Pennsylvania’s neurosurgeon supply

By Christopher Guadagnino, Ph.D.

Anecdotal reports have surfaced over the past few months that severe head trauma patients from Chester County have died because they had to be transported to neighboring counties instead of being treated locally, where there was no available neurosurgeon. Tragic incidents like these are not unheard of in rural counties that lack trauma centers, and in which emergency transport of serious cases is required from small community hospitals to tertiary centers.

But because Chester Co. has a much higher population density than the typical service shortage area – nearly half a million residents – and over the past five years has lost several full time neurosurgeons covering its five hospitals, and has lost its only trauma center, those anecdotes signify a disturbing dynamic: erosion of patient care from physician departures because of the high cost of high-risk specialty practice such as neurosurgery.

As medical malpractice insurance premiums in Pa. have spiraled upward during the past few years the physician community has vigorously warned of this erosion, and the state Legislature and Supreme Court have implemented a number of tort reforms, as well as abatement of MCARE premiums for physicians – including 100 percent abatement for neurosurgeons and other high-risk specialists. An acrimonious battle was recently waged to permit a state constitutional amendment to cap noneconomic damages in malpractice jury awards to further rein in premium costs, but the provider community lost that battle.

Whether, or to what extent Pa. is experiencing a shortage of neurosurgeons – or physicians of any kind – are notoriously difficult and heavily politicized questions, as data are difficult to obtain, consensus is lacking on how to define shortage, and political interpretations of the same data frequently clash. The provider community continues to call for limits on plaintiff attorney fees and noneconomic malpractice awards to reduce malpractice costs and attract high-risk specialists back to Pa., while an increasing scarcity of neurosurgical services may be outpacing the speed with which existing malpractice reforms are working.

Accounts by practicing neurosurgeons, department chairs, hospital administrators, regulators and health plans across the state reveal a nuanced answer to the question of whether Pa. is experiencing a growing shortage of neurosurgeons. Erosion of neurosurgical care appears particularly acute in Chester Co., while erosion is also apparent in other parts of the state, although some numerical supply data send mixed signals. Changes in neurosurgical practice patterns fueled by malpractice costs appear to be impacting patient care throughout Pa., reducing regional supplies and resulting in substantial recruitment difficulties and increases in patient travel times and office appointment wait times.

Chester County: Anatomy of a Crisis

The Chester County Medical Society released a statement in December declaring that, because of the current medical malpractice crisis, the loss of neurosurgeons from the county “now clearly jeopardizes” area residents and creates “a healthcare situation of extreme concern” for patients with brain injuries who can no longer receive immediate, life-saving intervention without any full-time neurosurgeon in the county. “The current situation is no longer safe for our patients and families, and should not be passively accepted,” the release said.

Some head trauma patients from Chester Co. have died in route to facilities that have neurosurgeons, says Perry Argires, M.D., one of five neurosurgeons in Lancaster Neuroscience and Spine Associates. Argires says he knows of two emergency patients from the Brandywine region who died during the one-hour ambulance ride to Lancaster General Hospital’s trauma center, and he says their outcome would have been different if they had been treated within that window of opportunity.

Physician advocates report that several such incidents have occurred, involving the deaths of Chester Co. patients with serious head injuries who were transported to trauma centers in other counties. According to Robert Surrick, Esq., executive director of the Politically Active Physicians Association, physicians tell him about such cases at medical staff meetings and Grand Rounds sessions at which Surrick gives presentations about Pa.’s medical liability situation. Surrick says that emergency and trauma physicians from Crozer-Chester Medical Center in Delaware Co. have told him of five cases in which head trauma patients transported from Chester Co. died either in transport or on the operating table. Surrick has hired a private investigator to get more information on the cases.

“I think, over time, just by the law of probability, there are going to be more trauma deaths because of no full-time neurosurgeons or trauma center in Chester County. It is inevitable that people are dying because they have to be transported,” says Jeffrey Yablon, M.D., a private practice neurosurgeon based in West Chester. With the county’s loss of several full-time neurosurgeons and a trauma center, “People don’t realize how little infrastructure there is to support them,” Yablon adds.

