Obstetrician Scarcity in Pennsylvania
By Christopher Guadagnino, Ph.D.
About three years ago, when medical malpractice insurance premiums began to spiral upward, some physicians warned that women in the Philadelphia area would have to go to New Jersey or Delaware to deliver their babies if tort reforms were not enacted. Because that has not occurred, observers may have been lulled into complacency during a time in which the availability of obstetrical services has indeed continued to dwindle in various regions of the state, putting serious stress on the health care delivery system and potentially endangering the health of women and infants.
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.
in the same area she has decided to stick around on the west coast and maybe do a fellowship next year.
