By Christopher Guadagnino, Ph.D.
Obstetrics is one of the medical specialties most adversely impacted by Pa.’s malpractice crisis. That it is one of four specialties to receive 100 percent abatement for MCARE premiums, and is also targeted for increased Medicaid reimbursement by the Rendell administration, recognizes that the cost of obstetrical practice is too high and reimbursement is too low for it to remain viable in Pa. without intervention.
Several health systems across the state have recently made the decision to give up OB entirely. In Philadelphia, for example, seven hospitals have closed their OB departments in the past two years, while three other hospitals that offered OB have closed altogether. Institutions and private physicians across the state that are still offering OB are picking up the slack, but are experiencing strained capacity to handle the increased demand. Pa. physicians are seeing significantly more patients, doing more deliveries – including a greater proportion of complicated deliveries, and are experiencing more intense on-call duties, while patients are seeing greater wait times and may be foregoing prenatal care. Impact is disproportionately felt by low-income patients, and the Philadelphia Health Department is scrambling to ensure that the city’s health clinics continue to offer OB services and can remain staffed with physicians.
Not surprisingly, these pressures are most acutely being felt in Philadelphia, but they are alarming in other regions, including central, northeastern and southwestern Pa., where the dwindling supply of private OBs and the closure of some hospital OB departments has similarly intensified the workload of remaining physicians to capacity levels, where active recruitment of OB/GYNs – in some cases for years – has failed to secure a physician, and where many remaining OBs are close to retirement age, potentially jeopardizing the physician workforce at any time.
Quantifying the severity of physician scarcity in Pa. is notoriously difficult. Using data from the U.S. Bureau of Health Professions and the American Medical Association, the Pennsylvania Medical Society notes that Pa. lost 40 obstetricians between 2000 to 2002, the most recent data available. Regarding young physicians, Pa. ranked 41st among states in 2000 for its percentage of physicians under age 35, a sharp decline from its 12th-place spot in 1989.
According to the 2003 American College of Obstetricians and Gynecologists Survey on Medical Liability, 12.5 percent of OB/GYNs in Pennsylvania have stopped practicing OB and 57.5 percent have made some change in their practice because of issues with affordability or availability of liability coverage, including relocating, retiring, dropping OB, reducing number of deliveries, reducing amount of high-risk OB care, or reducing gynecological surgical procedures.
Philadelphia Hit Hard
Those statistics, however, do not come close to revealing the extent of the current problem of obstetrician supply in the five-county Philadelphia region, which lost 25 percent of its staffed OB beds between 1993 and 2003, according to Delaware Valley Healthcare Council President Andrew Wigglesworth. Within the past 18 to 24 months, he says, the region lost 10 hospital OB departments, including those at MCP, Methodist, Nazareth, Warminster, Mercy Fitzgerald, Episcopal and Elkins Park; while OB services were also lost from hospital closures including City Line, Sacred Heart in Norristown and Community Hospital in Chester.
Liability issues have put extraordinary pressure on OB programs in southeastern Pa., while well over 50 percent of practicing obstetricians in the region, perhaps closer to 75 percent, have become employees whose liability coverage is paid for by hospitals, says Wigglesworth, who adds that the trend toward employed OB status in southeastern Pa. has accelerated over the past three and a half years. “It is clear that, without the intervention of hospitals to employ and cover obstetricians in the region, we would have an extraordinary crisis, in terms of availability of OB services,” he says
Some institutions regard OB as part of their mission and remain committed to maintaining OB services even though it is “an extraordinarily difficult service to provide in a financially feasible way, given the reimbursement and liability environment,” says Wigglesworth, who notes that liability costs alone have approached two-thirds of the reimbursement level.
The recent MCARE abatement has helped, and Gov. Rendell has proposed increasing the state’s Medicaid reimbursement for deliveries to $1500, from the current $1000, Wigglesworth says, but threats of reductions loom on other fronts. Next year could bring another federal Balanced Budget Act, which Wigglesworth said has taken $1 billion away from hospitals in the region.