Yablon provides part-time neurosurgical care at Chester County Hospital, while he says he had to stop covering Brandywine Hospital last May because he was covering too many places at once, including Pottstown Memorial Medical Center in Montgomery County, and Temple University Hospital and Graduate Hospital in Philadelphia.

Yablon also says he had to stop performing complex cranial surgeries because of the demanding schedule of covering at multiple hospitals, and also because reimbursement – from auto insurance, workers comp and private insurance – is too low for him to make up for high malpractice insurance costs – despite four percent average annual fee increases from Independence Blue Cross over the last five years.

Yablon currently collects 28 cents on the dollar in professional charges, compared to 94 cents on the dollar when he came out of residency in 1986, and has not raised his charges in 19 years. He says he is able to supplement his income with additional sources of revenue, and noted that the MCARE abatement pays one-third of his $150,000 total annual malpractice insurance costs. Yablon asserts that MCARE abatement is a band-aid remedy that is not bringing malpractice insurers back into Pa. with competitive rates, and says he would like to see malpractice costs reduced by creating some form of expert panel to adjudicate malpractice cases and mete out appropriate payment to the legitimately injured. Health plan reimbursement enhancement is also needed, he adds, to restore hospitals’ and neurosurgeons’ ability to provide services.

Private practice neurosurgery in southeastern Pa. is not sustainable and hospitals are finding it necessary to employ neurosurgeons to keep them in their community – a barometer of a less-than-favorable economic environment, according to James Kenning, M.D., one of two neurosurgeons employed by Main Line Health. He splits his time seeing patients at Paoli Hospital in Chester Co. and Bryn Mawr Hospital in Montgomery Co., while also receiving a stipend for emergency room coverage at Lankenau Hospital in Montgomery Co.

Kenning had been in private practice on the Main Line for 16 years until his employment by Main Line Health began this January, when PMSLIC would have doubled his malpractice premium, he says. He told the Main Line Health administration that his “revenue and expenditure curves will cross,” and that he was going to change his practice location by the end of the year. “I have a drawer full of recruitment letters, but have elected not to go out of state,” says Kenning.

Kenning says he cannot certify any case in which a major trauma patient from Chester Co. has died because of a lack of local neurosurgeons, although he notes that such cases would have been routed to a trauma center and bypassed Paoli Hospital anyway. He feels the impact of fewer neurosurgeons in the region in a different way: “I have patients every day who have pain from a brain tumor and have to wait longer to see me.” As a stop gap measure, Kenning says he no longer does most of the routine patient evaluations and instead substitutes other practitioners – such as neurologists, rheumatologists and rehabilitation specialists – to identify genuine surgical patients who have urgent care needs. As a result of the time pressures, “There is little ongoing medical management in my practice,” he says.

While Kenning has been able to triage his patients by referring to other specialties, he states that, “The water can’t keep flowing downhill,” as he loads up neurologists with patients they formerly would not have seen, requiring them to push some of their patients to other physicians. This phenomenon has progressively developed in tandem with an attrition of neurosurgeons from Chester Co., making it a struggle to provide timely and appropriate care, says Kenning. “I’m seeing patients from areas I never have before, who are being referred by physicians I’ve never heard of,” he adds.

Some neurological care is also hindered without available services of neurosurgeons in Chester Co., according to Heidar Jahromi, M.D., a private neurologist with privileges at Brandywine and Chester County hospitals. He notes that he can administer medication such as tissue plasminogen activator (tPA) for acute stroke victims only if a neurosurgeon is available because it carries a risk of hemorrhage. Jahromi says he has seen three or four patients within the past six months who were candidates for this drug but couldn’t get it locally and had to be transported to a hospital in Philadelphia, where a neurosurgeon was available. In one case, he says, a stroke patient at Chester County Hospital was administered the drug, then transported downtown to be monitored by a neurosurgeon. A typical community hospital would see a candidate for tPA at least once or twice a month, Jahromi adds.

