Emergency care crisis
Soaring premiums put area trauma centers at risk

The day may be fast approaching when North Central Florida residents find their health in jeopardy if they require emergency care.

When they are rolled through the doors of the emergency department of one of Gainesville's three hospitals, there may not be a highly skilled specialist there to treat their spinal cord injury or mend the ruptured blood vessel in their brain.

The American Medical Association lists Florida as one of a dozen states most affected by the medical liability crisis. Beset by skyrocketing premiums to protect themselves in malpractice cases, doctors are opting to quit, move elsewhere or scale back high-risk areas of their practice, the AMA reports.

Local hospital officials predict that the pressures on physicians - particularly such highly-skilled specialists as neurosurgeons and emergency room physicians - will have a domino effect that will soon be felt in Gainesville. In fact, some say the crisis in health care is already here.

"The patient-physician relationship is very special. Nobody should have to lose their physician because of the medical malpractice situation in the state of Florida," said Jennifer Scott, practice administrator at Florida Neurosurgical Associates, affiliated with North Florida Medical Center.

Scott warns that is just what is happening in parts of the state.

"People need to wake up and smell the coffee," she said. "If we can't get coverage and cannot be protected, then we will be relocating. The question may become one of 'Who is going to take care of me now?' "

Orlando Regional Medical Center has asked state regulators to close the doors of its Level 1 trauma center, saying it can no longer maintain the staffing levels required to keep its trauma center designation. Surgeons working in the Level 2 trauma center at Halifax Medical Center in Daytona Beach say they will stop performing emergency surgeries March 31.

What is happening in Central Florida could happen in Gainesville, as well.

"Those of us who live here have felt immune to a lot of bad things," said Will Earnest, vice president of physical services and development at North Florida Regional Medical Center. "But the issue (of skyrocketing malpractice insurance costs) is like a reef just below the surface. If malpractice reform fails, the wave is going to break in Gainesville, too. And it will happen very quickly."

NFRMC has recently recruited two of the neurosurgeons from Orlando Regional Medical Center, which now cites a severe shortage in its neurosurgical staff as the reason it cannot meet state requirements for a Level 1 trauma center.

Neurosurgeons are a critical part of the trauma care unit, since the majority of trauma injuries involve brain or spinal cord damage. The Orlando hospital handles about 3,500 trauma cases a year. The center is expected to lose all of its neurosurgeons at the end of this month.

One of them, Dr. Steven Bailey, has already relocated his practice to Gainesville, where he has joined Dr. Eric Scott at Neurosurgical Associates. A partner, Dr. Robert Masson, will soon join them.

In addition to his private practice in Orlando, Bailey spent between two and nine days a month on trauma call, available to immediately handle any brain or spinal cord injury that came through the doors of ORMC's trauma center. Because he took trauma call, Bailey said, he watched the cost of his medical liability insurance skyrocket.

The Florida Department of Insurance approved rate increases ranging from 14 to 27 percent for the handful of companies insuring physicians and surgeons in 2002.

Historically, rates for physicians in Gainesville have been significantly lower than those for specialists practicing in South or Central Florida. That may be changing, however.

Many area physicians, renewing their professional liability coverage at the end of last year, found that their rates would double or triple for less coverage, according to Susan Crowley, executive vice president of the Alachua County Medical Society.

"For years, Alachua County has enjoyed access to excellent health care," Crowley said. "We now see a marked change in access to care, which will inevitably lead to a change in the overall quality of care available to all of us."

Scott said rates she was recently quoted to cover the three neurosurgeons in the Gainesville practice ran in the neighborhood of $250,000 each.

'It's a real fiasco'
Bailey describes the question of liability insurance as "a real fiasco."

He said, "I'm happy to be coming back to Gainesville, where I went to medical school and did my neurosurgery residency. But if things get worse in Florida, I will want to get out of here."

He says a host of other physicians practicing high-risk specialties are also prepared to transfer their practices to one of the many other states where insurance costs are lower and tort reform may have limited damages awarded in malpractice suits. California, which faced the same malpractice crisis Florida is dealing with now, is one such state.

Bailey explained, "As physicians, we are not only squeezing ourselves, but squeezing our patients in terms of calling for too many tests because we are practicing defensive medicine. It is not just an issue of how much I have to pay for my premiums, but how much patients have to pay for their care."

Earnest sees another side to the potential closing of two Central Florida trauma centers.