“Surviving” OB programs in the region are mostly represented by teaching hospitals, including Hospital of the University of Pennsylvania (HUP), Pennsylvania Hospital, Einstein, Hahnemann, Jefferson and Temple.
The remaining programs have seen significant increases in their census, including their labor and delivery, post partum, and neonatal intensive care beds, according to Garry Scheib, senior vice president of the University of Pennsylvania Health System and executive director of the Hospital of the University of Pennsylvania (HUP).
Over the past three years, HUP has seen its annual delivery volume increase from 3,200 to around 3,600, with some months exceeding the monthly average. “That’s capacity for us. When you average close to 100 percent occupancy, that means there are many times where you’re exceeding your licensed capacity,” says Scheib.
HUP is working to expand its neonatal intensive care capacity, having seen its average census grow beyond 30, which is HUP’s current number of licensed neonatal ICU beds, says Scheib. From an administrative perspective, Sheib says that increase has grown faster than overall rate of growth in the hospital’s deliveries, perhaps signifying a decline in prenatal care received by women delivering at HUP – although Scheib says a broader community study would need to bear that out scientifically.
From a cost standpoint, HUP has sustained nearly a four-fold increase in overhead during the past several years, has recently had to become self-insured for medical malpractice, and continues to serve a high proportion – about 50 percent – of Medicaid and uninsured patients, says Scheib. “It is difficult to cover the full cost of HUP’s OB program,” he says, adding that an OB inpatient program with a comparable patient mix requires a minimum of 1,000 to 1,200 deliveries per year – and ideally, 2,000 – to cover fixed costs and break even. Most OB programs that closed were running below 1,000 annual deliveries, he notes.
Physicians are being challenged to handle the increased OB workload resulting from service termination throughout the region. With delivery volume up 20 percent, OBs are less able to work effectively the day after being on call, which now typically involves six deliveries throughout the night, according to George Macones, M.D., director of HUP’s OB program. Patient acuity has increased as well as volume. HUP’s OBs are seeing more complicated patients than before, and the combination of increased volume and intensity “makes for a long night,” says Macones.
The number of patients who are coming to HUP’s labor unit with no prior prenatal care has also increased – by 25 percent, which Macones says could either be a subset of the increased number of deliveries at HUP, or a sign that patients are having problems accessing prenatal care in general.
Because so few obstetricians in Philadelphia specialize in high-risk patients anymore, Macones has limited his practice to high-risk patients only, and has had to add one or two half-day office visit sessions per week to handle the increased volume.
Because HUP’s labor unit is frequently operating at capacity, “There have been a number of times where we have told the emergency room not to have the ambulance service bring OB patients here, because we couldn’t take them. That has never happened once in the ten years I’ve been here, up until about a year and a half ago. Over the past year its been fairly common – every couple of weeks we need to close the ER to OB patients,” says Macones, noting exceptions for patients who show up at HUP’s doorstep, as required by law. From talking with his peers at other hospitals, Macones believes that, when HUP is at capacity, other hospitals are generally close to capacity as well.
“If a couple more hospitals close their OB service, places like Penn, Drexel and Jefferson are just not going to be able to absorb more deliveries,” according to Macones. He does not believe that current liability reforms come close to preventing further closures or physician departures. While HUP employs and pays for the liability insurance for its OBs, Macones’ practice is not insulated from the institution’s overhead costs increases: “Last year, we were 20 percent busier and nobody got a raise in our group. That was purely because of rising malpractice premiums. I can’t believe that MCARE abatement is going to be the answer for the woes of OB/GYNs in Pennsylvania,” he says.
Macones’ practice is busy enough to add another physician, and the group thought about doing so, but found that malpractice insurance for the next fiscal year is too costly to do that without taking unacceptably large pay cuts. “If we get to the point where our malpractice is so high that our salaries go down appreciably, why would anyone stay?,” he adds.