Jahromi says he has been called five or six times over the past year to evaluate head trauma patients in the emergency room, some of whom had hemorrhaging in the brain – an evaluation ordinarily done by a neurosurgeon or trauma surgeon, but neither of which were available. Such an evaluation is within a neurologist’s scope of practice, but a significant cerebral hemorrhage would require quick response by a neurosurgeon, and patient transport to obtain it, says Jahromi. There may be as many as four or five such patient transports per month from Chester County Hospital, he adds.

While hospitals in Chester Co. would like to attract replacements for the neurosurgeons they have lost, none have been successful, and some are pursuing other priorities that supercede their neurosurgical needs.

Chester County Hospital, which had the services of five neurosurgeons in 1994 and is now down to coverage by Yablon about one week out of the month, is not currently recruiting additional neurosurgeons, according to Richard Donze, D.O., senior medical officer. The frequency of the hospital’s patient transport to other facilities – not just emergency, but also inpatients needing the services of a neurosurgeon – has probably increased in proportion to those losses, he says. Given the relatively low volume of neurosurgery cases compared to those requiring other services at the hospital, such as its invasive cardiology unit, the hospital is faced with a difficult resource allocation decision. “We’re not happy about a neurosurgeon deficiency, or attention-getting cases when they occur, but limited resources must go to higher-volume services,” Donze says. The emergency transport network allows Chester County Hospital to handle the neurosurgery cases, and the hospital is trying to work out a preferred receiving arrangement with Pennsylvania Hospital in Philadelphia to expedite bed availability and facilitate those transfers, Donze adds.

One of Brandywine Hospital’s two neurosurgeons recently left for El Paso, Texas, while the other – Yablon – stopped covering the hospital last year because of commitments to other institutions, notes the hospital’s CEO Don Henderson. Despite using the national recruitment resources of Community Health System – the hospital’s owner – Brandywine Hospital for nearly two years has not been able been able to find a neurosurgeon candidate who is willing to accept reimbursement rates that are below the national average, take on the region’s malpractice liability risk and pay malpractice insurance premiums that are projected to double in three years, says Henderson.

Henderson says that the community’s need makes attracting a neurosurgeon an active priority for Brandywine Hospital, but he notes that restoring the trauma center it lost in 2002 – because it couldn’t retain or recruit trauma surgeons or neurosurgeons – faces tough obstacles, despite a state law passed last year that establishes a new, Level Three category of trauma center. The law allocates $12.5 million to Pa. hospitals that were forced to shut down or curtail trauma center services due to increased medical malpractice insurance costs, and draws $15 million in federal grants to help hospitals establish Level Three trauma centers. The new category of trauma center still requires neurosurgeons available on call, as well as a surgeon with trauma training, which Henderson says the hospital is working on securing, with difficulty.

The option of employing a neurosurgeon, for a community hospital of Brandywine’s size, would be “robbing Peter to pay Paul,” and would compromise other services, says Henderson. “We’re not ready to make that commitment,” he notes. Brandywine is in discussions with other hospitals about forging an arrangement to share subsidies for a neurosurgeon – albeit one who would only be able to provide cross-coverage at multiple emergency rooms, Henderson adds.

Phoenixville Hospital has also been unable to identify a neurosurgeon it can recruit, and would consider an employment arrangement if that were the only option a recruitment candidate would accept, according to CEO Steve Tullman. “Our hospital is an open staff. Employing neurosurgeons, by default, may end up being a necessity,” he adds.

Experience Elsewhere

Academic medical centers can attract neurosurgeons by offering career features unavailable to community hospitals, as well as subsidize malpractice costs through employment arrangements, while community hospitals have been forced either to find coverage arrangements from elsewhere or strain their budgets by employing neurosurgeons for the first time ever.

