Sunday, March 18, 2007

It Doesn't Pay to Be an Ob/Gyn

New Mexico obstetricians are crying foul over an agreement forged by the state's human services department, several managed care organizations, and the state's midwives that will allow for Medicaid reimbursement for home births yet not require the midwives to carry liability insurance.

New Mexico has unusual parity in its numbers of midwives and obstetricians. According to the state Department of Health, there are 55 licensed midwives and 144 certified nurse-midwives in the state, a total of 199. According to the American College of Obstetricians and Gynecologists, there are 146 ACOG members (plus 51 junior fellows) in the state. In 1997, the New Mexico Medicaid program was privatized, and it's now run by managed care organizations (MCOs). The state requires that MCOs carry medical malpractice insurance, and MCOs in turn require the same of all their providers.

Midwives performing home births typically do not carry malpractice insurance. When that insurance is available, the cost is prohibitive, but few insurance companies are willing to write policies covering home births at any cost. It's not that there have been a large number of expensive claims, said Roberta Moore, maternal health program manager for the New Mexico Department of Health. Insurers simply don't see this market as profitable.

The new agreement provides for reimbursement of midwives provided that Medicaid-eligible women who choose to use their services acknowledge that they are aware of the midwife's lack of insurance and formally waive their rights to pursue legal again action against the state, the MCOs, or the midwife. The relatively small number of obstetricians in New Mexico and the state's rural character helped proponents of the agreement argue that it offers women in underserved remote areas access to care that they ordinarily would not have.

Dr. Sharon T. Phelan, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, doesn't buy this argument. In an interview, she noted that family physicians frequently perform births in rural areas of New Mexico where there are no obstetricians, so these areas are not really underserved. Those family physicians have mandatory malpractice insurance.

In addition, the agreement does not limit Medicaid reimbursement to midwives in rural areas. An Albuquerque-based midwife would receive reimbursement, even though there are many obstetricians in that city, Dr. Phelan pointed out.

Furthermore, there is a fundamental unfairness in allowing midwives to go without malpractice insurance while receiving about the same fee as an obstetrician does for a birth, Dr. Phelan said.

"When you're getting paid $1,200 for 9 months of care and a delivery, there are places where docs are having to deliver a hundred babies just to meet their malpractice [insurance premiums]," Dr. Phelan said, noting that with premiums of approximately $80,000 annually, New Mexico obstetricians are getting somewhat of a bargain, compared with colleagues in other parts of the country. New Mexico authorities basically treated the malpractice insurance problem "with an aspirin, which is to say [that midwives] are an exception to the rule and they don't have to carry insurance and they could still get paid. But they did not deal with the underlying problem," which is the malpractice insurance crisis.

And she noted that when a home birth starts going wrong, mother and baby would be transferred to a hospital. Supposing the infant or the mother dies or the child has an ongoing deficit, "who's going to be sued?" Dr. Phelan asked. "It's the doctor who inherited a problem that was already in development, because he or she is the one with the malpractice insurance. We're the ones with the deep pockets, so we're the ones who are going to get dragged to court and have to spend days in depositions and in court going through all that emotional stuff on our own."


At 2:53 AM, Anonymous Anonymous said...

Well, ya know ... if docs would take a bit of a clue from midwives and stop medicalizing normal childbirth maybe they wouldn't get sued so damn much!

How often are midwives sued compared to OBs and all their drugs, devices and such?

Let the docs pay, they created their mess. They can stew in it.

At 12:29 PM, Anonymous Anonymous said...

I'm struggling to find the words to describe the ignorance reflected in the previous comment. To suggest that the malpractice suits which are rampants in the field of obstetrics are the fault of the MDs is just stupid. Anon 2:53, if you were pregnant and suffered a complication of childbirth such as a placental abruption, you had better hope to God there is an MD available to help you. However distasteful it may be, sometimes medical intervention is needed, period. I am certainly not anti-midwife, but midwives have bad outcomes too, and should be required to carry the same liability insurance as the MDs. If they want to be treated as equally skilled practioners, then they should have to pay too.

