Joyce Frieden

Michigan physicians are divided over efforts by Gov. Jennifer Granholm (D) to pass a physician tax that would help increase payments to Medicaid providers in the state.

Under her proposal, a 2.28% gross receipts tax would be levied on all physicians in the state. The tax would raise $96 million, which would then be put into the Medicaid program and would increase the amount of matching funds the program receives from the federal government.

“In that scenario, the state keeps $40 million, and then the $56 million left would be paired with Medicaid matching dollars, so we can return $125 million to providers, bringing up to Medicare rates our physicians who've long complained that Medicaid [reimbursement] rates were too low,” said T.J. Bucholz, spokesman for the Michigan Department of Community Health in Lansing.

In the case of physicians who have at least 3.5% of their practice revenue coming from Medicaid, “they will get more back in terms of Medicaid reimbursement” than they paid into the system in taxes, he noted.

But the Michigan State Medical Society (MSMS) isn't buying it. “Inherent in that is an underlying current of a lot of trust, and for those of us who have paid attention to legislative and gubernatorial activities in the state over the last decade, a track record of trust is one that needs to be earned. People have a lot of questions about that,” said Gregory Forzley, M.D., a member of the society's board of directors.

For instance, “when they introduced the state lottery, it was going to benefit K-12 education programs and colleges in the state, but it appears they used the lottery money in place of other governmental funding,” said Dr. Forzley, a family physician in Grand Rapids. “So when they come with a similar-sounding proposal in a system already fraught with cutbacks and underfunding, most people say, 'I don't believe you when you say you are going to put safeguards in.'”

But Stephen DeSilva, M.D., president of Michigan Doctors Making a Difference, said that some of these problems could be overcome. For example, the law could be written so that “when the federal matching funds go away, the tax would automatically sunset,” he said.

Dr. DeSilva, an orthopedic surgeon, noted that similar tax assessments in the state have worked very well for hospitals, pharmacies, and nursing homes. “It would work well for physicians, but it's difficult to overcome the knee-jerk reaction to taxes as well as the paranoia about how the state will use the money.”

He acknowledged that his own 750-member practice group at Wayne State University in Detroit would have a lot to gain if the proposal became law, since 20% of the group's patients are on Medicaid. In Michigan, Medicaid pays $22 per work unit, and Medicare pays almost $38, “so you can see it's a big increase,” he said. “For our group, it would mean an extra $30 million to our bottom line.”

John M. Flack, M.D., director of the cardiovascular epidemiology and clinical applications program at Wayne State and a member of Dr. DeSilva's practice group, supports the tax but doesn't agree with Dr. DeSilva's revenue projection. “It will make our life tougher [at Wayne State] because it will open doors for patients [to medical offices] around the city; it will make it tougher to keep the patient population we have. That's sort of a dark lining in the clouds for us, but it's good for Medicaid participants to be able to have more options.”

And increased access is the main reason to support the program, Dr. DeSilva said. “Right now, they either go without or use the emergency room for primary care, because very few physicians are willing to see patients at that very low reimbursement rate,” he said. “If you look in the 50 states, there is a direct correlation between access to physician office practices and the ratio of Medicare to Medicaid reimbursement. In states where the ratio approaches [1:1], access is usually good, but as rates fall, access usually falls as well.”

Like Dr. DeSilva, Dr. Forzley said he thinks the Michigan Medicaid program needs fixing, but he doesn't think a physician tax is the way to do it. “We can get more creative,” he said. For example, “a long time ago, a lot of studies showed that if you provide people with transportation to their physician, they stay out of the hospital. It's worthy to look at those experiments out there and see how we can make a broader effort to touch rural and urban populations most effectively.”

“We're willing to work with the governor on trying to create a solution, and we don't think a tax is the best solution,” he added. That may mean using a Band-Aid approach—such as the cut in Medicaid rates currently in place in the state—while all parties work on a long-term fix, he said.

For now, though, the provider tax seems unlikely. Neither the house of representatives nor the senate included the provider tax in their budget proposals, although it is still in the governor's budget proposal.

Michigan is not the only state to have considered provider taxes. Outgoing Washington Gov. Gary Locke (D) also proposed such a tax in January, but Christine Gregoire (D), the current governor, did not include it in her budget proposal, nor has the state legislature moved to implement it.

Physician concerns about taxing providers actually reflect issues revolving around Medicaid copayments, said Diana Ewert, senior manager for state government relations at the American Academy of Family Physicians. These are proposals in which “if you contract with the state to provide Medicaid services … they would require you to take the patient, whether or not the patient pays the copay, and the state will still deduct the copay on other end because you should have collected it,” she explained. “That makes the losing proposition of taking Medicaid patients even more critical, which we believe will impact the safety net and result in less access.”

Ms. Ewert expressed concern regarding states enacting legislation such as provider taxes to increase federal Medicaid matching funds—a strategy known as intergovernmental transfers (IGTs)—for the coming fiscal year. She noted that the federally chartered commission on Medicaid will be looking at all financing mechanisms, including IGTs, in a preliminary report due to Congress on Sept. 1 (see story above). The goal is to cut $10 billion from Medicaid over the next 5 years.

“If states are depending upon IGTs to offset Medicaid costs and for some reason that doesn't come through, that may put states in an untenable situation,” Ms. Ewart said.

Michigan physicians are divided over efforts by Gov. Jennifer Granholm (D) to pass a physician tax that would help increase payments to Medicaid providers in the state.

Under her proposal, a 2.28% gross receipts tax would be levied on all physicians in the state. The tax would raise $96 million, which would then be put into the Medicaid program and would increase the amount of matching funds the program receives from the federal government.

“In that scenario, the state keeps $40 million, and then the $56 million left would be paired with Medicaid matching dollars, so we can return $125 million to providers, bringing up to Medicare rates our physicians who've long complained that Medicaid [reimbursement] rates were too low,” said T.J. Bucholz, spokesman for the Michigan Department of Community Health in Lansing.

In the case of physicians who have at least 3.5% of their practice revenue coming from Medicaid, “they will get more back in terms of Medicaid reimbursement” than they paid into the system in taxes, he noted.

But the Michigan State Medical Society (MSMS) isn't buying it. “Inherent in that is an underlying current of a lot of trust, and for those of us who have paid attention to legislative and gubernatorial activities in the state over the last decade, a track record of trust is one that needs to be earned. People have a lot of questions about that,” said Gregory Forzley, M.D., a member of the society's board of directors.

For instance, “when they introduced the state lottery, it was going to benefit K-12 education programs and colleges in the state, but it appears they used the lottery money in place of other governmental funding,” said Dr. Forzley, a family physician in Grand Rapids. “So when they come with a similar-sounding proposal in a system already fraught with cutbacks and underfunding, most people say, 'I don't believe you when you say you are going to put safeguards in.'”