Temple University Hospital, just eight months ago, recruited Christopher Loftus, M.D., as chair of its Department of Neurosurgery. “Everyone told me I was crazy,” says Loftus, whose malpractice insurance costs in Oklahoma were ten percent of what they are now. Loftus says he came for an academic appointment, which offers professional rewards that are not typically present in community practice settings, e.g., research, administration and teaching. As an employed position, his academic appointment also covers most of his malpractice insurance, although he says he contributes a portion of it. Loftus also felt personal attraction to Philadelphia, having been from the region before leaving 20 years ago.

Loftus says Temple has hospitals from the suburban regions “knocking on our doors” to provide neurosurgery coverage in their communities, but notes that Temple’s five neurosurgeons and two pediatric neurosurgeons are kept busy staffing Temple’s Level One trauma center and being available through an on-call arrangement with Graduate Hospital. “There are days when we are stretched and taxed to the maximum of our ability,” says Loftus. “To be spread too thinly and have to travel too much – that’s lousy medical care,” says Loftus.

Abington Memorial Hospital in Montgomery County lost two of its five neurosurgeons in 2002 to other states because of untenable malpractice costs, while a third discontinued performing operations, forcing Abington’s trauma center to close in Dec. 2002, according to Meg McGoldrick, executive vice president and COO. Abington responded in Jan. 2003 by employing its remaining two neurosurgeons – to prevent them from moving to New Jersey – and making the commitment to employ two more, with the goal of being a regional neurosurgical center for the northern suburbs of the Philadelphia region, she adds. Abington hired a third neurosurgeon in mid-2003 and has been trying to recruit a fourth since then, while its three neurosurgeons now have staff privileges at Central Montgomery Medical Center in Lansdale, and Doylestown and Grandview hospitals in Bucks Co., and have offices in Willow Grove and Montgomeryville, McGoldrick notes. The number of neurosurgeons in the northern suburbs appears to be shrinking, says McGoldrick, based on the high demand for appointments to see Abington’s neurosurgeons.

A practice of four neurosurgeons based at Crozer-Chester Medical Center became employees of Crozer-Keystone Health System’s physician network two years ago, and provides services to residents of Delaware Co.

Former Scranton neurosurgeon Brian Holmes, M.D., considered a hospital-based employment arrangement before he left Pa. in 2002, but says that hospitals were not prepared to do that at the time. Instead, he relocated to Hagerstown, Maryland after his Pa. malpractice insurer converted to a claims-made policy and could not give him a firm premium quote for policy renewal with tail coverage, and after being unable to recruit a partner to his private practice for at least two years. He also had reservations about the adequacy of capital reserves of a risk retention group put together by Moses Taylor Hospital, which was offering malpractice insurance to neurosurgeons. Holmes says he chose Maryland because it dropped his malpractice insurance costs by two-thirds, and it had stronger tort reforms than Pa., including a $600,000 cap on noneconomic damages for malpractice awards. Holmes does not believe that existing Pa. malpractice reforms are substantial enough to reduce costs, and he notes that, however many times MCARE abatement is renewed, there still remains the Fund’s huge unfunded liability resting on Pa. physicians’ shoulders.

Holmes still travels to Scranton’s Community Medical Center (CMC) one weekend every other month in a locum tenens coverage arrangement for their Level Two trauma center, for which he receives a stipend and the hospital pays the Joint Underwriters Association a daily rate for his malpractice coverage. He says that two full-time neurosurgeons work at CMC’s trauma center, while four neurosurgeons work at a similar-sized trauma center where he currently practices in Maryland. Holmes also has a portion of his practice in Chambersburg, Pa., which his Maryland-based malpractice insurer covers because it comprises less than 20 percent of his entire practice. He also sees patients in his Maryland office who travel 200 miles from Scranton, both patients from his former practice who still want to see him, and new patient referrals from physicians in Scranton.

Lancaster Neuroscience and Spine Associates has been trying to recruit another neurosurgeon for three years to ease a workload that is difficult to sustain, says Argires, one of the group’s five private neurosurgeons who operate at Lancaster General Hospital. Part of that increased workload is coming from the region’s loss of neurologists – from 13 to three, which Argires says was caused by malpractice insurance costs – requiring Argires and his partners to screen patients who otherwise would have been seen by neurologists, and producing appointment wait times of up to three months to see either a neurologist or neurosurgeon.