At 5:08 PM, Anonymous Anonymous said...

Does this mean that I, as a future OB/GYN, would be allowed to not carry malpractice insurance and then have my patients sign a waiver stating that they understand that I don't have malpractice and agree not to sue if I am negligent in some way? Wouldn't that be a violation of the patient's rights? Aren't midwives violating patient's rights by making them agree to this?

At 1:54 AM, Anonymous Anonymous said...

In olden times, docs could only be sued for intentional torts, as any halfwit would know that docs have only limited control over patient outcomes. If docs were in fact Gods, then no one would ever die in a hospital.

Many recent factors have contributed to a malpractice system which has nothing whatever to do with justice and most closely resembles a kidnapping ring. In the last 30 years, the value of a brachial plexus injury went from 30,000 to nearly 1,000,000. Yet the injury, and its treatment, were fundamentally the same. And the child is still well enough to be a US senator or lawyer.

The only way to deal with terrorists and kidnappers is to tell them to bug off (In medical terms-don't have malpractice!). There are busy OBs in south florida who are never sued over 20 years in one of tghe nation's worst malpractice environments. Why don't they get sued? Because they don't have malpractice ! The plaintiffs attorneys scram when they find they are working for free.

One pediatrician told me about his experience with malpractice. Two midwives did a delivery and had a brachial plexus injury. Three weeks after the delivery, the baby was brought to the pediatrician. The pediatrician was sued but the midwives were not sued because they did not have malpractice. The case against the pediatrician was thrown out twice, as he had obviously nothing to do with it. What did the plaintiff's attorney do then? He brought the case against the pediatrician a third time!

If we would all go without malpractice, none of us would be sued. If half of us would go without malpractice, only half of us would get sued. Those who maitain malpractice should not blame those who don't have it.

In the case above, for the plaintiff's atty to strike it rich, he must assert the absurd-that the pediatrician did it. When the one who is at fault has no malpractice, the plaintiff's case becomes more difficult. This helps everybody.

The good solution is for each one to go bare, and hopefully for as many as possible to do so. Until we have the guts to do so, we will all be beaten into the dirt by a system that thrives on our cowardice.

Further, the current system institutionalizes many different rules (joint/several liability and many others) which are rules for injustice not justice. Thus the plaintiffs attys are indeed thieves, but their subservient tools in the judiciary cooprerate in malfeasance.

Here is how crooked the judiciary are. The greatest injustice is the number of cases which should be thrown out but are not. Why? My brother worked in Madison county illinois, a notorious judical hellhole. One judge was appointed who aspired to inject a little fairness into the proceedings. The pliantiff's attys as a group were incensed when this judge made two simple decisions to making the playing field a little more level. The plaintiff's attys put their money together and ran a campaign against the guy, and got him thrown out at the next election.

Thus, the system is crooked at all levels. It is not just a little crooked. It is profoundly crooked. It is far more crooked than you think it is.

It is now well established and has been for a very long time that evemnts in labor and delivery have little or no bearing on long term neurologic performance, cerebral palsy, autism, add, etc. These neurologic outcomes probably relate to factors in the mother present from before birth. There is no convincing evidence that tracings, or any action based on tracings, will have any significant effect on outcome. You OBs who do not agree with me look up scientific data and ACOG opinions before speaking up for the plaintiffs Bar. Thus nearly all litigation for neurologic outcome (except shoulder dystocia) should be thrown.

The whole industry is rife with dishonesty and corruption. It needs to be defunded in the worst way. The litigation explosion outside of OB is destroying the economy.

In China, many years ago, kidnappers stole a missionary priest and held him for ransom. They requested their usual sum. The missionary priests replied, "he is not worth much-you can keep him." He was returned by sundown.

This is how you handle kidnappers and plaintiffs attys. Can we have the courage to do it?


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