But Stephen DeSilva, M.D., president of Michigan Doctors Making a Difference, said that some of these problems could be overcome. For example, the law could be written so that “when the federal matching funds go away, the tax would automatically sunset,” he said.

Dr. DeSilva, an orthopedic surgeon, noted that similar tax assessments in the state have worked very well for hospitals, pharmacies, and nursing homes. “It would work well for physicians, but it's difficult to overcome the knee-jerk reaction to taxes as well as the paranoia about how the state will use the money.”

He acknowledged that his own 750-member practice group at Wayne State University in Detroit would have a lot to gain if the proposal became law, since 20% of the group's patients are on Medicaid. In Michigan, Medicaid pays $22 per work unit, and Medicare pays almost $38, “so you can see it's a big increase,” he said. “For our group, it would mean an extra $30 million to our bottom line.”

John M. Flack, M.D., director of the cardiovascular epidemiology and clinical applications program at Wayne State and a member of Dr. DeSilva's practice group, supports the tax but doesn't agree with Dr. DeSilva's revenue projection. “It will make our life tougher [at Wayne State] because it will open doors for patients [to medical offices] around the city; it will make it tougher to keep the patient population we have. That's sort of a dark lining in the clouds for us, but it's good for Medicaid participants to be able to have more options.”

And increased access is the main reason to support the program, Dr. DeSilva said. “Right now, they either go without or use the emergency room for primary care, because very few physicians are willing to see patients at that very low reimbursement rate,” he said. “If you look in the 50 states, there is a direct correlation between access to physician office practices and the ratio of Medicare to Medicaid reimbursement. In states where the ratio approaches [1:1], access is usually good, but as rates fall, access usually falls as well.”

Like Dr. DeSilva, Dr. Forzley said he thinks the Michigan Medicaid program needs fixing, but he doesn't think a physician tax is the way to do it. “We can get more creative,” he said. For example, “a long time ago, a lot of studies showed that if you provide people with transportation to their physician, they stay out of the hospital. It's worthy to look at those experiments out there and see how we can make a broader effort to touch rural and urban populations most effectively.”

“We're willing to work with the governor on trying to create a solution, and we don't think a tax is the best solution,” he added. That may mean using a Band-Aid approach—such as the cut in Medicaid rates currently in place in the state—while all parties work on a long-term fix, he said.

For now, though, the provider tax seems unlikely. Neither the house of representatives nor the senate included the provider tax in their budget proposals, although it is still in the governor's budget proposal.

Michigan is not the only state to have considered provider taxes. Outgoing Washington Gov. Gary Locke (D) also proposed such a tax in January, but Christine Gregoire (D), the current governor, did not include it in her budget proposal, nor has the state legislature moved to implement it.

Physician concerns about taxing providers actually reflect issues revolving around Medicaid copayments, said Diana Ewert, senior manager for state government relations at the American Academy of Family Physicians. These are proposals in which “if you contract with the state to provide Medicaid services … they would require you to take the patient, whether or not the patient pays the copay, and the state will still deduct the copay on other end because you should have collected it,” she explained. “That makes the losing proposition of taking Medicaid patients even more critical, which we believe will impact the safety net and result in less access.”

Ms. Ewert expressed concern regarding states enacting legislation such as provider taxes to increase federal Medicaid matching funds—a strategy known as intergovernmental transfers (IGTs)—for the coming fiscal year. She noted that the federally chartered commission on Medicaid will be looking at all financing mechanisms, including IGTs, in a preliminary report due to Congress on Sept. 1 (see story above). The goal is to cut $10 billion from Medicaid over the next 5 years.

“If states are depending upon IGTs to offset Medicaid costs and for some reason that doesn't come through, that may put states in an untenable situation,” Ms. Ewart said.

Michigan physicians are divided over efforts by Gov. Jennifer Granholm (D) to pass a physician tax that would help increase payments to Medicaid providers in the state.

Under her proposal, a 2.28% gross receipts tax would be levied on all physicians in the state. The tax would raise $96 million, which would then be put into the Medicaid program and would increase the amount of matching funds the program receives from the federal government.

“In that scenario, the state keeps $40 million, and then the $56 million left would be paired with Medicaid matching dollars, so we can return $125 million to providers, bringing up to Medicare rates our physicians who've long complained that Medicaid [reimbursement] rates were too low,” said T.J. Bucholz, spokesman for the Michigan Department of Community Health in Lansing.

In the case of physicians who have at least 3.5% of their practice revenue coming from Medicaid, “they will get more back in terms of Medicaid reimbursement” than they paid into the system in taxes, he noted.

But the Michigan State Medical Society (MSMS) isn't buying it. “Inherent in that is an underlying current of a lot of trust, and for those of us who have paid attention to legislative and gubernatorial activities in the state over the last decade, a track record of trust is one that needs to be earned. People have a lot of questions about that,” said Gregory Forzley, M.D., a member of the society's board of directors.

For instance, “when they introduced the state lottery, it was going to benefit K-12 education programs and colleges in the state, but it appears they used the lottery money in place of other governmental funding,” said Dr. Forzley, a family physician in Grand Rapids. “So when they come with a similar-sounding proposal in a system already fraught with cutbacks and underfunding, most people say, 'I don't believe you when you say you are going to put safeguards in.'”

But Stephen DeSilva, M.D., president of Michigan Doctors Making a Difference, said that some of these problems could be overcome. For example, the law could be written so that “when the federal matching funds go away, the tax would automatically sunset,” he said.

Dr. DeSilva, an orthopedic surgeon, noted that similar tax assessments in the state have worked very well for hospitals, pharmacies, and nursing homes. “It would work well for physicians, but it's difficult to overcome the knee-jerk reaction to taxes as well as the paranoia about how the state will use the money.”

He acknowledged that his own 750-member practice group at Wayne State University in Detroit would have a lot to gain if the proposal became law, since 20% of the group's patients are on Medicaid. In Michigan, Medicaid pays $22 per work unit, and Medicare pays almost $38, “so you can see it's a big increase,” he said. “For our group, it would mean an extra $30 million to our bottom line.”

John M. Flack, M.D., director of the cardiovascular epidemiology and clinical applications program at Wayne State and a member of Dr. DeSilva's practice group, supports the tax but doesn't agree with Dr. DeSilva's revenue projection. “It will make our life tougher [at Wayne State] because it will open doors for patients [to medical offices] around the city; it will make it tougher to keep the patient population we have. That's sort of a dark lining in the clouds for us, but it's good for Medicaid participants to be able to have more options.”