Argires says that Pa.’s venue law, which requires malpractice cases to be tried in the county where an alleged incident occurred, has alleviated the cost burden on his practice, while he and his partners perform one-third more surgeries than they did six years ago to afford their costs. Argires’s group also switched malpractice insurers, from GE Medical Protective – which he said was raising premiums substantially – to coverage under the Central Pennsylvania Risk Retention Group, which includes 350 physicians from the region in various specialties.

Over the past three years, malpractice costs reduced the number of Wilkes-Barre General Hospital’s staff neurosurgeons from four to one, and the hospital was not able to recruit replacements, according to Thomas Campbell, M.D., vice president of medical affairs of the Wyoming Valley Health Care System. Through an arrangement with Penn State Hershey Medical Center, Wilkes-Barre now has two full-time-equivalent neurosurgeons – one Penn State faculty member whose practice is located adjacent to the hospital, as well as long-term locum tenens neurosurgeons – while Penn State continues to recruit for one or two additional neurosurgeons for the Wilkes-Barre practice, according to Robert E. Harbaugh, M.D., professor and chair of Penn State Hershey’s neurosurgery department.

Penn State Hershey’s seven neurosurgeons who rotate call schedules are being overwhelmed with trauma and elective patients, with emergency transfers every night, clinics being booked months in advance and ORs booked weeks in advance, says Harbaugh. The institution’s annual number of neurosurgery procedures and patients has more than doubled in recent years, growing from 800 cases a few years ago to 1,400 cases last year, while Harbaugh projects this year’s caseload to be 1,800.

Some of that growth reflects recent recruitment by the institution – growing from six neurosurgeons to the seven rotating neurosurgeons plus one who only does endovascular procedures, and one in State College – but Harbaugh says that there “seems to be a reservoir of neurosurgery patients who don’t have adequate services,” and notes that Penn State Hershey over the past six months is seeing more patients who are traveling from further away.

St. Luke’s Hospital and Health System lost all three of its neurosurgeons from the Bethlehem area two years ago because of malpractice costs, and had to employ two neurosurgeons to keep its Level One trauma center open, according to Marc Granson, M.D., St. Luke’s chief of surgery. Hiring specialists is a new phenomenon for St. Luke’s – which has also employed two general surgeons and two oncological surgeons within the past two years – and has become necessary to insure coverage of those services in the region, Ganson adds. The health system has since hired two more neurosurgeons, offering them malpractice insurance coverage and premium salaries as inducements – and is looking for number five in order to handle the demand, which currently entails a three-month wait time for non-emergency office appointments rather than a more acceptable wait time of two to three weeks, a shift that Granson says signifies a dearth of neurosurgeons in the region.

Western Pa. has experienced reduction and turnover in its neurosurgeon supply. The number of board-certified practicing neurosurgeons in the region has fallen almost 25 percent – to 36, from 47 in 1998 – while the region has replaced half of its 22 departures over that time, according to Pennsylvania Neurosurgical Society President Daniel Bursick, M.D., citing data from the American Association of Neurological Surgeons. Bursick notes that the county’s, and state’s, aging population needs more neurosurgeons, to handle a higher incidence of strokes and other age-related conditions. Bursick – who is part of a formerly private practice of six neurosurgeons that faced large spikes in malpractice insurance and became employed by Mercy Hospital of Pittsburgh less than two years ago – says he is seeing more patients coming from Washington and Fayette counties, a rarity two years ago.

