Indemnity Problem May Be A Case Of Poor Diagnosis
Sydney Morning Herald
Tuesday January 23, 2001
The best way to stop the increasing cost of doctors' professional insurance is to make the health system safer, writes Merrilyn Walton.
Doctors would have us believe that they are being sued so often that insurance costs are driving them out of business, and they say specialists are leaving because of high premiums. But a few anecdotes are not evidence.
Recent research involving New York obstetricians, who pay $US92,000 ($167,000) a year for indemnity insurance, showed no link between increases in liability premiums and the likelihood that obstetricians would stop delivering babies. Quality of life and practice activities were more important.
If younger Australian doctors are not attracted to the specialty, it could be they want more than five hours' sleep and to spend more time with their partners. This is a significant issue for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Its proposal to survey members about their plans is a good idea and long overdue.
Between 1991 and 1995, a national review of compensation and professional indemnity established a birthing issues sub-committee, which examined the issues now being debated and recommended useful reforms. But the Australian Medical Association and the medical defence unions bagged the proposals and they were relegated to the dustbin. Now doctors say the community should subsidise their insurance for their private patients.
Yet even back in 1992 obstetricians were earning between $320,000 and $550,000 (latest available figures based on Medicare gross fee-based incomes). It would be more now. And the $60,000 paid by obstetricians today for premiums is tax-deductible.
If practitioners can't meet overheads, they should change the way they do things. However, if doctors started rearranging their finances and going ``bare" (without insurance) it would be another story. This would be of public interest. During my time as NSW health care complaints commissioner, a number of doctors facing disciplinary proceedings were found to be without cover. The problem would be resolved by making professional indemnity mandatory.
There is an argument for assisting full-time salaried staff specialists in public hospitals. They earn about $176,000 and do not make the money their colleagues in private practice do, while their income from private patients pales in comparison.
If premiums rise too steeply, they might not be able to afford them. They are fully covered by the Government for their public patients but not private patients. Government might consider covering catastrophic damages awards to private patients or permitting doctors to access their own trust funds to cover their indemnity for private patients.
The recent premium increases are double what doctors expected and single out the high-risk categories of practice rather than ``frequent flyers" those doctors with the most claims against them. It is important that we know which are the high-risk procedures and the number of doctors generating most payouts.
Why have premiums for obstetricians increased when the Government has for the past two years paid full coverage for private obstetricians for their work in the public system, where most babies are delivered?
With a monopoly in NSW, the insurer, United Medical Protection (UMP), maintains that data about the type and number of claims are commercial-in-confidence. Does it fear that disclosing detailed information will generate claims? It might do the opposite give doctors data about outcomes and make potential patients aware of the risks.
Further, UMP is not subject to the regulations governing insurance companies and does not face the usual accounting, actuarial and prudential requirements. Large premium increases in a climate of uncertain viability can be a recipe for instability. Members could seek interstate insurers offering more attractive packages, leaving the home organisation with members who have the highest risk.
Treat the causes not the symptoms. Doctors are expert in distinguishing symptoms and causes of diseases but not when it comes to diagnosing their own problems. Government tweaking of medical indemnity and the legal system is of only limited value in the long term. Tort reform is not the only solution and continues the trend of treating symptoms and not causes.
Many believe making it harder for patients to sue will solve the problem. Yet we know that patients do not readily sue if doctors are immediately honest about mistakes and give detailed information. A 1992 study showed that just under half a million patients suffered an adverse event, but that there were only 1,500 cases for damages for the same period.
We need to shift the focus away from the legal system and protecting doctors to protecting patients within the health system. Making the health system safer will reduce the number of claims against doctors.
© 2001 Sydney Morning Herald