And increased access is the main reason to support the program, Dr. DeSilva said. “Right now, they either go without or use the emergency room for primary care, because very few physicians are willing to see patients at that very low reimbursement rate,” he said. “If you look in the 50 states, there is a direct correlation between access to physician office practices and the ratio of Medicare to Medicaid reimbursement. In states where the ratio approaches [1:1], access is usually good, but as rates fall, access usually falls as well.”

Like Dr. DeSilva, Dr. Forzley said he thinks the Michigan Medicaid program needs fixing, but he doesn't think a physician tax is the way to do it. “We can get more creative,” he said. For example, “a long time ago, a lot of studies showed that if you provide people with transportation to their physician, they stay out of the hospital. It's worthy to look at those experiments out there and see how we can make a broader effort to touch rural and urban populations most effectively.”

“We're willing to work with the governor on trying to create a solution, and we don't think a tax is the best solution,” he added. That may mean using a Band-Aid approach—such as the cut in Medicaid rates currently in place in the state—while all parties work on a long-term fix, he said.

For now, though, the provider tax seems unlikely. Neither the house of representatives nor the senate included the provider tax in their budget proposals, although it is still in the governor's budget proposal.

Michigan is not the only state to have considered provider taxes. Outgoing Washington Gov. Gary Locke (D) also proposed such a tax in January, but Christine Gregoire (D), the current governor, did not include it in her budget proposal, nor has the state legislature moved to implement it.

Physician concerns about taxing providers actually reflect issues revolving around Medicaid copayments, said Diana Ewert, senior manager for state government relations at the American Academy of Family Physicians. These are proposals in which “if you contract with the state to provide Medicaid services … they would require you to take the patient, whether or not the patient pays the copay, and the state will still deduct the copay on other end because you should have collected it,” she explained. “That makes the losing proposition of taking Medicaid patients even more critical, which we believe will impact the safety net and result in less access.”

Ms. Ewert expressed concern regarding states enacting legislation such as provider taxes to increase federal Medicaid matching funds—a strategy known as intergovernmental transfers (IGTs)—for the coming fiscal year. She noted that the federally chartered commission on Medicaid will be looking at all financing mechanisms, including IGTs, in a preliminary report due to Congress on Sept. 1 (see story above). The goal is to cut $10 billion from Medicaid over the next 5 years.

“If states are depending upon IGTs to offset Medicaid costs and for some reason that doesn't come through, that may put states in an untenable situation,” Ms. Ewart said.

WASHINGTON — It doesn't surprise most physicians to hear that populations in certain cities have higher rates of chronic disease. But new work in small-area analysis can help pinpoint exactly which areas of a city suffer from a higher disease burden, Robert Bonow, M.D., said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

For example, Dallas turns out to be a complicated area when it comes to cardiovascular mortality, said Dr. Bonow, chief of the division of cardiology at Northwestern Memorial Hospital, in Evanston, Ill. He and Sean Cleary, Ph.D., associate professor of epidemiology and statistics at George Washington University, performed small-area analysis on the city using data from state Vital Statistics offices and the 2000 U.S. Census.

Data were based on the U.S. Postal Service's definition of a “minority Zip code” consisting of 50% or greater African American, Native American, Hispanic, Asian, or Pacific Islander residents.

The data showed that there are disparities in cardiovascular disease mortality not only between minority and nonminority populations, but also within minority Zip codes.

“Is one area more Hispanic, and one area more African American?” Dr. Bonow asked. Of course, there could be other factors driving differences in mortality, such as differing opportunities for exercise or lesser or greater availability of fresh fruits and vegetables in one community than in another, he added.

Dr. Bonow noted that the maps produced by small-area analysis could be a useful lobbying tool for health care advocates. “Imagine walking into [a Congressman's office] with a map showing that minority areas in his district have very high rates of cardiovascular disease,” he said. And if the analysis also found that there were few health centers in the area, advocates could argue that services are not being offered where they are needed.

WASHINGTON — It doesn't surprise most physicians to hear that populations in certain cities have higher rates of chronic disease. But new work in small-area analysis can help pinpoint exactly which areas of a city suffer from a higher disease burden, Robert Bonow, M.D., said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

For example, Dallas turns out to be a complicated area when it comes to cardiovascular mortality, said Dr. Bonow, chief of the division of cardiology at Northwestern Memorial Hospital, in Evanston, Ill. He and Sean Cleary, Ph.D., associate professor of epidemiology and statistics at George Washington University, performed small-area analysis on the city using data from state Vital Statistics offices and the 2000 U.S. Census.

Data were based on the U.S. Postal Service's definition of a “minority Zip code” consisting of 50% or greater African American, Native American, Hispanic, Asian, or Pacific Islander residents.

The data showed that there are disparities in cardiovascular disease mortality not only between minority and nonminority populations, but also within minority Zip codes.

“Is one area more Hispanic, and one area more African American?” Dr. Bonow asked. Of course, there could be other factors driving differences in mortality, such as differing opportunities for exercise or lesser or greater availability of fresh fruits and vegetables in one community than in another, he added.

Dr. Bonow noted that the maps produced by small-area analysis could be a useful lobbying tool for health care advocates. “Imagine walking into [a Congressman's office] with a map showing that minority areas in his district have very high rates of cardiovascular disease,” he said. And if the analysis also found that there were few health centers in the area, advocates could argue that services are not being offered where they are needed.

WASHINGTON — It doesn't surprise most physicians to hear that populations in certain cities have higher rates of chronic disease. But new work in small-area analysis can help pinpoint exactly which areas of a city suffer from a higher disease burden, Robert Bonow, M.D., said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

For example, Dallas turns out to be a complicated area when it comes to cardiovascular mortality, said Dr. Bonow, chief of the division of cardiology at Northwestern Memorial Hospital, in Evanston, Ill. He and Sean Cleary, Ph.D., associate professor of epidemiology and statistics at George Washington University, performed small-area analysis on the city using data from state Vital Statistics offices and the 2000 U.S. Census.

Data were based on the U.S. Postal Service's definition of a “minority Zip code” consisting of 50% or greater African American, Native American, Hispanic, Asian, or Pacific Islander residents.

The data showed that there are disparities in cardiovascular disease mortality not only between minority and nonminority populations, but also within minority Zip codes.

“Is one area more Hispanic, and one area more African American?” Dr. Bonow asked. Of course, there could be other factors driving differences in mortality, such as differing opportunities for exercise or lesser or greater availability of fresh fruits and vegetables in one community than in another, he added.

Dr. Bonow noted that the maps produced by small-area analysis could be a useful lobbying tool for health care advocates. “Imagine walking into [a Congressman's office] with a map showing that minority areas in his district have very high rates of cardiovascular disease,” he said. And if the analysis also found that there were few health centers in the area, advocates could argue that services are not being offered where they are needed.