Demand for neurosurgical services is increasing because of technological advancements as well, which allow less invasive spine and brain procedures, and use more sophisticated vascular disease imaging, according to L. Dade Lunsford, M.D., chair of University of Pittsburgh Medical Center’s neurosurgery department. UPMC’s patient referral base has also widened in the wake of neurosurgeon departures from Sharon; Oil City; and Wheeling, West Virginia, he notes. As a result, the volume of cases handled at Presbyterian, Shadyside, Children’s and VA Medical Center hospitals has nearly doubled – from 4,500 cases five years ago to 8,600 cases last year – while the number of neurosurgeons employed by UPMC, has remained the same at about 20, says Lunsford. A UPMC neurosurgeon who handled an average of 200 major cases per year five years ago now averages 350 to 400 major cases per year, which Lunsford says has been made possible by the academic medical center’s infrastructure of nurses, physician assistants, technicians and other resources.

The increased workload takes a toll on physicians, with a typical evening on call requiring five to 12 neurological trauma cases, compared to two cases per evening three years ago, says Douglas Kondziolka, M.D., a UPMC Presbyterian neurosurgeon employed by University of Pittsburgh Physicians. Kondziolka says he has had to reduce the amount of time devoted to research and teaching in order to handle his 400 procedures per year.

Sensitivity to malpractice liability has also led Kondziolka to restrict his practice. “There are operations I refuse to do because of the risk of being sued,” he says, noting that he rules out high-risk procedures and offers alternative surgeries. Kondziolka believes that malpractice concerns are driving neurosurgeons to become highly subspecialized, requiring larger-sized practices to cover a wider range of procedures.

Numerical Data Mixed

Numerical data on neurosurgeon supply provide less detailed information about severity and impacts on health care delivery than do reports of local impacts, while some numerical data do not portray shortages at all.

AMA Masterfile data show that in 2001 there were 202 practicing neurosurgeons in Pa., while that number dropped to 188 in 2003, the most recent data available, according to Stephen Foreman, J.D., Ph.D., MPA, associate professor of Health Administration and Economics at Robert Morris University. The trend of hospitals subsidizing and employing neurosurgeons may be mitigating an exodus from the state, although the statewide numbers still mask uneven supply and demand dynamics in specific regions, he notes.

The AMA data also include residents, three-fourths of whom do not remain in Pa. upon completing their residency. The University of Pennsylvania Medical School has graduated 10 neurosurgical residents over the past five years; of those, only one has remained in the state. From Thomas Jefferson University, 12 have graduated during that time and five have remained in the state. Temple University Medical School graduated four, and three have remained. The University of Pittsburgh Medical School graduated 13, of which two have remained. Penn State Milton S. Hershey Medical Center graduated five over the past five years, and none remained in Pa. Hahnemann University did not have a neurosurgical residency program during that time.

The Pennsylvania Neurosurgical Society has lost nearly one-third of its membership over the last ten years, dropping from 215 members in 1995 to 152 members currently, while membership comprises about 90 percent of all neurosurgeons in Pa., according to Bursick.

Neurosurgeon supply is also decreasing nationally, as an estimated 400 neurosurgeons plan to retire next year, while 135 will graduate from their residencies, according to American Association of Neurological Surgeons data cited by Kenning. The impact of this dynamic will mount each year and neurosurgeons will not come to Pa. if it continues to be seen as less attractive than other states because of its high malpractice costs and lower reimbursement from private insurers with market power, he notes.

Neurosurgical and orthopedic practices in nearly half of Pa.’s counties report surgeons moving out of state or reducing their surgical services since July 1, 2002, while 50 percent of neurosurgical practices claim they are trying to recruit a surgeon into their practice – and of those indicating the length of their search efforts, 88 percent of neurosurgical practices report no success for over a year, according to 72 Pa. neurosurgeons and 558 Pa. orthopedic surgeons who responded to a recent survey released by Pennsylvania Physicians for the Protection of Specialty Care, a coalition advocating for long-term liability reforms such as limits on attorneys fees, and spearheaded by the Pennsylvania Orthopaedic Society.

The threat of neurosurgeon shortage is showing up on the radar screens of some of Pa.’s health insurers, while others report an adequate supply on their provider panels. Medical access regulations for the service areas of health insurance plans, spelled out by the Pennsylvania Code and relevant to 14 specialties including neurosurgery, require that a health plan provide for at least 90 percent of its enrollees in each county in its service area access to covered services that are within 20 miles or 30 minutes travel from an enrollee’s residence or workplace in a county designated as a metropolitan statistical area (MSA) by the Federal Census Bureau, and within 45 miles or 60 minutes travel from an enrollee’s residence or workplace in any other county.

