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Crisis presses OB docs

December 21, 2003 1:12 am

Still in his scrubs late in the day, Dr. James F. Hamilton talked about crises: one acute, the other chronic, both potentially fatal.

The acute crisis involved the survival of a Northern Neck baby.

The chronic crisis is a nationwide lack of affordable malpractice insurance that now threatens the survival of Hamilton's obstetrics practice and the well-being of mothers and babies in the Northern Neck.

That morning, Hamilton said, a mother was in labor at the Maternity Center of Rappahannock General Hospital next door to Hamilton's Rappahannock OB-GYN office in Kilmarnock.

About 10 a.m., a maternity nurse called Hamilton to report a prolapse of the baby's umbilical cord.

"Nobody knows why it happens. It just happens in about one in 200 births," Hamilton said.

In normal births, he explained, the umbilical cord follows the baby. In a prolapse, the umbilical cord is delivered ahead of the baby. Pressure on the cord can then strangle the baby in 10 minutes or less.

Hamilton ran across the parking lot to the hospital's operating room. Eighteen minutes later, with the help of nurses and other doctors, he had performed a successful emergency Caesarian delivery of a healthy 7-pound, 8-ounce girl.

"If we hadn't been here, that baby would be dead. There's no way she would have survived an hourlong trip to a hospital in Richmond," Hamilton said.

Hamilton, 56, has delivered more than 4,500 babies in his 21 years of practice. He and his partner, Dr. Mathew F. Vogel, are the only two obstetricians in the Northern Neck, a rural and remote region lacking in prenatal care.

Now Hamilton is worried that their obstetrics practice may end March 1, the day his medical liability insurance coverage expires.

Without that malpractice coverage for Hamilton and Vogel, the hospital's maternity ward may also close, forcing many Northern Neck mothers to travel long distances for prenatal care and delivery of their babies.

Hamilton's malpractice coverage almost expired this month.

His insurance company notified him Oct. 20 that it would not renew his coverage. His policy, which cost about $80,000 a year, was set to expire Nov. 30. He and Vogel were unable to find replacement coverage at any cost.

Ten days before the deadline, the administrator of Rappahannock General Hospital met with maternity nurses to warn them that the hospital's four labor rooms and its delivery room might also shut down if Hamilton and Vogel failed to find new coverage.

The news sent shock waves through the Northern Neck. Politicians and state health officials scrambled to find ways to keep Hamilton and Vogel in practice and the maternity center open.

"Closing that OB unit would be absolutely devastating in terms of local community health," said Del. Albert C. Pollard Jr., who represents the region. "Closing it is not an option because we'd lose a lot of babies if somebody has to drive to Richmond or Newport News."

About 250 babies are born each year at the hospital. The next-closest delivery rooms are an hour or more away in Fredericksburg, Williamsburg, Newport News and Richmond.

With seven days left on Hamilton's malpractice policy, Paul Kitchen, executive vice president of the Medical Society of Virginia, persuaded the insurance company to extend coverage 90 days, until March 1.

Even with the extension, Hamilton said he is not optimistic about finding new coverage.

"I'm discouraged," he said. "I can't get anyone to give us a quote. The companies all say they're not writing any new OB coverage in Virginia."

Kitchen said the insurance problems faced by Hamilton and other doctors in Virginia and elsewhere are "the leading edge of a crisis that threatens to limit access to health care."

"The question that makers of public policy must ask," Kitchen said, "is do you want to end up with the Dr. Hamiltons of the world out of business and leave areas like the Northern Neck with no access to health care?"

Kitchen said the Medical Society of Virginia will lobby the upcoming session of the General Assembly next year to adopt new caps on malpractice awards.

Doctors in white coats from around the state will march on the state Capitol in Richmond Feb. 4 to show their support for the changes, he said.

The insurance situation is especially severe for obstetricians, emergency-room doctors and other physicians in high-risk practices, Kitchen said. ER doctors in Fredericksburg this year managed to obtain malpractice coverage at almost the last minute, at twice the cost of their previous policy.

The skyrocketing cost of malpractice insurance played a major role in the recent decisions of four Fredericksburg doctors to drop obstetrical practice, said Brenda Beverly, office manager of Gynecology Associates of Fredericksburg.

"The insurance crisis is causing a truly epidemic loss of obstetrical care," Beverly said.

One Fredericksburg obstetrician said the annual cost of his liability coverage has doubled over the past three years, even though he has had no malpractice lawsuits filed against him.

About 2,200 Virginia doctors were forced to find new malpractice insurance this year when regulators declared one company, Doctors Insurance Reciprocal, insolvent.

For most of the years of his practice, Hamilton said, he bought malpractice coverage from the St. Paul Cos., once the nation's largest provider of medical liability insurance.

St. Paul dropped its malpractice line two years ago when its malpractice losses reached $940 million because of huge damage awards in lawsuits.