WASHINGTON – The new database on hospital quality from the Centers for Medicare and Medicaid Services may herald a new era in patient assertiveness in terms of health care preferences, several experts said at a briefing sponsored by the Alliance for Health Reform.

“We're beginning a change in how doctor-patient relations are established and [considering] how paternalistic they have been, I think we'll see major changes in the future where they become less that way,” said Elliot Sussman, M.D., president and CEO of Lehigh Valley Hospital and Health Network in Allentown, Pa.

“When people come into a community, they'll look at measures like this and say, 'Which are the kinds of places I want to be cared for at, and who are doctors on staff at those places?'” he commented.

In fact, such changes have already begun to occur, he said. “We've seen experiences where people change their doctor relationship because 'I really like Dr. Jones, but he's not on the staff of what seems to be the best hospital. Either he does that or I'm going to find myself a new physician.'”

CMS launched its “Hospital Compare” database on April 1. Available online at www.hospitalcompare.hhs.gov

Gerald M. Shea, assistant to the president for government affairs at the AFL-CIO, said that the feeling of partnership that comes from empowering consumers should spill over onto the physician side of the equation.

“I could make the argument that there are very serious limits to how much consumers can drive change in the health decision making process,” he said. “An equally fruitful strategy would be trying to change the preparation and education of physicians, so they come to this suggesting that a partnership would be a good idea.”

In fact, physicians also have much to gain from being able to access hospital quality data, said Margaret E. O'Kane, president of the National Committee for Quality Assurance.

“Physicians have been working in an information vacuum as well–both doctors involved in performing particular procedures in the hospital, and the primary care physicians who are making referrals to specialists,” she said. “We can't underestimate the impact that transparency has on changing everything. I feel very optimistic this will lead to lot of positive changes.”

One panelist warned that empowerment does have its limits. Charles N. “Chip” Kahn, president of the Federation of American Hospitals, said that as databases such as Hospital Compare begin adding more measures, “it will be more and more difficult for the average consumer … to figure things out other than, 'This is either an okay place or a dreadful place' and you obviously want to stay away from dreadful places.”

In the end, he said, databases like this “are more about using accountability to improve care than they are about consumers making more decisions.”

Ms. O'Kane said she was confident that “intermediaries” would rise up to help consumers interpret the database information.

And she also had a prediction.

“What we've seen so far is not hospitals that are excellent at everything or terrible at everything, but hospitals that are excellent at one thing and maybe not so great at others. As process engineering becomes more core to the hospitals, you'll see hospitals that will break out and be excellent across the board.”

WASHINGTON – The new database on hospital quality from the Centers for Medicare and Medicaid Services may herald a new era in patient assertiveness in terms of health care preferences, several experts said at a briefing sponsored by the Alliance for Health Reform.

“We're beginning a change in how doctor-patient relations are established and [considering] how paternalistic they have been, I think we'll see major changes in the future where they become less that way,” said Elliot Sussman, M.D., president and CEO of Lehigh Valley Hospital and Health Network in Allentown, Pa.

“When people come into a community, they'll look at measures like this and say, 'Which are the kinds of places I want to be cared for at, and who are doctors on staff at those places?'” he commented.

In fact, such changes have already begun to occur, he said. “We've seen experiences where people change their doctor relationship because 'I really like Dr. Jones, but he's not on the staff of what seems to be the best hospital. Either he does that or I'm going to find myself a new physician.'”

CMS launched its “Hospital Compare” database on April 1. Available online at www.hospitalcompare.hhs.gov

Gerald M. Shea, assistant to the president for government affairs at the AFL-CIO, said that the feeling of partnership that comes from empowering consumers should spill over onto the physician side of the equation.

“I could make the argument that there are very serious limits to how much consumers can drive change in the health decision making process,” he said. “An equally fruitful strategy would be trying to change the preparation and education of physicians, so they come to this suggesting that a partnership would be a good idea.”

In fact, physicians also have much to gain from being able to access hospital quality data, said Margaret E. O'Kane, president of the National Committee for Quality Assurance.

“Physicians have been working in an information vacuum as well–both doctors involved in performing particular procedures in the hospital, and the primary care physicians who are making referrals to specialists,” she said. “We can't underestimate the impact that transparency has on changing everything. I feel very optimistic this will lead to lot of positive changes.”

One panelist warned that empowerment does have its limits. Charles N. “Chip” Kahn, president of the Federation of American Hospitals, said that as databases such as Hospital Compare begin adding more measures, “it will be more and more difficult for the average consumer … to figure things out other than, 'This is either an okay place or a dreadful place' and you obviously want to stay away from dreadful places.”

In the end, he said, databases like this “are more about using accountability to improve care than they are about consumers making more decisions.”

Ms. O'Kane said she was confident that “intermediaries” would rise up to help consumers interpret the database information.

And she also had a prediction.

“What we've seen so far is not hospitals that are excellent at everything or terrible at everything, but hospitals that are excellent at one thing and maybe not so great at others. As process engineering becomes more core to the hospitals, you'll see hospitals that will break out and be excellent across the board.”

WASHINGTON – The new database on hospital quality from the Centers for Medicare and Medicaid Services may herald a new era in patient assertiveness in terms of health care preferences, several experts said at a briefing sponsored by the Alliance for Health Reform.

“We're beginning a change in how doctor-patient relations are established and [considering] how paternalistic they have been, I think we'll see major changes in the future where they become less that way,” said Elliot Sussman, M.D., president and CEO of Lehigh Valley Hospital and Health Network in Allentown, Pa.

“When people come into a community, they'll look at measures like this and say, 'Which are the kinds of places I want to be cared for at, and who are doctors on staff at those places?'” he commented.

In fact, such changes have already begun to occur, he said. “We've seen experiences where people change their doctor relationship because 'I really like Dr. Jones, but he's not on the staff of what seems to be the best hospital. Either he does that or I'm going to find myself a new physician.'”

CMS launched its “Hospital Compare” database on April 1. Available online at www.hospitalcompare.hhs.gov

Gerald M. Shea, assistant to the president for government affairs at the AFL-CIO, said that the feeling of partnership that comes from empowering consumers should spill over onto the physician side of the equation.

“I could make the argument that there are very serious limits to how much consumers can drive change in the health decision making process,” he said. “An equally fruitful strategy would be trying to change the preparation and education of physicians, so they come to this suggesting that a partnership would be a good idea.”

In fact, physicians also have much to gain from being able to access hospital quality data, said Margaret E. O'Kane, president of the National Committee for Quality Assurance.

