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Christopher Fleming

Malpractice Premium Spike In Pennsylvania Did Not Decrease Physician Supply

Contrary To Survey Responses, The Number Of Physicians In “High-Risk” Specialties In Pennsylvania Who Restricted Or Left Their Practices Did Not Increase During Malpractice “Crisis”

Bethesda, MD -- When surveyed, many physicians say that they will restrict their scope of practice or stop practicing medicine altogether in response to rising malpractice insurance premiums. However, when push comes to shove, physicians’ responses to the latest liability “crisis” have been much more modest. That’s the conclusion of a new look at Pennsylvania’s experience during its malpractice crisis, by the Harvard School of Public Health’s Michelle Mello and coauthors, published today as a Health Affairs Web Exclusive.

You can read the article by Mello and coauthors, which was funded by The Pew Charitable Trusts, at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.3.w425

Using administrative records from a state-run insurance fund in which most Pennsylvania doctors must participate, Mello and colleagues looked at the behavior of physicians in “high-risk” specialties -- practice areas such as obstetrics/gynecology and cardiology for which malpractice premiums tend to be relatively high -- over the years from 1993 through 2002. They found that contrary to predictions based on the findings of earlier physician surveys, only a small percentage of these high-risk specialists reduced their scope of practice (for example, by eliminating high-risk procedures) in the crisis period, 1999-2002, when malpractice insurance premiums rose sharply.

On average during the crisis period, fewer than 3 percent of high-risk specialists shifted annually from performing major procedures to minor procedures only (0.7 percent) or no procedures (1.8 percent); 8.2 percent of specialists performing only minor procedures stopped doing any procedures, shifting entirely to evaluation and management. What’s more, the proportion of high-risk specialists who restricted their practices during the crisis period was not statistically different from the proportion who did so during 1993-1998, before premiums spiked. “It doesn’t appear that the restrictions we did observe after 1999 were a reaction to the change in the malpractice environment,” said Mello, the C. Boyden Gray Professor of Health Policy and Law at the Harvard School of Public Health.

The number of high-risk specialists who stopped practicing in Pennsylvania entirely during the crisis period was more substantial: On average, 15.5 percent left each year during 1999-2002. However, this percentage was not statistically different from the proportion of high-risk specialists who left the state during the pre-crisis 1993-1998 period, nor was it statistically different from the proportion of physicians in a comparison group of “low-risk” specialties who left the state during the crisis period.

Moreover, taking into account new physicians coming into the state, the overall supply of specialists in high-risk fields did not decrease during the crisis period, except in obstetrics-gynecology. The ranks of Pennsylvania OB/GYNs did dip 8 percent from 1999 to 2002, but “this trend had begun before liability premiums soared, and it did not accelerate noticeably afterward. Further, the total number of physicians delivering babies, including family/general practitioners, did not fall significantly as a proportion of the population during the crisis,” Mello and coauthors write.

In addition to obstetrics/gynecology and cardiology, the high-risk specialties examined by Mello and colleagues included anesthesia, emergency medicine, general internal medicine, neurosurgery, orthopedics, radiology, surgery, and urology. The comparison group of low-risk specialties included allergy, dermatology, geriatrics, infectious disease, neurology, pediatrics, and psychiatry.

Why Findings From Studies Of Administrative Databases
Differ So Much From Findings Of Physician Surveys

“Our analysis found more modest effects of the liability crisis on physician supply than have been suggested by physician survey studies, including our own,” Mello and coauthors write. In a 2003 survey of 824 Pennsylvania physicians in high-risk specialties, by the same group of researchers, “one-third or more reported their intention to retire or relocate their practices out of state within the next two years, and nearly half reported having reduced or eliminated high-risk aspects of their practices.”

Mello and coauthors identify several reasons why findings from physician surveys might overstate the effect of malpractice premium hikes on physician practice restrictions. Surveys might exhibit response bias, they note, with physicians most affected by rising premiums being the most likely to respond. In addition, “examining physician practice changes only during periods of liability crisis, as surveys typically do, provides no basis for comparison to baseline rates of such changes.” For example, the 8 percent crisis-period decrease in the number of Pennsylvania OB/GYNs looks significant in isolation but turns out to be part of a pre-existing trend.

Mello and coauthors also point out that “surveys have asked whether physicians reduced or eliminated certain procedures, whereas we measured only procedures eliminated.” Finally, physician self-reports may inaccurately predict what doctors end up doing. “One study found that only 35 percent of surveyed physicians who reported an intention to cease clinical practice within three years actually did so,” Mello and coauthors note. Physicians may change their minds, or they may find that it’s harder than they thought to make changes to their practice.

“Physicians in Pennsylvania clearly experienced considerable distress during the malpractice crisis,” Mello said. “But when we look statewide, it appears that most were able to hold their ranks, preventing the ‘physician exodus’ that many feared -- or at least forestalling it until the next malpractice crisis comes along.”


Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.


©2007 Project HOPE–The People-to-People Health Foundation, Inc.