The dwindling number of companies that provide malpractice insurance has caused those remaining in the business to become more selective in choosing doctors to insure, experts say.

Hamilton thinks four lawsuits filed against him between 2000 and 2002 were the reason his insurance was not renewed.

"Obstetricians are victims of their own success," Hamilton said. "It wasn't that long ago that mothers and infants dying in childbirth was a common event. Now it's a rare event, and people expect everything to be perfect. If a birth doesn't work out just right, it's easy to sue."

The four lawsuits sought combined damages of $22.8 million. Three of the four suits have been dismissed or settled.

Hamilton would not discuss the settlements, but a Dec. 1 court order in one of his cases detailed a settlement of $365,000 in a $3 million suit filed last year in the case of a baby who suffered an injury during birth.

The infant and its mother received $202,473. Their lawyers got $162,526.

Obstetricians endure a 20-year exposure to liability after the birth of a child. Hamilton said insurance coverage for his prior deliveries will cost a one-time fee of $150,000 or more.

"We'll just have to go borrow the money and hope we can pay it back," he said.

James M. Holmes, administrator of Rappahannock General Hospital, said the Northern Neck is not a lucrative place to practice obstetrics.

Few young doctors want to join small practices in rural places, he said. Young doctors prefer to practice with large groups in more affluent areas.

Relatively few young families live in the region that has grown increasingly popular as a mecca for retirees. The average age of Northern Neck residents is the oldest of any planning district in the state.

Many young people leave the economically depressed region for better futures elsewhere. Many of the young families who stay are poor.

Sixty percent of the hospital's obstetrical patients last year were Medicaid recipients, Holmes said. Medicaid pays the hospital $1,900 for its care of a mother and newborn. The hospital's cost for those services is $3,500, Holmes said.

The Northern Neck's four counties rank among the worst in Virginia in infant mortality, low birth weight, teenage and out-of-wedlock pregnancies and prenatal care.

Along with southwestern and Southside Virginia, the Northern Neck was identified as an underserved area for prenatal care in a 1999 state survey because of the region's shortage of prenatal services and the distance patients must travel to reach them.

Unlike other areas of Virginia, public health departments in the Northern Neck counties of Westmoreland, Richmond, Lancaster and Northumberland do not provide prenatal care. The departments refer pregnant women to family practitioners or to Hamilton and Vogel.

Many times, said Holmes, Hamilton and Vogel first see their patients "when they show up at the hospital in the middle of the night ready to deliver."

"We're forced to see all these high-risk patients," Hamilton said. "It's not unusual for us to see a 300-pound mom with diabetes or some other condition that could lead to an adverse outcome.

"And transportation is a huge issue for some of our patients," he added. "Some of them have a hard time getting to Kilmarnock, much less to Richmond."

Hamilton said he and Vogel are doing all they can to resolve the insurance issue, but have yet to find a solution.

Among his options, he said, is joining a larger obstetrical practice in an urban area. He also could drop obstetrics and limit his practice in the Northern Neck to gynecology, he said.

Kitchen said doctors of the Medical Society of Virginia will lobby the upcoming General Assembly to adopt provisions of California's Medical Injury Compensation Reform Act. Among other things, MICRA limits noneconomic awards in malpractice suits to $250,000.

Virginia has a $1.65 million damage cap for malpractice awards. Verdicts now do not distinguish between a plaintiff's actual damages and noneconomic damages such as pain and suffering, Kitchen said.

The American College of Obstetrics and Gynecology calls Virginia a "crisis state" because of the unavailability and cost of insurance for OB-GYNs, the number of medically underserved areas and its history of tort reform.

ACOG says 18 other states are also facing insurance crises for obstetricians and gynecologists, but West Virginia may have helped its malpractice problems with legislative reforms.

West Virginia, where some doctors participated in a work stoppage this year over malpractice issues, passed the West Virginia Healthcare Provider Professional Liability Insurance Act during a 2001 special session.

It made coverage available through the state's Board of Risk and Insurance Management for physicians unable to obtain policies through the commercial market. More than 1,000 West Virginia doctors are now enrolled.

"Those are physicians that without this alternative may have chosen to retire early or relocate their practices," West Virginia Insurance Commissioner Jane L. Cline said.

This year, the West Virginia legislature also passed a bill to use $24 million of a Tobacco Settlement Medical Trust Fund to create new insurance for doctors.

In Virginia, the medical society's Kitchen expects legislative debates on malpractice insurance issues to be among the General Assembly's hot topics when it convenes in Richmond Jan. 14.

The session ends March 13. By then, Hamilton's insurance, his obstetrical practice and the maternity center at the Kilmarnock hospital may all have ended, too.

To reach FRANK DELANO: 804/333-3834 DelanoBigtree@aol.com