MAHONING VALLEY Doctors consider leaving as premiums continue to rise

The exodus could lead to a shortage of surgeons.
By WILLIAM K. ALCORN
VINDICATOR HEALTH WRITER
Some doctors are leaving the Mahoning Valley and Ohio, retiring early or refusing to do certain high-risk procedures, primarily because of spiraling liability insurance costs.
An Ohio State Medical Association study shows 31 percent of physicians in their 40s -- and 53 percent of physicians in their 50s -- are considering early retirement because of rising professional liability insurance costs. Overall, 14 percent of physicians are considering leaving Ohio and 30 percent are contemplating early retirement, according to the study.
Dr. John H. Agnone, a Warren cardiovascular-thoracic surgeon, said he is leaving now before physician-friendly states get flooded with doctors fleeing Ohio.
The so-called friendly states -- Wisconsin, Indiana, Louisiana, Colorado, New Mexico and California -- don't have liability insurance crises because they either have tort reform that limits punitive damages and awards for pain and suffering, or some other system to hold down costs, he said.
The Ohio Legislature passed medical malpractice tort reform twice in the last decade, but each time it was appealed by trial lawyers and overturned by the Ohio Supreme Court.
Tort reform proposal
The Ohio State Medical Association is supporting tort reform as an answer to the drastically increased rates that have some Mahoning Valley doctors saying they will have to move their practices to another state or retire. The proposed Senate Bill 281 would limit awards for pain and suffering damages.
In Louisiana, for example, Dr. Agnone said, a panel of lay people, physicians and lawyers reviews proposed lawsuits against physicians before they go to court. If the panel decides the case has merit, it goes forward. If not, the litigant can still proceed, but if he loses he is liable for the costs of everybody involved.
Malpractice does occur, and patients should be compensated for economic loss, and even in excess of that within reasonable limitations, said Dr. James Sudimack, 47, emergency room physician at Forum Health Trumbull Memorial Hospital in Warren. The real problems are punitive damages and pain and suffering awards.
"It is extremely rare that a physician deliberately harms a patient, and that is where punitive damages should come into play," Dr. Sudimack said.
Based on California law
Senate Bill 281 is based on a California law known as the Medical Injury Compensation Reform Act, which the Ohio medical association said stabilized California's liability insurance market, increased access to care and reduced the time it takes to settle a claim by 33 percent.
"I've looked at it [California tort reform], and it is very reasonable. It doesn't limit medical cost awards, it just precludes pain and suffering," said Dr. David A. Brys, an orthopedic surgeon in Warren.
Ohio, Pennsylvania and West Virginia are all in the midst of liability insurance crises. There is no downside to filing lawsuits, which are very costly to process even if the doctor wins, Dr. Agnone said.
Dr. Agnone said liability insurance costs have tripled for him, and the cost for others has risen 50 percent to 300 percent, depending on the specialty.
In losing Dr. Agnone, the Valley is losing one of its own. He was born in New Castle, Pa., went to school in Brookfield, and his parents live in Liberty.
"I'm too young to quit at 51. I like what I do. I like the patients and the contact," he said.
"But, I'm getting out of the area. ... Where to, I don't know for sure yet. I probably will be done practicing in this area by the end of the calendar year," he said.
"The economics are bad. I think most of us are looking at finding situations where we can have our malpractice insurance covered under a hospital umbrella," Dr. Agnone said.
500 percent increase
Dr. Hira Khanna, a neurosurgeon with offices in Boardman and Salem, said his liability insurance premiums rose 500 percent between 1999 and 2002.
"It is really prohibitive. If it goes any higher, then I'm out. I'll have to quit or leave. I am not ready to quit. My only reason to quit would be this insurance liability," Dr. Khanna said.
He said he does not understand how his premiums could go up so dramatically. He said he has not been sued in the past 15 years, and only two nuisance suits were filed in his whole career. There are no judgments against him.
The exodus from Ohio could lead to a shortage of neurosurgery, orthopedic, cardiovascular and gynecological surgeons -- among the medical areas particularly affected by the rising costs, Dr. Brys said.
Exacerbating the situation is the dominance of Medicare, Medicaid and private insurance carriers in medical practices, Dr. Brys said.
Medicare and Medicaid have cut fees for procedures 50 percent to 60 percent over the past 10 years, and private insurance carriers have followed suit. As a result, doctors, locked into contracts with insurance companies, cannot raise fees to offset increased costs of liability insurance and other overhead costs, Dr. Brys said.
Reversal
Ironically it used to be that physicians viewed Medicare and Medicaid cases as part of their obligation to the community, knowing private insurance would pick up the difference. Now most physicians would rather have Medicare and Medicaid because they pay better, Dr. Agnone said.
The liability insurance issue is so critical it is causing even physicians for professional sports teams to quit those prestigious and high-profile positions, said Dr. Brys, who was team physician for the Pittsburgh Steelers from 1988 to 1991.
Dr. Brys, 46, who is on the liability insurance committee of the Trumbull County Medical Society, said he also is considering early retirement.
"I've seen 15 years of degradation of my practice by oversight and dominance of insurance. That bothers me more than the malpractice insurance issue," Dr. Brys said.
Dr. Frank P. Vargo, an internal medicine family doctor, who has had a private practice in northwest Warren since the early 1960s, said he, too, has felt the pinch of escalating liability insurance costs. And, he said, a number of doctors who have retired have mentioned the high cost of liability insurance as a factor.
Situation exaggerated?
However, Dr. Vargo believes it is an exaggeration to say doctors won't come to Ohio and the Mahoning Valley to practice because of the liability insurance issue.
"We've had many new physicians come to the area, largely foreign-trained physicians, who are very good," he said.
"The only place we have a problem right now is neurosurgery. There is only one [practice] in the Warren area," he said.
Doctors say another problem caused by liability insurance costs is the curtailing of certain high-risk procedures.
Dr. Brys said that even though he is board-certified, he doesn't do back surgery anymore because of a lawsuit resulting from a very complicated case.
Doctors are less willing to do complicated, risky, long procedures with outcomes that are less predictable, and are "cherry-picking" the lower-risk procedures. The rest are sent to hospitals in Pittsburgh, Cleveland and Akron where physicians' liability insurance is provided by the institution, Dr. Brys said.
What caused the liability crisis? Attorneys will tell you it's the greedy insurance companies, and insurance people will say it's the greedy attorneys. The median settlement of a malpractice case went up 43 percent from 1999 to 2000. The average jury award now is $3 million, Dr. Sudimack said.
"When I first came out of training, the criteria for losing a malpractice suit were that there had to be damage, proof that the physician did or didn't do something to cause the damage, and that the damage caused a problem. Those criteria have been blurred. Now, you can have a patient who dies, because patients die, and you can lose a lawsuit," Dr. Sudimack said.
Even the local hospitals are feeling the liability insurance crunch.
"Patients are more likely to get transferred out of the area now than in the past. When I first started working at TMH, we transferred out spinal cases, bad burns and some heart cases. Almost everything else was taken care of here.
"Now, many of the more complicated cases, even bone breaks, end up in Youngstown, Cleveland or Akron," Sudimack said.
Doctors are caught in the middle. Patients go where their insurance company tells them to, and managed care tells doctors to accept lower payments or lose their contract. Insurance companies say pay the higher amount or your policy will be canceled and you can't practice, Dr. Khanna said.
"It's clear-cut blackmail," he said.
"I would rather stay here, but unless something happens, I may have to move or quit," Dr. Khanna said.