HUP has taken other measures to manage the increased workload on its obstetricians. Two years ago, it was rare for HUP to refuse OB transfers from other hospitals; now the hospital is closed to OB transfers “at least one-third to one-half of the time,” says Macones. So far, he notes, HUP has been able to find alternate hospitals for those patients.
To further consolidate the work efforts of its OBs and limit the number of patients that enter the its system, HUP has discontinued sending its OBs to two city health clinics, Macones adds.
The eight district health centers in Philadelphia that provide prenatal care are under a tremendous amount of pressure resulting from malpractice costs and hospital OB closures, making it increasingly difficult to retain OBs from the region to provide care at the centers, according to Kate Maus, director of the Division of Maternal, Child and Family Health, Philadelphia Department of Public Health. “A number of practices have left us or have threatened to leave,” she says, including the departure of HUP’s OBs from two centers in West Philadelphia – although she notes that HUP has agreed to see patients from one of the clinics, at HUP.
Other centers, which used to have more than one OB practice offering multiple sessions per week, have lost all but one practice and have cut back to fewer sessions, increasing wait times for patients and forcing the Health Department to seek contractual arrangements with other entities to offer care at other sites, says Maus.
Because hospitals are doing many more deliveries than they are accustomed to, and wait times are increasing for prenatal care, Maus says the Health Department would expect to see some impact on outcomes, but notes that no data demonstrate that yet. The Department is monitoring C-section, morbidity and mortality data, but is limited by the timeliness of birth record data to detect correlational trends, which can mean up to a two-year time lag between data collection by the state Health Department and the Cost Containment Council, and the ability to draw conclusions, says Maus.
“We don’t know whether we have an ‘appropriately lean’ system or a problem until it shows up as an increase in morbidity and/or mortality,” says Maus. That neonatal ICUs are at capacity more regularly than they have been in the past, could be a sign that mothers are receiving less prenatal care, or it could plausibly indicate better management and higher survival rates of high-risk deliveries, she notes.
The Department remains committed to providing prenatal care at all eight centers, and is implementing measures to address cost and physician availability pressures, says Maus, including managing transportation difficulties when women must travel further to deliver their babies; meeting with hospitals, HAP, and community organizations to discuss issues related to access to care; considering hiring staff for the centers; and considering other models of prenatal care that could produce cost savings, such as group sessions.
Access to prenatal care is being affected outside the city clinics as well. New patients have had to call several physicians before finding one that was available to offer prenatal care, according to Ann Honebrink, M.D., medical director of Penn Health for Women at Radnor and president of the Pennsylvania Section of the American College of Obstetricians and Gynecologists. A woman will average 12 to 15 prenatal care visits over the course of a pregnancy, and would typically have her baby delivered by the physician group that provided the prenatal care. Now, says Honebrink, patient load is so great that some OB groups are not accepting patients for prenatal care, and are only taking late-term pregnancies.
Access to non-OB women’s services is also suffering. Groups that are handling an increasing volume of prenatal care visits have to compensate by increasing wait times for routine GYN patient visits. The wait time for new GYN patients at Honebrink’s practice, she says, has gone from one month to nine months.
The need for OBs to see 25 percent more patients in a day may be impacting the quality of individual office visits in less tangible ways. A physician in a private OB/GYN practice who might have seen 15 to 18 patients per day in office sessions may now have to see 22 patients. “On routine days, I find I can’t be as personable. That changes the doctor-patient relationship and makes me enjoy my job less. I will take the extra time with a patient who has a problem, and the real impact is when I have a busy day,” according to Joan Zeidman, M.D., a shareholder of Bryn Mawr Womens’ Health Associates, a four-physician, private group that as of June 1 is losing one physician who is moving to Maine.
Zeidman says she frequently hears from patients that they tried to see her a month or two ago, but couldn’t get an appointment because the practice’s phone line was busy.