"Two to three times a month, North Florida Regional will transport emergency patients for trauma care to either Jacksonville or Orlando," he said. "If you lose Orlando Regional, which takes care of 30-plus counties in Central Florida, your next options (for a Level 1 trauma center) are Jacksonville or Tampa. They will quickly be overwhelmed, and may in turn lose their trauma service."

Overwhelmed in Jacksonville
In trauma cases, statistics have long shown, the farther you have to transfer a critically injured patient, the higher the chance of them losing their life or losing some function.

Dr. J.J. Tepas III is medical director of the Shands Regional Trauma System, and a trauma surgeon at Shands Jacksonville, the closest Level 1 trauma center to Gainesville. The trauma unit there treated 4,300 patients in 2001.

Tepas says the trauma system at Shands Jacksonville is overwhelmed as it is, but the staff is approaching the current crisis as a team. The trauma center has also lost one of its neurosurgeons.

"We still have two absolutely spectacular, committed neurosurgeons. We as trauma surgeons can extend their capabilities, but when a patient comes in and needs their head opened, only a neurosurgeon can do it," Tepas said.

Recruiting another neurosurgeon to a trauma center has been a tough sell, he admits.

"Nobody that is practicing medicine now wants to put themselves into a position of unnecessary risk - whether it's through complex care, complex surgery or emergency surgery," Tepas said.

There has to be some limitation to the process, Tepas warned.

"Physicians are not willing to sacrifice their quality of life to play a game of continuous Russian roulette, where an event where they have no culpability results in a malpractice suit," he said.

Protection in the ER?
Timothy Goldfarb, chief executive officer for Shands HealthCare network, said the Shands family - which includes Shands at AGH, Shands at Lake Shore, Shands at Live Oak and Shands at Starke - among other affiliates, is definitely affected by the current malpractice crisis.

"People who know and trust their physicians, even when things don't go as well as expected, are less likely to sue them," Goldfarb said. "If you have no relationship with the physician, which is the classic definition of the surgeon in a trauma situation, your feelings may be far different."

The governor's task force on healthcare professional liability insurance has recommended that the Legislature adopt limited liability protections for emergency care providers. For now, that protection does not exist.

Dr. David Seaberg, president of the Florida College of Emergency Physicians, warns that the Florida residents soon may find their health jeopardized in the event they require emergency care.

"Emergency care providers, including those physicians working in emergency departments and trauma centers, are required by law to treat all patients, regardless of their condition, their past history of litigation, their citizenship or their ability to pay," Seaberg said.

"These ER specialists are compelled by federal and state law to provide care to any patient who appears. Typically, more than a third of that care goes uncompensated. We do it because we believe - and the government believes - that emergency care must be universally applicable."

Spiraling medical liability rates have forced specialists such as neurosurgeons to stop providing care in the state's emergency departments, Seaberg emphasized. Patients may face long delays as emergency physicians scramble to find needed specialists willing to provide care.

Bill Bell calls it the domino effect. He's the attorney for the Florida Hospital Association, which represents 230 hospitals across the state. According to Bell, for many of those hospitals, trying to piece together a team to cover the ER on any given night is a major headache.

Emergency physicians plan to rally in Tallahassee Tuesday and Wednesday to press the Legislature for reforms.

According to FHA figures, Florida's hospitals saw over six million people in their emergency departments and trauma centers in 2001. Another two million were admitted to their facilities.

Over the past two years, the association reports, the state's hospitals have seen insurance premium increases of 140 percent. Where hospitals are forced to spend more on insurance, Bell said, less money is available to invest in new staff, equipment and facilities to improve patient care.

"The current medical liability crisis couldn't have come at a worse time for Florida's hospitals," Bell said. "At the same time insurance premiums are skyrocketing, hospitals are facing revenue cuts from the federal and state governments and the private sector."

House is tackling issue
On Wednesday, the Florida House health care committee approved a bill that would cap noneconomic damages for pain and suffering in malpractice suits at $250,000. The committee voted down amendments trying to roll back the rates companies were charging for liability insurance, however.

The bill is expected to go to the full House this Wednesday. The Senate does not yet have a bill on the issue.

Goldfarb believes it will require a combination of approaches, including a cap on damages, to solve the current crisis and eventually lower physicians' medical liability premiums. He warns that it will not be a quick solution, and it is unrealistic to think the bill under consideration will provide an immediate fix to a problem that has been decades in the making.

"Just leaving the situation as it is will be a danger to the community. Only implementing part of the plan, but not including a hard cap on damages, is also endangering the whole health care system," the Shands CEO said.

Diane Chun can be reached at (352) 374-5041 or chund@gvillesun.com.