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Florida's Rural Medicine:
CAN SOMEONE CALL A DOCTOR?
Florida's Rural Medicine

Live out of town? When it comes to health care in Florida, you're increasingly out of luck, too.

As the Florida legislature charged into the fray between doctors, lawyers, and patient advocates in 2003, all seeking relief from sky-high medical malpractice premiums, at least two things were certain: Insurance rates for doctors had spiraled out of control; and patients, especially in rural areas, were losing out. No one knew for sure who was to blame; they just wanted to blame someone else.

Two years earlier, the alarm on medical liability had sounded. Policymakers and the health care community called for action as the country became mired in its fifth medical malpractice insurance crisis in as many decades. And almost as reliably as a law of nature, Florida quickly leapfrogged to the fore of the nationwide debate.

For every year since then, some Florida doctors could have invested in a new home per year for the premiums they were forking over for malpractice insurance. Though on average a Florida internist paid $35,000 for insurance, a 2002 report by the U.S. Department of Health and Human Services found that Florida obstetricians were slapped with the highest premiums in the country, up to $211,000 annually to cover costs in case of a malpractice lawsuit for a birth defect or other potential delivery complication. Florida surgeons were shelling out up to $124,000 a year, out-paying their counterparts in all other states. And rates continued to rise before stabilizing in the past year. In De—C. 2006, the American Medical Association reported that annual premiums for general surgeons and obstetricians in Dade, Fla., had almost reached the $300,000 mark.

Meanwhile, obstetricians and surgeons in California, which capped medical liability payouts more than 25 years ago, were paying maximum annual rates of $72,000 and $49,000 respectively.

But in Florida, the finger-wagging and name-calling continued. Doctors testified in 2003 legislative hearings that they were leaving the state or cutting services. Lawyers and insurers countered that this simply wasn't true. But doctor head-counting aside, no one had bothered to collect hard numbers on the services offered by doctors who were staying put.

The turmoil prompted a team of researchers from FSU's College of Medicine to determine what was really going on. They surveyed both urban and rural doctors in 2003 and 2004, before and after the state legislature finally agreed in the fall 2003 special session on a half-million dollar cap on non-economic damages, such as pain and suffering, in hopes of reining in insurance rates.

What the researchers found was likely already taking a heavy toll on patients—most severely in rural areas where physicians have historically been in short supply. In a series of five articles published in the Archives of Internal Medicine and other journals, the researchers reported that doctors were slashing high-risk and preventive services such as emergency care and vaccinations at alarming rates.

Doctors shunned at the highest rates services that attend to the two most inevitable facets of life: birth and aging. They stopped or cut back on deliveries and nursing home care.

More than half of rural physicians in the first survey answered that "difficulty with finding or paying for medical liability insurance" played a large role in their decisions to cut services. Another 40 percent said it played "some" role. Indeed, physicians' actions bore out their words. Nearly 63 percent of doctors who reported the highest premium hikes reduced or cut certain services entirely. In comparison, of the physicians who experienced the lowest insurance rate increases, 47 percent said they were making cutbacks in care.

New laws capping payouts proliferated in various states, but the medical malpractice climate is still hostile in more than a dozen including Florida, as gauged by the American Medical Association.

As the FSU study suggests, nowhere is the crisis being felt more severely than in rural communities.

Researchers and policymakers have long recognized that rural residents suffer from limited access to doctors and medical services, particularly specialized care. In 1991 the Florida Legislature established the Office of Rural Health to address rural patients' needs. In 2002 the office released a plan to address the problems of rural health care, and tacitly acknowledged that the challenge is formidable.

As the plan described, rural areas tend to have relatively high infant mortality, attract too few physicians willing to practice in small towns, and in general have poorly equipped hospitals and unstable financial situations.

In recognition of the same problem repeated across the country, U.S. lawmakers early this year introduced a handful of bills, including one that would give rural doctors tax relief. The question of whether these initiatives and the caps on damages in malpractice lawsuits, which can result in multi-million-dollar awards to patients, will ultimately result in better rural care could go unanswered for years.

In the meantime, two of the College of Medicine < http://med.fsu.edu/> researchers who conducted the surveys talked to Research in Review about the highlights of their analysis, their views on the current situation in rural health and where to go from here.

Nir Menachemi is an assistant professor and director of the Center on Patient Safety, and Dr. Ken Brummel-Smith is a professor and chair of the Department of Geriatrics. -—C.S.

RinR:Is Florida facing a rural health care crisis?

Menachemi: Let me just paint the picture. (We found) more than half the physicians (in Florida) are cutting back on services. In some cases, individual services are being cut at 50, 60 and 70 percent. Doctors are leaving practice or saying that they can't afford to stay in practice anymore. And the patient is left to prove that something is actually wrong. I think anyone looking at it would say there are serious problems going on.

Brummel-Smith: And the crisis isn't restricted to Florida. Sen. Lisa Murkowski from Alaska called it a national crisis (on February 16) when she called for hearings in rural health care.

RinR:In your opinion, what is the biggest contributor to the crisis?

