Ending the PLI Crisis

Neurosurgery is a liability-laden specialty. We know this because we treat the brain tumors and the head and spinal injuries, we perform the craniotomies and laminectomies, and we explain the traumatic quadriplegias and ischemic hemiplegias to distraught families. By virtue of the kind of work we do, the professional liability insurance (PLI) industry ranks neurosurgeons in the highest risk category.

We choose to live with this risk when we choose the specialty. The challenge attracts a personality type willing to take on the relatively high risk, compared to other specialties, for the privilege of experiencing the great rewards of improving the quality of our very ill patients’ lives.

But the risk has suddenly grown to absurd and unsustainable levels — not the risk of the neurological condition, but the risk of treating it. Annual liability premiums have increased from 25 percent to more than 100 percent: Never before have we faced liability premiums equivalent to one-quarter to one-half of personal earnings. The Council of State Neurosurgical Societies’ 2002 survey of liability premiums showed that 43 percent of neurosurgeons are considering reducing services, 29 percent are planning early retirement, and 19 percent are considering relocation: Never before have we faced such a growing exodus of neurosurgeons from states, from types of practice, or from practice altogether, forced out by unaffordable premium costs, or by the loss of all coverage altogether. The fact is that today a $1 million/$3 million policy does not protect us against the average judgment or settlement for the type of case we treat: Never before has fear of personal consequences so dominated neurosurgeons’ thinking.

The Washington Committee of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) has been working diligently to pass federal legislation that will set effective and fair limits on liability and preserve the availability in all states of neurosurgical services. In fact, the Help Efficient, Accessible, Low-Cost, Timely Healthcare (HEALTH) Act of 2003, which would, among other provisions, limit noneconomic awards in liability lawsuits to $250,000, passed the U.S. House of Representatives on March 13. The debate now moves to the Senate, where we face an uphill battle. Even so, the political landscape for reform has never been better.

How Can We Pass the HEALTH Act?
To pass the HEALTH Act in the Senate, we must effectively tell our side of the story to every person who is or may be a patient: people who need the protection of available expert medical care, but who value the right to compensation for substandard care; that is, legislators and their constituents. To do this, we must participate in a focused and organized public information campaign. Adequate funding is necessary for achieving our goal.

On March 14 the Washington Committee recommended that the AANS and CNS jointly fund a bold and aggressive public information campaign that will achieve effective federal medical liability reform. With this new funding resource, neurosurgery will lead by example and others will follow in a powerful bid to achieve passage of the HEALTH Act.

$3/Day Can Say Goodbye to the PLI Crisis
The Washington Committee recommended that each neurosurgeon pay an assessment of $1,000 per year for three years, if necessary, to pass the HEALTH Act. This war chest, combined with funds from other specialties and coalitions, will fund a public information campaign designed to build public opinion and political pressure to pass federal medical liability reform. Although the amount seems high, the lobby against the HEALTH Act is better funded, chiefly by the Association of Trial Lawyers of America, a source that is traditionally much more willing to give. Each neurosurgeon’s contribution amounts to $3 per day, only a small fraction of the current and future PLI premiums we face.

This funding campaign will, in fact, test the commitment of neurosurgeons to saving their practice and their specialty. Without full membership participation, there is no charge to lead, no campaign, and no end to the liability risk.

It’s time to stop hoping the crisis won’t affect me (it already does), to stop running and hiding from the enemy (there is no sanctuary), and to stop the rules of liability from destabilizing or destroying the practice of neurosurgery.

If we take charge of our future now, victory is within our grasp. If we fail by refusing our share of the burden, we choose capitulation. We must not fail.

James R. Bean, MD, is associate editor of the Bulletin and chair of the AANS/CNS Washington Committee. He is in private practice in Lexington, Ky.