JOHN DAY - There is a silent crisis happening in rural Oregon and Grant County is ground zero. No one has noticed this crisis. No one can hear it. No one has seen its full effects. But the crisis is real. And it's only going to get worse. What's at stake are lives - namely babies and mothers - for baby doctors, commonly known as OBs, or obstetricians and family doctors that practice OB, are quitting. Why? Because malpractice insurance and potential law suits with no ceilings are scaring them out of business and doing what they trained for many years to do.
"So what," you may say. Young people are leaving the area, retired people are taking their places, fewer babies are being born here - we don't need as many obstetricians. Correct. But there are waves from this attrition that will splash everyone in the community.
This fall out of obstetricians, which in the near future includes one of Grant County's own, coupled with fear and frustration, prompted a large group of health care professionals to collect at the Blue Mountain Hospital, March 10.
"We brought this group together to solve some rural health practice issues - the accelerated loss of obstetrical providers and especially young physicians," Karen Whitaker said, opening the Rural Obstetrical Health Symposium in the crowded conference room. Whitaker is the vice-provost and rural health director at the Center for Rural Health at Oregon Health and Sciences University (OHSU).
Doctors from across the state, medical students, residents, hospital administrators, fellows from OHSU, hospital board members, people from the State Office of Health Policy and Sen. Ted Ferrioli by speaker phone - approximately 30 in all - gathered to grapple with some solutions.
As a concerned clinician hoping not to see obstetrical practice disappear in Grant County, Dr. David Graham, brought the group together. As a founding member of the Oregon Rural Practice-based Research Network (ORPN), or a group of rural doctors from across Oregon working on research and coordinated through OHSU Graham was able to act as leader and pull this cohesive yet geographically distant group together.
The Oregon Center for Rural Health at Oregon Health and Sciences University, the Area Health Education Center (AHEC) a program dedicated to advancing and placing doctors and other health professionals in rural under-served areas and ORPN were all part of orchestrating the evening that took place March 10.
"My [liability] insurance increased 800 percent last year," Scott Spence, MD from Burns complained. He mitigated this figure as insurance is lower when doctors first leave medical school and gets higher after subsequent years as their practice grows. "This means more work and more stress and less money."
Liability insurance can cost OB doctors as much as $80,000 a year and that means they have to birth plenty of babies.
What exacerbates this problem, outside of forcing OB doctors out of practicing, is most insurance companies are not writing new policies for obstetricians nor reinstating former policies. This does not allow retiring or doctors who quit obstetrics to be replaced or to return, nor does it allow new doctors to enter the field.
"Trying to recruit a new doctor is very difficult due to the OB policies and not having enough help. We're on call every other day." Dr. Russ Nichols explained at the symposium.
Dr. Robert Holland, who left obstetrics because of prohibitively expensive malpractice insurance, the number of Medicaid patients and low reimbursements, echoed Nichols comment as did Graham.
"Being on call every other night is not a long-term option," Graham said.
"It takes away from family when you're on call 24/7. Even if there were tort reform and a cap I probably won't return because of the life style issues." Holland commented.
Tort reform, or changing the policies surrounding medical malpractice lawsuits, and capping insurance premiums are two options on the table as solutions to the problems facing these doctors.
But there's another catch - especially in rural areas like Eastern Oregon where unemployment is 16 percent and approximately 50 percent of the population is retired.
"Seven of nine of my patients are Medicaid patients. If there isn't more reimbursement or more patients I can't afford my malpractice insurance. I will leave my two partners to do obstetrics - and they won't want to do that for long," Dr. Eric Lamb of Baker City carped. He stated that approximately 80 percent of the patients in Baker City were on the Oregon Health Plan (OHP).
Whereas some practices cap these Medicaid/Medicare patients to 20 percent to 35 percent, according to Graham, here in Grant County 60 to 65 percent of all patients are on one or the other program. These figures are prompting doctors to cease seeing these patients because reimbursement for these people is so low.
Government funds for rural hospitals are drying up Graham said, and with state funds atrophying - at an even accelerated pace next year due to Measure 30 - most hospitals are not getting reimbursed for Medicaid/Medicare patients.
"We suck up the costs and that's why hospital overhead runs at 25 percent to 35 percent," Graham explained.
Furthermore, when OB doctors leave so do other services the hospitals provide. Graham explained: "Hospitals are places of many services. A hospital's reputation is often based upon the services it provides. If the community sees that it can no longer do OB care then they may automatically overlook it for other important services. Similarly, OB, like surgery, is a relatively high paying service ... so if there are not many babies being born then a hospital might not be able to afford to keep an ultrasound technician in business."
That's the business and practical side of losing OB doctors. The most urgent problem is of course lives.
"The main ripple in my opinion," Graham said, "is the loss of life that could happen. Docs and nursing staff who are not used to having babies are going to have troubles with a delivery; that also goes for the OR [operating room] crew to handle a c-section [cesarean section]. There are always going to be examples of a patient that no one knows and shows up to deliver or needing a c-section. A mistake could happen and a big lawsuit could kill the hospital and doc involved."
Luckily Dr. Graham is still at Blue Mountain Hospital. For just after the symposium, at 2:30 in the morning, a local woman who gets OB care out of town arrived complaining of labor. Graham and his experienced team had to perform an urgent c-section - which had a wonderful outcome.