“Physicians have been working in an information vacuum as well–both doctors involved in performing particular procedures in the hospital, and the primary care physicians who are making referrals to specialists,” she said. “We can't underestimate the impact that transparency has on changing everything. I feel very optimistic this will lead to lot of positive changes.”

One panelist warned that empowerment does have its limits. Charles N. “Chip” Kahn, president of the Federation of American Hospitals, said that as databases such as Hospital Compare begin adding more measures, “it will be more and more difficult for the average consumer … to figure things out other than, 'This is either an okay place or a dreadful place' and you obviously want to stay away from dreadful places.”

In the end, he said, databases like this “are more about using accountability to improve care than they are about consumers making more decisions.”

Ms. O'Kane said she was confident that “intermediaries” would rise up to help consumers interpret the database information.

And she also had a prediction.

“What we've seen so far is not hospitals that are excellent at everything or terrible at everything, but hospitals that are excellent at one thing and maybe not so great at others. As process engineering becomes more core to the hospitals, you'll see hospitals that will break out and be excellent across the board.”

Michigan physicians are divided over efforts by Gov. Jennifer Granholm (D) to pass a physician tax that would help increase payments to Medicaid providers in the state.

Under the governor's proposal, a 2.28% gross receipts tax would be levied on all physicians in the state. The tax would raise $96 million, which would then be put into the Medicaid program and would increase the amount of matching funds the program received from the federal government.

“In that scenario, the state keeps $40 million, and then the $56 million left would be paired with Medicaid matching dollars, so we can return $125 million to providers, bringing up to Medicare rates our physicians who've long complained that Medicaid [reimbursement] rates were too low,” said T.J. Bucholz, spokesman for the Michigan Department of Community Health in Lansing.

In the case of physicians who have at least 3.5% of their practice revenue coming from Medicaid, “they will get more back in terms of Medicaid reimbursement” than they paid into the system in taxes, he noted.

But the Michigan State Medical Society (MSMS) isn't buying it. “Inherent in that is an underlying current of a lot of trust, and for those of us who have paid attention to legislative and gubernatorial activities in the state over the last decade, a track record of trust is one that needs to be earned. People have a lot of questions about that,” said Gregory Forzley, M.D., who is a member of the society's board of directors.

For instance, “when they introduced the state lottery, it was going to benefit K-12 education programs and colleges in the state, but it appears they used the lottery money in place of other governmental funding,” said Dr. Forzley, a family physician in Grand Rapids. “So when they come with a similar-sounding proposal in a system already fraught with cutbacks and underfunding, most people say, 'I don't believe you when you say you are going to put safeguards in.'”

But Stephen DeSilva, M.D., president of Michigan Doctors Making a Difference, said that some of these problems could be overcome. For example, the law could be written so that “when the federal matching funds go away, the tax would automatically sunset,” he said.

Dr. DeSilva, an orthopedic surgeon, noted that similar tax assessments in the state have worked very well for hospitals, pharmacies, and nursing homes. “It would work well for physicians, but it's difficult to overcome the knee-jerk reaction to taxes as well as the paranoia about how the state will use the money.”

He acknowledged that his own 750-member practice group at Wayne State University in Detroit would have a lot to gain if the proposal became law, since about 20% of the group's patients are on Medicaid.

“In Michigan, Medicaid pays $22 per work unit, and Medicare pays almost $38 per work unit, so you can see it's a big increase,” Dr. DeSilva said. “For our group, it would mean an extra $30 million to our bottom line.”

But the main reason to support the program is that it would improve access for Medicaid patients, Dr. DeSilva said. “Right now, they either go without or use the emergency room for primary care, because very few physicians are willing to see patients at that very low reimbursement rate,” he said. “If you look in the 50 states, there is a direct correlation between access to physician office practices and the ratio of Medicare to Medicaid reimbursement. In states where the ratio approaches [1:1], access is usually good, but as rates fall, access usually falls as well. In New York and New Jersey, which are near the bottom, almost no physician will see a Medicaid patient.”

Like Dr. DeSilva, Dr. Forzley said he thinks the Michigan Medicaid program needs fixing, but he doesn't think a physician tax is the way to do it. “There are some areas where we can get more creative,” he said. For example, “a long time ago, a lot of studies showed that if you provide people with transportation to their physician, they stay out of the hospital. It's worth it to look at those experiments out there and see how we can make a broader effort to touch rural and urban populations most effectively.”

“We're willing to work with the governor on trying to create a solution, and we don't think a tax is the best solution,” he added. That may mean using a Band-Aid approach–such as the cut in Medicaid rates currently in place in the state–while all parties work on a long-term fix, he said.

Michigan is not the only state to have considered provider taxes. Outgoing Washington Gov. Gary Locke (D) also proposed such a tax in January, but Christine Gregoire (D), the current governor, did not include it in her budget proposal, nor has the state legislature moved to implement it.

Physician concerns about taxing providers actually reflect issues revolving around Medicaid copayments, said Diana Ewert, senior manager for state government relations at the American Academy of Family Physicians. These are proposals in which “if you contract with the state to provide Medicaid services … they would require you to take the patient, whether or not the patient pays the copay, and the state will still deduct the copay on other end because you should have collected it,” she explained. “That makes the losing proposition of taking Medicaid patients even more critical, which we believe will impact the safety net and result in less access.”

Ms. Ewert expressed concern regarding states enacting legislation such as provider taxes to increase federal Medicaid matching funds–a strategy known as intergovernmental transfers (IGTs)–for the coming fiscal year. She noted that the federally chartered commission on Medicaid will be looking at all financing mechanisms, including IGTs, in a preliminary report due to Congress on Sept. 1. The goal is to cut $10 billion from Medicaid over the next 5 years.

“If states are depending upon IGTs to offset Medicaid costs and for some reason that doesn't come through, that may put states in an untenable situation,” she said.

Michigan physicians are divided over efforts by Gov. Jennifer Granholm (D) to pass a physician tax that would help increase payments to Medicaid providers in the state.

Under the governor's proposal, a 2.28% gross receipts tax would be levied on all physicians in the state. The tax would raise $96 million, which would then be put into the Medicaid program and would increase the amount of matching funds the program received from the federal government.

“In that scenario, the state keeps $40 million, and then the $56 million left would be paired with Medicaid matching dollars, so we can return $125 million to providers, bringing up to Medicare rates our physicians who've long complained that Medicaid [reimbursement] rates were too low,” said T.J. Bucholz, spokesman for the Michigan Department of Community Health in Lansing.

In the case of physicians who have at least 3.5% of their practice revenue coming from Medicaid, “they will get more back in terms of Medicaid reimbursement” than they paid into the system in taxes, he noted.

