership Directory, the 2002-2003 Missouri State Medical Association Membership Directory, and the American Neurological Surgery Political Action Committee (ANS PAC) database. The latter, found to be the largest database, was used as the master list. It was then cross-referenced with other two directories, and any neurosurgeons who were not found on the ANS PAC list were added to it.
Any names that could not be cross-referenced with either the AANS/CNS or Missouri State Medical Association directories were then further researched. Doctors were grouped by location to simplify the research. Each hospital or practice was asked to confirm all practicing neurosurgeons in the group. Neurosurgeons still in residency were removed from the list. If, after extensive research, contact information could not be found for a neurosurgeon, the name was removed from the list.
The Missouri Professional Liability Insurance Survey 2003, which covered data from 2000 to 2003, was developed and mailed to the known 89 practicing neurosurgeons in Missouri. A total of 79 surveys were completed and returned by fax, for a response rate of 88.7 percent. The survey results were entered into a Microsoft Excel spreadsheet and then tabulated and analyzed.
Findings Respondents reported significant annual increases in PLI premiums during the three-year period studied. Premiums increased by 36 percent between 2001 and 2002 and by 67 percent between 2002 and 2003, for an overall increase of 116 percent between 2001 and 2003.
Neurosurgeons most affected by increases in PLI premiums experienced increases of 164 percent (2001-2002), 148 percent (2002-2003), and 295 percent (2001-2003). The lowest premium in 2003 was found to be $33,687.00 and the highest $180,000.
Click here for PDF of graphic.
As a result of the increases in premiums, 40 percent of the respondents indicated that they were considering early retirement. Six neurosurgeons already had retired in the past three years. Considering that 46 percent of the respondents were age 50 or older, such retirement plans could lead to a significant decrease in practicing neurosurgeons in Missouri during the next five to 10 years. Further, 26.6 percent stated that they were considering relocating to another state; Kansas and Indiana were the states most commonly mentioned.
Two-thirds of the respondents indicated that they plan to reduce the type of service they provide in their communities. The following areas were identified for reduction of services: Pediatric Neurosurgery, 33 percent; Trauma/Emergency Room Coverage, 33 percent; Cerebrovascular Surgery, 43 percent; and Cranial Work, 23 percent.
Fifty-three percent reported that they will decline accepting Medicaid patients, and 23 percent say they will stop accepting Medicare patients. This is not surprising considering that, when calculating the cost of liability insurance per case, neurosurgeons were paying up to $582.00 per case in 2001, $647.00 per case in 2002, and are paying $1,240.00 per case in 2003. Given the low reimbursement rates for Medicaid and Medicare, it is evident that it would be impossible to sustain successful viable practices taking care of those patients.
Findings in Major Missouri Cities
The survey data was further broken down to show what is really happening in the main areas where Missouri neurosurgeons practice: Joplin, St. Joseph, Cape Girardeau, Kansas City, and St. Louis (where 53 percent practice).
In Joplin, five neurosurgeons have been covering the metropolitan area and now three are leaving the state. Two could not obtain insurance in Missouri and are moving to Kansas, and the third is moving to a “tort friendly” state where his insurance will be $30,000 each year instead of $110,000 each year. In St. Joseph the lone neurosurgeon left the state altogether. In Cape Girardeau two of the four neurosurgeons reported that their insurance was not renewed, and that they will be moving out of the state, as well.
Far worse, neurosurgeons living in eastern Kansas City (Missouri) have left the area: One chose to retire while the others moved to practice in Topeka, Kan. As for western Kansas City (Kansas), there were approximately 25 neurosurgeons practicing at the beginning of 2003. Those who are insured under the Kansas Healthcare Stabilization Fund and who are practicing in Missouri are considering limiting their practices to Kansas; if they decide to do so, the number left practicing in eastern Kansas City may drop to 15.
In the greater St. Louis area, 25 neurosurgeons are in private practice. Three retired when they saw their annual premiums triple to the $100,000 range. Four neurosurgeons in one large-group practice were notified several weeks ago that they will not have their liability insurance renewed by their current carrier; two of them will retire, and the fate of the remaining two is unknown at the present time.
In another large practice, the liability policies of two neurosurgeons are not being renewed by their carrier, one due to three prior settlements and the other due solely to pending claims. One surgeon has been told that his premium will increase this year to $311,000 and further, that he will not be allowed to perform any intracranial surgery! The other members in that group saw an increase in insurance premiums from $60,000 this year to $120,000 next year.
The data demonstrate that adequate delivery of neurosurgical care in Missouri is in serious jeopardy and that, in less than three years, Missouri has become a state in crisis. The uncontrolled increases in PLI premiums are a great threat to the practicing neurosurgeon. Given the Missouri neurosurgeons’ plans to relocate, retire, and reduce services, there is indeed a real threat of significant reduction in the numbers of practicing neurosurgeons and therefore in patients’ access to care in this state.
We are no longer dealing with simple anecdotes. We now know the extent of our problem, and more importantly, we can share this knowledge with others. This information has been appropriately relayed to legislators in Missouri, as well as those in the U.S. Congress. The governor and, more importantly, our patients, also are being informed of the true severity of this crisis. With verifiable data, there is hope that we will be able to turn the tide and achieve meaningful tort reform in Missouri or at the national level.
David F. Jimenez, MD, is professor in the Division of Neurosurgery at the University of Missouri-Columbia.
Additional Resources: Missouri Professional Liability Insurance Survey 2003, click here; and Missouri State Medical Association, www.msma.org