In Rural Areas, Doctors Are Delivering Sad Message to Mothers-to-Be

When Delain Lindgren of Choteau became pregnant last year, she called her local doctor--and learned that he had dropped obstetrical services to save on spiraling malpractice insurance costs.

He was the last doctor delivering babies in the town of 1,700, so Lindgren had no choice but to look for a doctor in Great Falls, a 100-mile round trip.

Even there, she found few doctors taking new patients. “I had to wait three months before I could see one.”

But nine days before her first appointment, her baby was born at home, three months premature. The 2-pound, 15-ounce girl was taken in the Jan. 4 cold to the Choteau hospital, airlifted to Great Falls and later transferred to a Salt Lake City hospital, where she remains while her lungs develop further.

Lindgren is one of many women affected by a national shift by doctors abandoning obstetrical services, many citing malpractice costs. For women in large metropolitan areas it’s an inconvenience; in the country it can mean life or death.

“It happens in cities, but when it happens in cities, there are plenty of alternatives around. When it happens in rural areas, already there aren’t very many doctors providing that care,” said Robert Van Hook, executive director of the National Rural Health Assn.

He said there have been informal discussions in Congress about the possible use of special pools of doctors from the National Health Service Corps to assist hard-hit areas.

“Somebody’s going to have to do something pretty soon, or we’re going to end up having to rebuild those systems of care out there,” he said. “We’re concerned that . . . we’ll end up with higher infant mortality.”

A survey last year by the American Academy of Family Physicians found that just over half of its members who delivered babies had stopped doing so, said Mike Miller, the organization’s general counsel. One-third of those who quit blamed malpractice insurance costs.

“We’re very concerned,” Miller said. “The whole concept of a family doctor is to take care of the whole family. The big area of concern is in some of these isolated areas.”

Not everyone agrees that malpractice coverage is the villain, and yet the national average annual premium for doctors delivering babies has risen from $10,946 in 1982 to $37,015 now, according to the American College of Obstetricians and Gynecologists. Premiums average $52,000 in Florida and New York, spokeswoman Teri Malone said.

She said about 12% of obstetricians-gynecologists stop doing deliveries each year, and that the age at which they stop is getting lower.

Mirroring the national trends is Montana.

At least 60 of the approximately 250 doctors delivering babies in the state three years ago have quit that service, according to the Montana Academy of Family Physicians.

The vast expanse of rural Montana has never enjoyed an abundance of physicians. Now, there is too often a disheartening search for medical care that is basic yet unattainable.

In Malta, on the north-central plains, only a part-time obstetrician remains. Women travel 90 miles to Havre or 70 miles to Glasgow to see a doctor who delivers babies.

In Thompson Falls, in the western mountains, no doctors do so. The journey is 100 miles to Missoula or 90 miles to Sandpoint, Idaho.

Montana doctors say they are victims as well, paying soaring rates despite the fact that none has been hit by a fabled multimillion-dollar verdict.

Insurance executives say they have been forced to increase rates not only to cover the higher and more frequent settlements in malpractice suits, but also to build up reserves in anticipation of future damages.

But doctors pay the tab despite flawless records.

Four years ago, Dr. Jim Ashcraft of Sidney, Mont., paid about $7,000 for a malpractice insurance policy that covered claims made at any time for treatment he performed that year. This year, he faced a $19,500 insurance premium that would cover him only for claims brought by the end of the year.

If he quit the practice, he would have to pay an additional $36,000 to cover any claims brought in the future.

In 12 years of practice, Ashcraft has never been sued for malpractice in connection with a delivery.

Such cases are rare in Montana, in fact. But malpractice claims and pay-outs for obstetrical cases have been increasing here. And insurers point to those increases to justify their rates.

“Obstetrics are our loss leader without question,” said Martin Oslowski, president of Utah Medical Insurance Assn., which insures about 200 doctors in Montana. “It’s probably damn near everyone’s loss leader.”

About 15% of the malpractice claims in Montana in the last five years have been obstetric cases, but Oslowski said such cases accounted for 25% to 50% of insurance losses.

Precise figures on losses in Montana obstetrical cases are not readily available. But insurers say it is the fear of huge verdicts that not only forces them to charge higher premiums, but also to frequently settle malpractice claims out of court.

Figures compiled by the Montana Medical Assn. show that since 1982, actual payments to malpractice claimants in the state rose steadily from $1 million that year to a high of $3.8 million in 1985. They dropped to $3.3 million in 1986.

Doctors and their insurers want to deal with the problem by altering the legal system that resolves torts, or wrongful acts, such as medical malpractice. They say if tort reform is enacted to make the system more predictable, insurance rates will stabilize or drop.

An advisory council appointed by Montana Gov. Ted Schwinden is studying the issue and most likely will recommend tort-reform measures to the 1989 Legislature.

Solutions Questioned

But others question whether the rate increases are justified and whether reforming the system will really solve the problem of costly insurance or doctors quitting obstetrical services.

Dr. Sydney Wolfe, director of the Public Citizen Health Research Group in Washington, D.C., said many physicians stop delivering babies because of the inconvenience of being on call at all hours. “It’s easy to blame everything on the malpractice insurance crisis, but it ain’t so,” he said.

Karl Englund, an attorney representing the Montana Trial Lawyers Assn., added: “Everyone has looked at (the problem) only in terms of tort reform. That may result in lowering of insurance rates for doctors . . . . But it certainly doesn’t solve the whole problem of the availability of health care in rural communities.”

That problem may not be solved until lawmakers feel the pressure from women who need medical care and cannot find it, Plains physician Jacob Lulack said.

“If you took a thousand pregnant women and had them sit on the Capitol steps, we’d have this problem solved in a minute,” Lulack said.