But the Michigan State Medical Society (MSMS) isn't buying it. “Inherent in that is an underlying current of a lot of trust, and for those of us who have paid attention to legislative and gubernatorial activities in the state over the last decade, a track record of trust is one that needs to be earned. People have a lot of questions about that,” said Gregory Forzley, M.D., who is a member of the society's board of directors.

For instance, “when they introduced the state lottery, it was going to benefit K-12 education programs and colleges in the state, but it appears they used the lottery money in place of other governmental funding,” said Dr. Forzley, a family physician in Grand Rapids. “So when they come with a similar-sounding proposal in a system already fraught with cutbacks and underfunding, most people say, 'I don't believe you when you say you are going to put safeguards in.'”

But Stephen DeSilva, M.D., president of Michigan Doctors Making a Difference, said that some of these problems could be overcome. For example, the law could be written so that “when the federal matching funds go away, the tax would automatically sunset,” he said.

Dr. DeSilva, an orthopedic surgeon, noted that similar tax assessments in the state have worked very well for hospitals, pharmacies, and nursing homes. “It would work well for physicians, but it's difficult to overcome the knee-jerk reaction to taxes as well as the paranoia about how the state will use the money.”

He acknowledged that his own 750-member practice group at Wayne State University in Detroit would have a lot to gain if the proposal became law, since about 20% of the group's patients are on Medicaid.

“In Michigan, Medicaid pays $22 per work unit, and Medicare pays almost $38 per work unit, so you can see it's a big increase,” Dr. DeSilva said. “For our group, it would mean an extra $30 million to our bottom line.”

But the main reason to support the program is that it would improve access for Medicaid patients, Dr. DeSilva said. “Right now, they either go without or use the emergency room for primary care, because very few physicians are willing to see patients at that very low reimbursement rate,” he said. “If you look in the 50 states, there is a direct correlation between access to physician office practices and the ratio of Medicare to Medicaid reimbursement. In states where the ratio approaches [1:1], access is usually good, but as rates fall, access usually falls as well. In New York and New Jersey, which are near the bottom, almost no physician will see a Medicaid patient.”

Like Dr. DeSilva, Dr. Forzley said he thinks the Michigan Medicaid program needs fixing, but he doesn't think a physician tax is the way to do it. “There are some areas where we can get more creative,” he said. For example, “a long time ago, a lot of studies showed that if you provide people with transportation to their physician, they stay out of the hospital. It's worth it to look at those experiments out there and see how we can make a broader effort to touch rural and urban populations most effectively.”

“We're willing to work with the governor on trying to create a solution, and we don't think a tax is the best solution,” he added. That may mean using a Band-Aid approach–such as the cut in Medicaid rates currently in place in the state–while all parties work on a long-term fix, he said.

Michigan is not the only state to have considered provider taxes. Outgoing Washington Gov. Gary Locke (D) also proposed such a tax in January, but Christine Gregoire (D), the current governor, did not include it in her budget proposal, nor has the state legislature moved to implement it.

Physician concerns about taxing providers actually reflect issues revolving around Medicaid copayments, said Diana Ewert, senior manager for state government relations at the American Academy of Family Physicians. These are proposals in which “if you contract with the state to provide Medicaid services … they would require you to take the patient, whether or not the patient pays the copay, and the state will still deduct the copay on other end because you should have collected it,” she explained. “That makes the losing proposition of taking Medicaid patients even more critical, which we believe will impact the safety net and result in less access.”

Ms. Ewert expressed concern regarding states enacting legislation such as provider taxes to increase federal Medicaid matching funds–a strategy known as intergovernmental transfers (IGTs)–for the coming fiscal year. She noted that the federally chartered commission on Medicaid will be looking at all financing mechanisms, including IGTs, in a preliminary report due to Congress on Sept. 1. The goal is to cut $10 billion from Medicaid over the next 5 years.

“If states are depending upon IGTs to offset Medicaid costs and for some reason that doesn't come through, that may put states in an untenable situation,” she said.

Michigan physicians are divided over efforts by Gov. Jennifer Granholm (D) to pass a physician tax that would help increase payments to Medicaid providers in the state.

Under the governor's proposal, a 2.28% gross receipts tax would be levied on all physicians in the state. The tax would raise $96 million, which would then be put into the Medicaid program and would increase the amount of matching funds the program received from the federal government.

“In that scenario, the state keeps $40 million, and then the $56 million left would be paired with Medicaid matching dollars, so we can return $125 million to providers, bringing up to Medicare rates our physicians who've long complained that Medicaid [reimbursement] rates were too low,” said T.J. Bucholz, spokesman for the Michigan Department of Community Health in Lansing.

In the case of physicians who have at least 3.5% of their practice revenue coming from Medicaid, “they will get more back in terms of Medicaid reimbursement” than they paid into the system in taxes, he noted.

But the Michigan State Medical Society (MSMS) isn't buying it. “Inherent in that is an underlying current of a lot of trust, and for those of us who have paid attention to legislative and gubernatorial activities in the state over the last decade, a track record of trust is one that needs to be earned. People have a lot of questions about that,” said Gregory Forzley, M.D., who is a member of the society's board of directors.

For instance, “when they introduced the state lottery, it was going to benefit K-12 education programs and colleges in the state, but it appears they used the lottery money in place of other governmental funding,” said Dr. Forzley, a family physician in Grand Rapids. “So when they come with a similar-sounding proposal in a system already fraught with cutbacks and underfunding, most people say, 'I don't believe you when you say you are going to put safeguards in.'”

But Stephen DeSilva, M.D., president of Michigan Doctors Making a Difference, said that some of these problems could be overcome. For example, the law could be written so that “when the federal matching funds go away, the tax would automatically sunset,” he said.

Dr. DeSilva, an orthopedic surgeon, noted that similar tax assessments in the state have worked very well for hospitals, pharmacies, and nursing homes. “It would work well for physicians, but it's difficult to overcome the knee-jerk reaction to taxes as well as the paranoia about how the state will use the money.”

He acknowledged that his own 750-member practice group at Wayne State University in Detroit would have a lot to gain if the proposal became law, since about 20% of the group's patients are on Medicaid.

“In Michigan, Medicaid pays $22 per work unit, and Medicare pays almost $38 per work unit, so you can see it's a big increase,” Dr. DeSilva said. “For our group, it would mean an extra $30 million to our bottom line.”

But the main reason to support the program is that it would improve access for Medicaid patients, Dr. DeSilva said. “Right now, they either go without or use the emergency room for primary care, because very few physicians are willing to see patients at that very low reimbursement rate,” he said. “If you look in the 50 states, there is a direct correlation between access to physician office practices and the ratio of Medicare to Medicaid reimbursement. In states where the ratio approaches [1:1], access is usually good, but as rates fall, access usually falls as well. In New York and New Jersey, which are near the bottom, almost no physician will see a Medicaid patient.”