Zeidman, who is on staff at Main Line Health’s Bryn Mawr Hospital, also notes that her practice’s delivery volume has increased to 780 in 2003, up from about 400 to 500 two or three years ago. Main Line Health’s three hospitals have lost 25 OBs – who have either curtailed OB or left the region over the past four to five years, while some OB groups have also limited their practice to only one hospital because they have been so busy, she adds.
To manage the increased volume of on-call coverage, OB groups are joining other groups for cross-coverage arrangements on nights and weekends. The arrangement has caused some disappointment among patients who have had their babies delivered by another practice’s physician, Zeidman says.
On the reimbursement side, Zeidman says that southeastern Pa. has the lowest private insurance reimbursement rates in the U.S. for OB, noting that her practice’s reimbursement has fallen to under 50 percent of its charges, compared to 70 percent in 1991, and that the MCARE reimbursement has helped some, but has not slowed the cost increase of primary malpractice insurance coverage. A particularly busy patient load has permitted her practice to remain viable, she says, noting: “We’re not in the red, but every year we’re taking home less and less in order to stay viable and at some point we’re not going to be able to.”
Central Pa. Pressured
Over the past few years, Lancaster has lost OB programs at St. Joseph and Community hospitals, while OB programs at three hospitals have been consolidated at one location within the Pinnacle Health System, and one out of eight private OBs in the region has left or has discontinued OB because of malpractice costs, according to Virginia Hall, M.D., associate professor of OB/GYN at the Penn State Hershey Medical Center, and House of Delegates member of the Pennsylvania Medical Society and the American Medical Association.
Hershey, which used to have 13 OBs performing deliveries three years ago, now has seven because of departures to more lucrative offers in other states, creating a burden on remaining OBs to cover residency training and on-call duty, notes Hall. Only half of the larger OB practices in the region are doing deliveries anymore, she adds.
“Our work has doubled, with GYN surgeries and demands of research and teaching on top of that,” says Hall, noting that Hershey’s 13 OBs had been performing about 100 deliveries each month – averaging about 90 per year for each physician, while its seven OBs performed 107 deliveries this March – averaging about 180 per year for each physician. Each physician is on call twice as often as he or she used to be, and new federal regulations restricting medical residents to 80-hour work weeks has further reduced the on-call physician supply, she notes.
Office scheduling is also impacted by the increased workload. For the past 18 months, Hall has only seen new patients who are relatives of her existing patients and do not have an urgent problem, or patients referred by other physicians in her network. Her office visit volume is up by about one-third and her practice is restructuring its scheduling to see OB patients only on some days, with no GYN visits at all for some weeks. Instead of scheduling early prenatal visits at four-week intervals, Hall’s practice is extending the time between visits for healthy patients to five- or six-week intervals. Hall says she is seeing more second-trimester patients for first visits than in the past, which she says may be indicative of patient access issues.
Hershey’s inpatient OB unit now frequently is alerted to “expedite all discharges,” and is at capacity most of the time, making it challenging to restock supplies between patients, according to Hall. “We’ve had a number of times when we’ve had to hold back deliveries until someone went home, to secure a bed,” she says. The capacity challenge is further aggravated by a nursing staff shortage, adds Hall.
The hospital would like to recruit three or four more OB/GYNs and has had positions unfilled for three years, says Hall.
Northeastern Pa. Vulnerable
The thin supply of community OB/GYNs in northeastern Pa. similarly offers little buffer against crisis, as seen in the Scranton-Wilkes Barre area in early 2003 when a large OB practice that performed the majority of deliveries in that region had temporarily dropped OB, then started it again when Rendell promised MCARE premium abatement.
Threats of a “meltdown” in OB services in northeastern Pa. have eased somewhat, but the problem has not gone away, according to Eric Bieber, M.D., chief of OB/GYN for the Geisinger Health System, who continues to see OBs leave across the health system’s 31-county service area. “In our region, there’s the constant threat that private OBs are living on the very edge and are close to shutting down,”says Beiber. “If there are 10, 20 or 30 percent increases in the cost of malpractice over the next 12 to 24 months, you will see a number of physicians cease to practice,” he adds, noting that his own patients drive substantial distances, suggesting that OB access difficulties may presently exist.