Independence Blue Cross (IBC) has over 150 neurosurgeons in its network and says that 95 percent of its subscribers can get neurosurgical services in under 20 minutes or within 20 miles, meeting state requirements and providing reasonable access to elective procedures, including those in Chester Co., according to I. Steven Udvarhelyi, M.D., senior vice president and chief medical officer. Through 2004, he has not seen a significant decrease in the total number of neurosurgeons in IBC’s service area. IBC does not have data on patient access to emergency services, and Udvarhelyi says he has not seen information about patients who are transported to facilities in other counties. He adds that IBC monitors trends in access, tracks complaints by its membership, and does not have clear cut examples of patients who are not able to get neurosurgical care.

Highmark Blue Cross Blue Shield’s supply of neurosurgeons in its managed care network has been relatively stable between 2002 and 2004, and its subscribers have good access to services, based on state regulations, according to spokesperson Michael Weinstein. In very rural counties with no hospitals or small hospitals that would not provide neurosurgery services – such as McKean, Cameron and Potter – patients would usually travel to Erie or New York for neurosurgical services, he adds.

Geisinger Health Plan currently has 23 neurosurgeons on its provider panel for a 40-county service area, down from 28 in 2002, and is concerned about access to neurosurgeons because it is at the minimum level required by state regulations, according to spokesperson Amy Bowen.

Blue Cross of Northeastern Pennsylvania (BCNP) had concerns about patient access to high-risk specialists a few years ago, and found that tracking departures and inventories was useless because numbers on paper did not tell whether or not remaining specialists had reduced their scope of practice to curtail risk, according to Brian Rinker, vice president of provider relations. In early 2003, four out of the 11 neurosurgeons in BCNP’s 13-county service area told the insurer that they were leaving the state or retiring early because of malpractice costs, and BCNP determined through phone calls that the cost burden on the remaining seven neurosurgeons was eased somewhat by MCARE’s premium abatement, and that they would continue to perform operations, says Rinker. Last year’s arrangement for Hershey Medical Center to provide neurosurgeons to Wyoming Valley Healthcare System’s hospital in Wilkes-Barre helped bring BCNP’s panel back up to 11 full time-equivalent neurosurgeons, while BCNP worries about the future of Pa.’s malpractice climate and what will happen when MCARE abatement is no longer available, Rinker adds.

Whether or not an neurosurgeon access crisis exists or is mounting in certain regions of Pa. is not conclusively resolved by looking at various sources of aggregate data. Indeed, those data have not prompted state regulators to launch an investigation of possible physician shortage in any particular medical specialty.

The Pennsylvania Office of Health Care Reform (OHCR), although it has not been called upon to collect data about any specific medical specialty, is responsible for coordinating the efforts of state departments relevant to health care access issues, according to Rosemarie B. Greco, OHCR’s director. The OHCR collates physician supply data submitted to it from various, incongruent sources, including MCARE enrollment, AMA Masterfile data and anecdotal information from health provider organizations, she says, although no one state entity is charged with the difficult task of sifting through the data to determine whether shortages exist, or to attribute controlling causes, if any, beyond malpractice and reimbursement. “The seriousness of whether or not we have enough physicians in the appropriate places has not been seriously focused on,” says Greco.

Instead of focusing on physician counts, per se, the OHCR is in the early stages of designing an assessment of the efficiency and effectiveness of health care access and delivery through Pa.’s existing infrastructure, says Greco, who hopes to have a completed assessment model by May, then conduct an assessment and report findings by the end of the year. Greco says that critically needed care services need to be defined to shape the assessment’s focus, and she notes that consensus is needed on facts and data before causes can be attributed to findings. On whether achievement of that consensus is possible in a politically contentious environment, Greco responds, “You have to try.”