Scientific and technical progress has borne neurosurgery from an infancy of possibility in Harvey Cushing’s operating theater to a maturity of high achievement in neurosurgical techniques that have helped thousands of patients across the country.
What irony, then, when poised at the threshold of new generations of research and of ever more refined surgical techniques, the engine of medical progress should grind to a crawl, even shift to reverse, due to exponentially escalating medical liability awards.
Today, the entire medical liability system is in a state of crisis. A major symptom is the rapid escalation of professional liability insurance (PLI) premiums: Since 2001, PLI premiums for high-risk specialists in states without legislative controls have grown to astonishing levels, some doubling overnight.
Some may recall that a situation exhibiting similar symptoms occurred in the 1970s. But never before has an exodus of neurosurgeons and other specialists from crisis states been so widespread. Never before have so many neurosurgeons sought retirement, career change or geographic refuge to escape the threat from random multimillion-dollar liability claims after years or decades of successful and respected practice. Never before have neurosurgeons abandoned their life’s calling in mid-career in such numbers, dropping privileges to perform high-risk procedures or to treat high-risk illnesses because of the threat of bankruptcy from exorbitant liability claims linked to imperfect outcomes. Sadly, I am reminded of W.B. Yeats’ words from “The Second Coming”: “Things fall apart; the centre cannot hold; mere anarchy is loosed upon the world.”
In general, a liability crisis gnawing through the nation’s social fabric is described nowhere so effectively as by Philip Howard in The Collapse of the Common Good. Payments for product liability claims reach billions of dollars and payments for professional liability claims, the hundreds of millions. In devising these awards, reason and proportion play no role and impose no restraint.
Today, the medical liability crisis is the most serious threat facing medicine, and particularly neurosurgeons and other high-risk specialists; all other political and professional issues pale in comparison. It is the only threat that drives physicians out of practice altogether, depriving patients of timely care and communities of the safety and security of medical resources in time of need.
Today, the medical liability crisis is the most serious threat facing medicine, and particularly neurosurgeons and other high-risk specialists; all other political and professional issues pale in comparison. It is the only threat that drives physicians out of practice altogether, depriving patients of timely care and communities of the safety and security of medical resources in time of need.
Opponents of reform claim that the astronomical PLI premiums are only a temporary product of economic recession, or of the insurance underwriting cycle, or of insurance company mismanagement, or of inadequate state insurance regulation, or of an epidemic of medical errors, or of poor medical and hospital quality control, or for various other diversionary reasons. Each of these arguments can be refuted when the facts are examined.
The one fact that looms insistently behind the blow and bluster is the inexorable rise in judgments and settlements that drives the PLI premiums through the roof. Claims without restraints and awards without limits, the real causes of the crisis, are what require control; this is where legislative reform must focus.
Medical liability reform that preserves patients’ access to neurosurgical care is both necessary and possible. Federal reform is necessary to bring consistency to a problem that neither recognizes nor respects geographic barriers. Medical liability qualifies for federal jurisdiction under the U.S. Constitution’s interstate commerce clause. Sixty percent of the nation’s $1.4 trillion in healthcare expenditures flows through federal, not state sources. The president and his administration support reform, and the House of Representatives passed an effective reform bill (H.R. 5 in 2003). Only the Senate stands between the bill and the president’s signature.
Public opinion drives legislative reform. The public is 75 percent in favor of medical liability reform, according to recent polls. But sympathy alone is no lifeline to healthcare access; it must be transformed into public demand for Senate action. Public opinion must be mobilized by an effective public information campaign that refutes disinformation and brings home to every voter the healthcare void opened by the medical liability crisis.
Neurosurgeons, among the hardest hit of specialists, must adopt a new and unaccustomed role: that of political activist. Personal practice survival demands it and public welfare requires it. We are not engaging in a campaign for this year alone. Since defeat means only spiraling claims, higher costs, and growing defections from specialty practice, defeat is not an option. Neurosurgery’s campaign for reform ends only with enactment of effective federal legislation.