Like Dr. DeSilva, Dr. Forzley said he thinks the Michigan Medicaid program needs fixing, but he doesn't think a physician tax is the way to do it. “There are some areas where we can get more creative,” he said. For example, “a long time ago, a lot of studies showed that if you provide people with transportation to their physician, they stay out of the hospital. It's worth it to look at those experiments out there and see how we can make a broader effort to touch rural and urban populations most effectively.”

“We're willing to work with the governor on trying to create a solution, and we don't think a tax is the best solution,” he added. That may mean using a Band-Aid approach–such as the cut in Medicaid rates currently in place in the state–while all parties work on a long-term fix, he said.

Michigan is not the only state to have considered provider taxes. Outgoing Washington Gov. Gary Locke (D) also proposed such a tax in January, but Christine Gregoire (D), the current governor, did not include it in her budget proposal, nor has the state legislature moved to implement it.

Physician concerns about taxing providers actually reflect issues revolving around Medicaid copayments, said Diana Ewert, senior manager for state government relations at the American Academy of Family Physicians. These are proposals in which “if you contract with the state to provide Medicaid services … they would require you to take the patient, whether or not the patient pays the copay, and the state will still deduct the copay on other end because you should have collected it,” she explained. “That makes the losing proposition of taking Medicaid patients even more critical, which we believe will impact the safety net and result in less access.”

Ms. Ewert expressed concern regarding states enacting legislation such as provider taxes to increase federal Medicaid matching funds–a strategy known as intergovernmental transfers (IGTs)–for the coming fiscal year. She noted that the federally chartered commission on Medicaid will be looking at all financing mechanisms, including IGTs, in a preliminary report due to Congress on Sept. 1. The goal is to cut $10 billion from Medicaid over the next 5 years.

“If states are depending upon IGTs to offset Medicaid costs and for some reason that doesn't come through, that may put states in an untenable situation,” she said.

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

“The District is home to some of the best medical care in the country,” Mayor Williams said when he announced the bill. “This bill is all about ensuring that our residents and visitors always get top-notch care and that our medical community can practice without undue burdens.”

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. “Linda Cropp's heart is in the right place,” Dr. Freeman, an internist, said in an interview. “She recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The Public Citizen study that Ms. Cropp referred to is one of several studies on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study, which used data from the years 1985–2000, also found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. and 5.5% more surgical specialists per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs. Finally, another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“Our results illuminate the mechanisms by which malpractice liability reduces growth in physician supply,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293: 2618–25). “In our study, the estimated effect of direct reforms was greater among physicians who practice in nongroup settings. … This is consistent with the lesser ability of smaller practices to spread liability insurance costs among many physicians, cushion premium volatility with high patient volume, or share risk with hospitals or other health care institutions.”

The authors noted several limitations, however. For instance, the study didn't take into account the effect of reforms adopted prior to 1986, nor did it address the trade-offs between the potential benefits of the reforms and their potential cost, such as reduced compensation for medical errors.

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

“The District is home to some of the best medical care in the country,” Mayor Williams said when he announced the bill. “This bill is all about ensuring that our residents and visitors always get top-notch care and that our medical community can practice without undue burdens.”

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. “Linda Cropp's heart is in the right place,” Dr. Freeman, an internist, said in an interview. “She recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The Public Citizen study that Ms. Cropp referred to is one of several studies on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study, which used data from the years 1985–2000, also found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. and 5.5% more surgical specialists per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs. Finally, another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“Our results illuminate the mechanisms by which malpractice liability reduces growth in physician supply,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293: 2618–25). “In our study, the estimated effect of direct reforms was greater among physicians who practice in nongroup settings. … This is consistent with the lesser ability of smaller practices to spread liability insurance costs among many physicians, cushion premium volatility with high patient volume, or share risk with hospitals or other health care institutions.”

The authors noted several limitations, however. For instance, the study didn't take into account the effect of reforms adopted prior to 1986, nor did it address the trade-offs between the potential benefits of the reforms and their potential cost, such as reduced compensation for medical errors.

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

“The District is home to some of the best medical care in the country,” Mayor Williams said when he announced the bill. “This bill is all about ensuring that our residents and visitors always get top-notch care and that our medical community can practice without undue burdens.”

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. “Linda Cropp's heart is in the right place,” Dr. Freeman, an internist, said in an interview. “She recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The Public Citizen study that Ms. Cropp referred to is one of several studies on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study, which used data from the years 1985–2000, also found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. and 5.5% more surgical specialists per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs. Finally, another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“Our results illuminate the mechanisms by which malpractice liability reduces growth in physician supply,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293: 2618–25). “In our study, the estimated effect of direct reforms was greater among physicians who practice in nongroup settings. … This is consistent with the lesser ability of smaller practices to spread liability insurance costs among many physicians, cushion premium volatility with high patient volume, or share risk with hospitals or other health care institutions.”

The authors noted several limitations, however. For instance, the study didn't take into account the effect of reforms adopted prior to 1986, nor did it address the trade-offs between the potential benefits of the reforms and their potential cost, such as reduced compensation for medical errors.

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. He said in an interview: Ms. Cropp “recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The study that Ms. Cropp referred to is one of several on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study used data from the years 1985–2000 and found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs.

Another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“Our results illuminate the mechanisms by which malpractice liability reduces growth in physician supply,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293: 2618–25).

“The estimated effect of direct reforms was greater among physicians who practice in nongroup settings. … This is consistent with the lesser ability of smaller practices to spread liability insurance costs among many physicians, cushion premium volatility with high patient volume, or share risk with hospitals or other health care institutions.”

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. He said in an interview: Ms. Cropp “recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The study that Ms. Cropp referred to is one of several on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study used data from the years 1985–2000 and found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs.

Another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“Our results illuminate the mechanisms by which malpractice liability reduces growth in physician supply,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293: 2618–25).

“The estimated effect of direct reforms was greater among physicians who practice in nongroup settings. … This is consistent with the lesser ability of smaller practices to spread liability insurance costs among many physicians, cushion premium volatility with high patient volume, or share risk with hospitals or other health care institutions.”

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. He said in an interview: Ms. Cropp “recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The study that Ms. Cropp referred to is one of several on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study used data from the years 1985–2000 and found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs.

Another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“Our results illuminate the mechanisms by which malpractice liability reduces growth in physician supply,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293: 2618–25).

“The estimated effect of direct reforms was greater among physicians who practice in nongroup settings. … This is consistent with the lesser ability of smaller practices to spread liability insurance costs among many physicians, cushion premium volatility with high patient volume, or share risk with hospitals or other health care institutions.”