Last spring, Geisinger Health System stopped delivering babies at its community-based Bloomsburg hospital, partly because of liability insurance costs, and also discontinued deliveries at its Sunbury hospital because of difficulty recruiting an OB there, according to Geisinger spokesperson Mark Davis. While prenatal care is still provided at those hospitals, deliveries are now performed at Geisinger’s Danville campus, about 20 to 35 minutes further away.
To ensure that its service area has an adequate supply of OB clinicians and facilities, Geisinger continues to recruit and hire physicians using a large, aggressive, nationwide staffing office for recruitment in order to counteract the negative image held by candidates who are leery of Pa.’s malpractice environment, says Bieber. That effort, combined with the ability to cover new OBs’ malpractice insurance entirely under an employed arrangement, has allowed the Geisinger system to recruit 13 OBs over the past two and a half years, resulting in an OB workforce of 33 physicians to handle a workload that has increased by about 35 percent over that period, Beiber adds.
Western Pa. Impacted
Some 18 months ago, Laurel Highlands OB/GYN, a three-physician OB group that was doing over 50 percent of the deliveries in Fayette County’s Uniontown Hospital, was forced to drop OB because of malpractice insurance costs, according to Lawrence Glad, M.D., one of the group’s physicians. About half of Fayette County’s deliveries are by women on Medicaid, who frequently have more complications and require the most visits, and whose insurance reimburses at a significantly lower level than private payors – and has not significantly increased since 1983, says Glad. The combination of low reimbursement from private insurers, a high Medicaid patient mix and increasing malpractice insurance costs meant that the group was literally losing money by providing OB services, with 65 percent of its work hours being spent to make less than 45 percent of the practice’s income, says Glad. “This is a decision we were forced to make,” he adds.
Uniontown Hospital never offered to subsidize Glad’s malpractice insurance. “If you’re in a poor, rural area, sometimes the hospital doesn’t have the funds to do that,” says Glad, adding that one or two hospitals in the region are even thinking of closing altogether because of financial difficulties.
Glad’s group has no immediate intention of returning to OB practice and has recently been granted a Rural Health Clinic designation that will allow its GYN services to be subsidized by the federal government, while it is rid of the daily fear of being sued, says Glad. The MCARE abatement does not mitigate matters, he says, because there is no guarantee of relief beyond a few years and it does not address causes of rising malpractice costs – a reversal of which is the first change that Glad says needs to occur before considering returning to OB. “What message would it send to patients if we came back to OB, then the problem came back?” he asks.
After Glad’s group dropped OB, Uniontown Hospital was left with four OBs performing deliveries, and has since brought in two more, one who came from West Virginia – which has a worse malpractice crisis than Pa. – and one who came from Frick Hospital in Westmoreland County, which closed its OB unit last November, says Glad, who is director of OB/GYN Department at Uniontown Hospital. He notes that the average age of the hospital’s OBs is over 60, making the hospital vulnerable to their retirement. “We can go from six to two in 12 months,” he adds.
Frick Hospital closed its OB services because it had lost three of its four obstetricians and couldn’t recruit replacements, even when offering 100 percent subsidy for malpractice insurance, according to Donald Kettering, M.D., the hospital’s medical director. “We went with a national recruiting firm that told us, ‘Pa. is the biggest exporter of physicians,’” he notes.
Physicians now travel from Westmoreland Hospital to handle prenatal office visits in Frick’s region, and the hospital is attempting to recruit more OBs to handle the increased patient volume coming from Frick, according to Sam Raneri, CEO of Westmoreland Health System. Although recruitment efforts have been difficult so far, Raneri believes that the six full-time OBs who currently work at Westmoreland – three of whom are in private practice and three who are employed by the hospital – offer a more attractive call coverage arrangement than Frick could offer. Westmoreland’s recruitment goal is for one or two additional private OBs, and the hospital is not offering to subsidize their malpractice insurance, says Raneri.
