The Doctors Are Out

Why are physicians fleeing Arizona?

Dr. Leonard Ditmanson, a Tucson physician and president of the Arizona Medical Association, is considering closing up shop in the next two months.

And there's anecdotal evidence that suggests he may not be alone.

Many Arizona physicians assert that increasing malpractice-insurance premiums--coupled with perennially low reimbursement rates from health-care providers--are threatening to knock them out of business.

"There are a lot of people with their heads in the sand about what's going on here," said Ditmanson, who estimates that he spends about 8 percent of his adjusted income on malpractice insurance.

At the very least, he said, the financial squeeze makes medical cash cows like Botox injections more attractive than sensitive specialties like neurosurgery, which carry a greater risk of lawsuits.

Shunning these sensitive specialties has led to gaps in medical care in Tucson, according to Dr. Robert P. Goldfarb, who practiced neurosurgery for 35 years before turning to consulting work about eight years ago.

Tucson has only one trauma center: University Medical Center. When it's overcrowded, no other hospitals have specialists on call 24 hours a day, making it necessary to send patients for treatment in places like Phoenix, San Diego and Albuquerque, Goldfarb said.

"Our health care system in Arizona is falling apart," he said. "We have serious injuries that are being sent out of town, because there are not enough physicians to take care of their injuries. It's hard to get doctors to come to town when they're looking forward to very, very high insurance premiums."

Besides neurosurgeons, the lack of hand-surgery specialists, orthopedic surgeons and obstetrician-gynecologists on the northwest side is especially acute, doctors have told the Weekly.

If doctors are leaving the state--or staying away from Arizona to begin with--it could have severe consequences for a medical system that is already understaffed.

According to a report released by Arizona State University's W. P. Carey School of Business and the University of Arizona Health Sciences Center, Arizona had only 207 doctors for every 100,000 patients in 2004--well below the national average of 283 for every 100,000. Rural areas are particularly strained, as 86 percent of Arizona practitioners work in urbanized Maricopa or Pima counties. Apache County has the lowest ratio in the state at 48 physicians per 100,000 patients, the report stated.

Arizona also "earned one of the worst grades in the nation, ranking 42nd for its lack of support for an emergency care system to meet the needs of its residents," according to the American College of Emergency Physicians. The report cited low funding, a dwindling supply of physicians and too few specialists on call--among other reasons--for giving the state a grade of D+.

It's difficult to find exact numbers of doctors who may be fleeing in search of a better insurance climate elsewhere. ASU's Dr. Mary E. Rimsza, one of the researchers in the 2005 health care workforce study, said they didn't look at how many physicians were leaving the state.

Steve Nash, executive director of the Pima County Medical Society, said his organization has been attempting to track the flight of doctors from Arizona--without success. But he said the average age of doctors in the state is now over 50 and that more and more are retiring early "because of the malpractice issue."

"Some people have retired early," Goldfarb, the neurosurgery consultant, said. "They can't afford to slow down in their practices, because their insurance is so high--so they quit."

But why are malpractice premiums so high? Dr. Jim Carland, chief executive officer for the Mutual Insurance Company of Arizona, said "a sudden and rather dramatic increase" in the number of malpractice lawsuits across the country, as well as the costs associated with defending against them and paying out claims, has pushed up premiums over the past five years.

MICA is the dominant malpractice insurer in Arizona, covering about 6,500 physicians--or 75 percent of the workforce.

The Arizona Department of Insurance said MICA informed them that liability premiums will increase an average of 5 percent on April 1. That's a much more moderate increase than in 2004, when they were hiked an average of 16 percent, and 2003, when they went up an average of 12.5 percent.

Carland said hikes for insurers with shareholders--which have to turn a profit--have been even more severe than those called for by MICA. Insurer Medical Protective's average rates shot up 91.7 percent in 2004, after an average hike of 27 percent in 2003. That company increased premiums an average of 18.7 percent in 2005.

To combat these premium hikes, the Arizona Medical Association has pushed for legislation limiting malpractice suits in a number of ways. "Tort reform" is on many doctors' lips

One of the pieces of legislation requires that lawsuits filed against physicians now include an affidavit by a qualified doctor detailing the merits of the case. Another law made it so that specialists can only testify in their area of expertise--a radiologist can't give expert testimony in an obstetrics case, for example.

Carland said these measures could "winnow out" frivolous lawsuits, adding that MICA spent $11.5 million in each of the past two years defending against cases that were withdrawn by the plaintiff or thrown out of court.

There's also a malpractice bill currently working its way through the Legislature, which proponents say will ease strains on ER doctors who are saddled with skyrocketing liability premiums. SB 1351 will make it more difficult for patients to prove wrongdoing by raising the burden of proof.

Not everyone is cheering SB 1351, however. John Hinz is director of Fairness and Accountability in Insurance, which is funded by the Arizona Trial Lawyers Association. He said SB 1351 amounts to an immunity bill for physicians in the ER when juries are already inclined to believe doctors over plaintiffs.

"A medical-malpractice lawsuit is one of the most difficult to prove," Hinz said. "People tend to like doctors, and juries are sympathetic to them."

Hinz accused insurers of making a concerted effort to chip away at patients' legal rights to improve their bottom line. Frivolous lawsuits are not the problem doctors and insurers are making them out to be, he said, because lawyers are reluctant to get dragged into costly malpractice cases with little chance of winning.

Arizona doctors have frequently said putting a cap on noneconomic damages awarded to malpractice-suit plaintiffs is an ultimate goal, adding that they worked in California to reduce premiums. But Hinz told the Weekly regulations making it necessary for Californian insurance companies to justify their premium increases led to lower costs--not caps on damages.

"Insurance reform made the difference," he said. "That's what we keep telling these doctors and we keep telling these individuals who are pushing for this."

In the end, all sides recognize there are problems with the health-care system in Arizona. But agreeing on a prescription to fix the problems is a different matter.

"If I had the solution, that would be wonderful," Goldfarb, the neurosurgery consultant, said. "But I can tell you the system can't continue to go on as it is."