Friday, July 30, 2004

From Medscape: Caring for Patients in a Malpractice Crisis: Physician Satisfaction and Quality of Care:
Physicians across the country have politically mobilized in response to dramatic increases in medical malpractice insurance premiums, particularly for high-risk specialists. By the American Medical Association's (AMA s) reckoning, about two-thirds of U.S. states are now in the midst of a "malpractice crisis" or showing signs of trouble. Nowhere is the problem more acute than in Pennsylvania, where several insurers have exited the market and premiums for coverage through the remaining insurers have increased dramatically.

To investigate the effects of the malpractice crisis on patient care, we conducted a series of key-informant interviews with representatives from Pennsylvania physician groups, hospitals, and insurers, followed by a mail survey of 824 Pennsylvania physicians in high-risk specialties. This paper presents findings concerning the effects of the liability crisis on specialists' satisfaction and quality of care.

Physician satisfaction is often neglected or discounted as self-serving in policy debates. In this paper we outline a framework for understanding why physician satisfaction matters for patient care and what factors influence it. We then report on how the malpractice crisis appears to have affected satisfaction in Pennsylvania and explore the implications for quality of care. Our findings from Pennsylvania are not nationally generalizable, but they do provide a lens into the environment in states in severe malpractice crisis -- a point at which several states have already arrived, and toward which many others appear to be headed.
The paper starts out with a very good question:
Why Does Physician (Dis)satisfaction Matter?

Hard evidence is lacking for some of the irritants that cause grumbling among physicians, but professional dissatisfaction deserves policy attention if it has damaging consequences for patients. Empirical studies have identified associations between physician satisfaction and a variety of measures of quality of care. For example, patients of physicians with higher levels of job satisfaction have exhibited superior adherence to medical treatment. Satisfied physicians tend to be more attentive to patients and to have higher levels of satisfaction among their patients. Physician dissatisfaction, on the other hand, has been linked to riskier prescribing practices. Dissatisfied physicians are also more likely to leave clinical practice or relocate, disrupting continuity of care and jeopardizing access to services in underserved regions.

When financial stress is a source of dissatisfaction, physicians may change the insurance mix of their patients, increase patient volume, and reduce support services. Physicians dissatisfied with liability risks and costs may also take specific steps to reduce their exposure, such as restricting scope of practice, avoiding high-risk patients, and engaging in "defensive medicine."
Sounds like a vicious cycle to me. Happy physicians seem to engage in practices that lead to better outcomes. Better outcomes, one hopes, should keep physicians from being sued. Unhappy doctors that engage in "questionable prescribing practices" may be setting themselves up for an additional title, that of "defendant". The study looks at the effects of liability concerns on the following areas of practice:income, relationships, autonomy, practice environment, and market environment. The report contains quotes from survey participants, which do a good job of summing things up. Let us have a look:

I think if it were just the malpractice situation that added financial burden, it could be absorbed. We'd raise our rates to make up for that. But we have no way of passing on that extra cost to our consumers. And so, [reimbursement and insurance costs] both play a role.
Nowadays the math doesn't work in one's favor:
I started alone in 1984, at which time my malpractice insurance was $18,000 and most people were getting $2,800 to deliver a baby. Today, the doctors are paying between $100,000 and $140,000 for malpractice [insurance], almost every patient is in an HMO, and we're getting $1,600 to deliver babies.

I heard a doctor say to a group of residents, "Every patient that comes in my office is a potential plaintiff, and that's the way I look at it." In my view, that's much more devastating to the health care system than [physicians relocating out of state].

When you are constantly looking over your shoulder and thinking that any less-than-perfect outcome is going to result in a lawsuit, it's not exactly the best psychological environment to try to concentrate on what you are doing with the patient.

Physician overhead is going up, reimbursement is going down, and doctors need to figure out how to make up this difference by either working longer hours, buying fewer medical supplies, or cutting down on certain high-risk procedures to reduce malpractice rates.

The more business [physicians] do, the more opportunity they have to pay their premiums. So access is going to be a very late victim. The first victim is going to be quality of care, in terms of how many patients you see an hour, the amount of time you give them.
A very salient point. This could mean that the frequently-cited "exodus" of physicians form certain areas may be a late symptom rather than an early sign. This turn into another self-fulfilling prophecy. That is, volume may come at the expense of safety:
"Doctors are delivering more babies per month than they should be," one head of a specialty society said. "They have to do it in order to generate enough money to maintain something of a lifestyle -- not their old lifestyle, but to just stay alive."
So, in other words, they have to work more than eighty hours a week.  There is more about the changes in market and practice environment. Mainly the respondents anticipate laying off staff. Many others have become hospital employees, joined group practices, or have restricted the amount of "high risk" medicine they practice. All factors that play into job satisfaction.

So again, why does physician dissatisfaction matter? Sounds like a great deal of whining to me. Rich, spoiled, crybaby physicians boo-hooing over their lack of "job satisfaction". Well it is important because any politician or governmental body that attempts to change (or not change) the health insurance, liability insurance, or access to care situation in this country ignores physician stakeholders at their own peril. Want examples? Start with the failed health care reform from the Clinton administration:
Moreover, the task force had neglected to identify the major stakeholders and seek “buy-in” for its health care plan. By excluding them—the insurance industry, the pharmaceutical industry, physicians’ groups, large and small employers, the media, and a multitude of others—from the planning process, the task force created a huge, powerful, and well-financed adversary.
and finish with the recent goings-on in West Virginia:
In the already overburdened Level I trauma center in the state capital of Charleston, the orthopaedic surgeons finally rebelled, faced with an avalanche of patients being transferred to their institution around the clock from outlying communities that found themselves without orthopaedic coverage or the courage to assume the risk of liability. The surgeons announced the decision to stop taking trauma call. Immediately thereafter, the hospital was downgraded to a Level III trauma center. The public perception based on the media coverage was that the hospital was essentially closed for all critical patients. The state capital was in an uproar as the legislature was about to convene for the 2003 session.....a large group of northern panhandle surgical specialists stopped all their elective cases. Hospitals in the area, which were already struggling under inadequate reimbursement, began to suffer mounting losses in income. The hospital association’s involvement in the lobbying effort intensified dramatically.....Critical portions of the tort reform bill include a $250,000 cap on noneconomic damages and a $500,000 cap on all damages for treatment of emergency conditions for patients who receive care at a designated trauma center. Joint liability has been eliminated, and each individual defendant bears liability equal to his or her percentage of fault. Collateral payments, which had not been allowed in court before, may now be presented. The “ostensible agency theory” of liability was abolished. Additionally, a committee was established to develop a patient injury compensation fund to provide for economic damages that exceed financial limits set in the bill.

I am sure it improved their job satisfaction.
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