Brummel-Smith: Probably the biggest is the closing of many rural hospitals. Transportation is a big issue for all rural people, but it's really a problem for elderly. With rural hospitals closing, they just don't get care until an emergency occurs. This has been going on for about 5 years and is increasing. Just near us, Gadsden Community Hospital closed last year and still hasn't reopened.

From the physician's side, the gradual reduction in the numbers of physicians choosing primary care fields—family medicine and internal medicine—is the biggest issue. With fewer primary care providers, older people have to go into larger towns to see a doctor. That feeds back into the transportation problem.

Everything is connected to everything.

RinR:Your studies focused on the effects of high medical malpractice insurance rates on physicians' services. How do these premiums come into play?

Menachemi: We identified a variety of different trends in our study—how malpractice insurance was affecting access to care. Vaginal and C-section deliveries, for example, were being scaled back. Rural family physicians do a lot of the deliveries, and that's the first thing that gets dropped.

On the urban side, there's more slack in health care. If a few people are eliminating services, there are other people to pick up the slack. Whereas in the rural setting there is no slack.

The $500,000 cap on non-economic damages set in 2003 may have helped. But there are some holes in the cap, especially related to emergency care. As long as there are holes, they defeat the purpose of having a cap.

RinR:You comment in your study that Florida has one of the most alarming medical liability environments in the country. What has contributed to this?

Brummel-Smith: I put the blame on all the parties equally. The ambulance-chasing nature of the legal system is the most aggressive I've seen in any state I've been in, and I used to live in California. On the other side, I think patients are more demanding and less understanding of the reality of medical care being an uncertain kind of practice. And we're not doing a good job either as physicians and making sure our quality is good. The reality is that Florida has one of the highest Medicare expense rates and one of the lowest measures of Medicare quality.

RinR:What does this mean, overall, for the health of rural citizens?

Brummel-Smith: There's been a tremendous increase in providing preventive services in the last 20 years, which is in part why we've seen a fall in a lot of the major chronic diseases like heart disease and stroke and even some cancers for the first time.

Those drops haven't been seen in the rural areas. Nationwide, there are so few physicians in rural areas that physicians aren't available to provide preventive services.

RinR:Backing up for a minute, in Florida who are the rural citizens?

Menachemi: When I first came to Florida, I didn't think of Florida as a rural state. But as it turns out, there are about 1.2 million people living in rural Florida, which is more than the number of people living in some traditionally rural states.

Those who live in rural areas are on average sicker, have more chronic conditions. There's a large minority population. They're also poorer and more likely to have issues with transportation. Compounding (these factors) is a lack of insurance or dependence on Medicaid.

RinR:At the moment, medical malpractice rates in Florida have stabilized. How will this affect access to care?

Brummel-Smith: That's good news. The bad news is because of the Iraq war, there is still this huge financial pressure on the government to cut back on Medicare spending. The Medicare spending plans that they're talking about are private models of health care savings accounts based on ownership society ideas where (patients) take responsibility.

But the people who can't take responsibility because they're too sick are the ones who cost the most…and aren't going to make decisions about which plan and which co-pay and which deductible they should choose. I think the crisis is going to get worse because of these plans that some people think will be beneficial.

RinR:Speaking of Medicare, your surveys revealed that two-thirds of rural doctors whose practices are largely dedicated to treating Medicare patients trimmed services. What's prompting these cuts?

Brummel-Smith: Medicare is the best thing that could have happened to older people as far as their medical care. But the government hasn't adjusted its payment rates to physicians.

When Medicare was originally designed, it was looking at the average internist and family physician. In both those cases around 20 percent of their patients would be elderly. The other 80 percent would be private pay and younger people…who allow your practice to stay afloat.

But if a doctor is living in a rural area and has 80 percent older patients, there's no way the practice can make it.

RinR:What about Medicaid? Your survey found that 40 percent of physicians practicing in rural areas were not accepting new Medicaid patients. Why is that?

Menachemi: Most physicians see Medicaid as the least generous reimburser-much more so than Medicare. As a result, many physicians are unwilling to see Medicaid patients because doing so would threaten the financial viability of their practice.

Also eroding the relationship between the Medicaid recipient and the physician is the perception among doctors—which is based on some good facts—that Medicaid patients are more likely to be no-shows because of transportation or other issues. Some doctors will double or triple book Medicaid patients, which creates other problems.

Brummel-Smith: Another problem with Medicaid is that it started, with Medicare, in 1965 as a parachute for people who suddenly became poor and needed some coverage for a period of time. But now the country has a population of people who are often unemployed and have no access to health care insurance. We're one of only two countries that tie medical insurance to employment.

The other aspect that's really changed since 1965 is the growth of the elderly population. Nationally, up to 60 percent of a state's Medicaid expenditures go to long-term care—mostly nursing homes—which means less money is available for patients in doctors' offices or outpatient clinics.

RinR:How does the country get out of the current malpractice climate and degrading Medicare and Medicaid cycle?

Menachemi: It is depressing because other countries seem to be doing the access part of health care better than us. By educating policymakers that there is indeed a problem, and it is quantifiable, and it is affecting people, I believe policies can be crafted to improve the system.