There are currently 12 actively practicing OB/GYNs in Westmoreland County, down from roughly 28 five years ago, according to Monica Philipkosky, M.D., one of two physicians in Westmoreland Obstetrics and Gynecology, and who is among the physicians traveling to the Frick Hospital region to handle prenatal visits. Latrobe Hospital used to have seven or eight OBs; it currently has two, she adds.
The resulting increased workload on Philipkosky’s practice has resulted in a six- to seven-month waiting list for new patients and for routine OB/GYN visits by existing patients, which Philipkosky says is the same situation with other OBs in the region. Whereas she used to see 25 to 30 patients per day, she currently averages 40 per day, including outpatient surgery over lunch time. Some of her exam patients have refused to be seen by a nurse practitioners or physician assistant, both of whom were recently hired by Philipkosky to handle the increased patient volume.
Because of high patient volume, high malpractice insurance costs and low reimbursement, Philipkosky has also had to limit her practice by no longer accepting Medicaid patients for GYN services.
Despite aggressive efforts for two to three years, Philipkosky has been unsuccessful in recruiting additional physicians to join her practice.
The situation is not sustainable over the long-term, she says: “I’m probably going to have to cut back OB within three years.”
Access issues related to OB scarcity are also visible in Allegheny County, as recent OB department closures in the region – including those at UPMC Passavant in Feb. 2003, St. Francis Medical Center in Jan 2001 and UPMC McKeesport in December 2000 – have concentrated OB patients at fewer institutions, while hospitals are also having difficulty recruiting OB/GYNS.
Although the birth rate has been declining years in Allegheny County and the Tri-State area, OB patient volume at Allegheny General Hospital has not decreased, while its demographics have shifted to a considerably higher number of high-risk, complicated pregnancies, according to Eugene Scioscia, Jr., M.D., chair and residency program director of the hospital’s OB/GYN department. Scioscia believes that the shift signifies fewer physicians practicing OB in the region, fewer practicing full-time, or fewer OBs who are willing to manage complicated cases because of malpractice costs. The hospital’s neonatal ICU is now typically at capacity, a rarity in the past, he notes.
Appointment backlogs have doubled the wait time for routine, uncomplicated visits to the hospital’s OBs, now requiring a six-month wait, says Scioscia.
Scioscia anticipates that OB/GYN availability will be even more scarce in the future, noting that there has been a marked decline over the last two years in the number of medical students applying to, and enrolling in OB/GYN programs. Nationally, only 68 percent of OB/GYN residency slots were filled with U.S. medical graduates last year, and Scioscia expects an even lower percent this year. The figure is ordinarily near 100 percent, he adds. “As we interview these medical students, we see more concerns about lifestyle: they are willing to sacrifice income and work reduced hours,” Scioscia notes.
In past years, it would be common for half of the OB/GYN residents from Magee-Women’s Hospital to remain in the region, whereas only six of those completing residency at Magee between 1998 and 2003 have remained, and all others have left the state, according to Dennis English, M.D., medical director of Women Care Associates at Magee-Women’s Hospital.
There is little reason to be optimistic that the region will be able to retain OBs in the coming years, says English, who notes that only one out of nine residents finishing this year is expecting to stay in the region. One of the reasons besides malpractice costs, he notes, is that private payor reimbursement for OB services in western Pa. is 30 percent lower than the national average.
OB/GYNs are also reducing their scope of practice at younger ages than seen before. One-quarter of OB/GYNs at Magee-Women’s Hospital who are under age 50 no longer do deliveries, whereas in the past they would continue doing deliveries until their late 50s and early 60s, says English. In 1996 there were 63 OB/GYNs doing deliveries at the hospital. There are currently 39, he adds.
“Western Pa. is near a crisis regarding women’s health care issues. We are unable to be competitive with the national market in attracting young OBs,” says English. “It is just a matter of time until we age ourselves and won’t have OBs to meet the demand.”