Brummel-Smith: I think a national health insurance plan is necessary. If you were assured you were going to get health care, I think people would feel a lot less worried. I think that's why people in other countries sue a lot less than they do here. The rate of suits in Canada, for example, is a third of the rate of suits here for the same kinds of problems.

RinR:In your 2003 survey, nearly 20 percent of the rural doctors identified themselves as Asian although Asians aren't well represented in rural Florida. First of all, where are these doctors coming from?

Menachemi: Another study has found that doctors in Florida practicing in rural areas are more likely to be international medical graduates, and typically from one of the countries in Asia: India, Pakistan, China, Korea and other surrounding countries. That fact has serious implications—after 9/11, for example, changes in visa requirements had the chance to impact Florida's rural physician supply more than anyone else.

RinR:With rural Florida facing a shortage of doctors, would the growth of foreign-trained physicians in these areas be a positive trend?

Brummel-Smith: I'm not sure of the quality of training they've had, but I don't think that's the major issue we have. I think some foreign physicians see it (rural practice) as a steppingstone before moving to a larger medical group in a larger city.

The ideal is for someone from a particular rural community to go back there after training and set up practice there. But there are never going to be enough people to do this. Second best is taking someone who had a similar rural environment growing up or who really wants a rural lifestyle. The third best option would be what the National Health Service Corps does, which says, 'We'll pay for your medical school training and then you give us four years of service after residency.'

RinR:It's hard enough to entice medical students to rural, family practice. But why is it so difficult to get medical students into urban family practice?

Brummel-Smith: What's really affecting us is that the reimbursement structures are very heavily weighted toward procedurally oriented specialties. For instance, after four years of medical school and then three years of internal medicine training and then a three-year fellowship, the gastroenterologist will make $250,000 a year. The rheumatologist will make only about $140,000 a year.

The difference: Gastroenterologists put tubes into people, so they're always doing some kind of (reimbursable) procedure. The only procedure rheumatologists perform involves injecting (treatments into) joints.

The average debt (upon graduation) is $150,000 for a medical student and more at a private medical school. If I'm going to make $130,000 a year and I have $150,000 in debt, why don't I go into a specialty that pays a lot more?

RinR:What is the College of Medicine doing to counter this mentality?

Menachemi: Among other things, mentorship plays a big role in who goes into what specialty. This is why our medical school is structured the way it is. Two out of our three clinical departments are stacked with potential (geriatrics and family practice) mentors for medical students.

Brummel-Smith: There are many aspects to our rural initiative. One program (Science Students Together Reaching Instructional Diversity and Excellence, or SSTRIDE) reaches out into the rural communities to support and encourage grade school and high school students to pursue careers in medicine or the sciences. We want them to apply, but they have to do well in school. The second initiative is during college to continue to give them support. Then when they get into medical school, we continue that support by providing training in rural settings. We even have arrangements with some of the rural communities that pay scholarships for students in exchange for their commitment to return to that community.

For geriatrics, we're in the first year of a four-year grant of $2 million with a matching million dollars from the university to incorporate geriatric training into the curriculum for all medical students. What that includes is teaching students to assess the patients' ability to care for themselves. To us (geriatricians) it's just natural. But to other specialties is a new thing. But these are good for all patients.

RinR:Myra Hurt, an associate dean in the college, wrote in 1999, "Internists leave their medical center training sites having not been exposed to a single case of osteoarthritis, early stage diabetes or allergic asthma; never having examined a normal geriatric patient versus such a patient close to death, or a rural farmworker suffering from exposure to herbicides." How did U.S. medical education become so far removed from teaching students to treat patients' basic health needs?

Menachemi: Research trends suggest that most people graduating want to practice very close to where they will have access to the high-tech equipment that they've trained with. They also want to enter specialties that allow them to use the latest and greatest technologies.

I've heard the development of our health care system described as spending the last 30 years building the most up-to-date, fastest sports car but neglecting to give it bumpers or seatbelts that are necessary for everyday driving. We can go 0 to 60 faster than any car, but we're not doing what the car needs to do for most people.

Brummel-Smith: It follows the money. Where do most medical schools have their emphasis? Tertiary, highly specialized care. Also, there is often an overwhelming emphasis on research rather than attention at the medical school training level on optimal patient care.

More than 40 years ago, a study from the New England Journal of Medicine found that if you started with 1,000 people at risk for a health care problem in any one month, 750 of them have some type of encounter or thought of health in a month, 300 will see a physician; 100 will go into a hospital, and one goes into an academic medical center.

Right now we have 144 medical schools, and 90 percent still provide their training on that one patient. So when doctors come out of school, they treat everything like a zebra even though the old medical phrase is, "Don't think zebras when you hear hoof beats." We've got a lot more horses around here than zebras.

For their research, Nir Menachemi and Dr. Ken Brummel-Smith also collaborated with College of Medicine faculty members: Dr. Robert Brooks, Art Clawson, Dr. Les Beitsch, Dr. Curtis Stine, and researcher and former graduate student of the College of Social Work, Cathy Hughes.

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