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

“The District is home to some of the best medical care in the country,” Mayor Williams said when he announced the bill. “This bill is all about ensuring that our residents and visitors always get top-notch care and that our medical community can practice without undue burdens.”

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. “Linda Cropp's heart is in the right place,” Dr. Freeman, an internist, said in an interview. “She recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The Public Citizen study that Ms. Cropp referred to is one of several studies on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study, which used data from the years 1985–2000, also found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. and 5.5% more surgical specialists per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs.

Finally, another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“In our study, the estimated effect of direct reforms was greater among physicians who practice in nongroup settings,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293:2618–25).

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

“The District is home to some of the best medical care in the country,” Mayor Williams said when he announced the bill. “This bill is all about ensuring that our residents and visitors always get top-notch care and that our medical community can practice without undue burdens.”

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. “Linda Cropp's heart is in the right place,” Dr. Freeman, an internist, said in an interview. “She recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The Public Citizen study that Ms. Cropp referred to is one of several studies on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study, which used data from the years 1985–2000, also found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. and 5.5% more surgical specialists per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs.

Finally, another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“In our study, the estimated effect of direct reforms was greater among physicians who practice in nongroup settings,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293:2618–25).

The District of Columbia is the latest in a growing number of jurisdictions trying to combat rising malpractice insurance premiums among physicians, as legislators there battle over whether the best solution is damage caps or increased regulation of insurers.

D.C. Mayor Anthony Williams has proposed legislation that would limit noneconomic damages to $250,000 and expand the city's Good Samaritan law to provide immunity to all health professionals who provide free care.

“The District is home to some of the best medical care in the country,” Mayor Williams said when he announced the bill. “This bill is all about ensuring that our residents and visitors always get top-notch care and that our medical community can practice without undue burdens.”

Linda Cropp, chair of the District of Columbia City Council and a frequent political adversary of Mr. Williams, has introduced her own medical liability reform bill. Under Ms. Cropp's bill, the city's insurance commission would be required to approve all proposed liability premium increases that exceed a certain percentage, would allow the insurance commissioner to consider a malpractice insurer's current surplus as a factor in rate making, and would authorize refunds for physicians who have paid excessive insurance premiums.

Unlike Mr. Williams, Ms. Cropp said she believed that tort reform wasn't the answer. “The problem is the high [cost] of insurance,” she said in a statement. “Payments to patients who sue doctors in the District have declined dramatically, even as doctors and politicians have blamed skyrocketing jury awards for driving up the cost of malpractice insurance and driving doctors out of business.”

Ms. Cropp cited a recent analysis by the consumer watchdog group Public Citizen to back up her contention. That analysis found that insurer payouts in the city, when factored for inflation, dropped from $29 million in 2001 to $11 million in 2004, a reduction of more than 62%.

“Did the malpractice insurance rates paid by doctors drop commensurately?” Ms. Cropp said. “No, they did not.”

But Victor G. Freeman, M.D., president of the Medical Society of the District of Columbia, disagreed with Ms. Cropp's approach. “Linda Cropp's heart is in the right place,” Dr. Freeman, an internist, said in an interview. “She recognizes there is a crisis, and her solution is to make sure there is tighter regulation around medical liability rates in town. Unfortunately, I think she's been misled by Public Citizen and the trial lawyers, because she believes medical liability companies are making huge profits in the city at the expense of physicians.”

Dr. Freeman suggested that Ms. Cropp might want to consider that NCRIC (formerly the National Capital Reciprocal Insurance Co.), the liability insurer for 80% of the District's physicians, lost $7 million last year. “If NCRIC wasn't losing money, other companies would come in and compete. They're staying out for one very clear reason: It's bad business to come into the District because of the high jury awards.”

The Public Citizen study that Ms. Cropp referred to is one of several studies on malpractice insurance that recently have been published. A study of 27 states appearing in the online version of the journal Health Affairs found that counties in states that had a cap on noneconomic damages had 2.2% more physicians per capita than counties in states without a cap (Health Aff. [Millwood] May 2005:[Epub ahead of print]). The study, which used data from the years 1985–2000, also found that rural counties in states with a $250,000 cap had 5.4% more ob.gyns. and 5.5% more surgical specialists per capita than did rural counties in states with a cap above $250,000.

Health Affairs also published an online study showing that malpractice payouts appear to be growing more slowly than previously thought (Health Aff. [Millwood] May 2005;[Epub ahead of print]). Using data from the National Practitioner Data Bank, Amitabh Chandra, Ph.D., of Dartmouth University, Hanover, N.H., and colleagues found that the average payment—including both settlements and judgments at trial—grew by 4% per year between 1991 and 2003, consistent with increases in other health care costs.

Finally, another recent study found that the adoption of “direct” malpractice reforms—including reducing damage caps—resulted in a 3.3% increase in physician supply.

“In our study, the estimated effect of direct reforms was greater among physicians who practice in nongroup settings,” wrote Daniel P. Kessler, Ph.D., of Stanford (Calif.) University, and colleagues (JAMA 2005;293:2618–25).

WASHINGTON — Improving health information technology could go a long way toward eliminating disparities in health care, Newt Gingrich said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

“The challenge is not to be futurist but to bring health care up to the world of the last 20 years,” said Mr. Gingrich, former speaker of the House of Representatives and founder of the Center for Health Transformation.

He criticized a recently adopted Florida law that requires physicians to print legibly when they write prescriptions. “First, it's a fantasy to think legislation will convince doctors to print legibly. Secondly, it's the wrong direction for change,” he said. “Even a clearly printed prescription remains a paper prescription and misses all the opportunities for checking medication errors, checking other medications, and seeing if there are contraindications. In the long run, the future is an electronic prescription with an expert system to make sure you get the right medication.”

People will need to think more creatively, he continued. “Imagine that the medical profession went to major cell phone manufacturers and said, 'We want you to develop a camera capability on a cell phone sufficiently vivid that we could do emergency diagnostics by phone.'”

At the same time, the health care industry needs to find better ways to standardize itself and to disperse information about best practices in medicine, Mr. Gingrich continued. “It can take 17 years for a best practice to reach the average doctor,” he said. “We want to set a standard and migrate everybody to that standard.”

He gave an example of how electronic health records could improve the standard of care. “A friend's father went in for an MRI, and her mother went in with him. They filled out five paper forms before the MRI. The mother happened to go into the doctor's office as they were preparing to do the MRI, and she said, 'You did know he has a pacemaker?' They stopped right there.”

But if the patient had had an electronic health record, “that would have been obvious and automatic, and the expert system would check against it,” Mr. Gingrich said, noting that his center is trying to develop “a 21st-century intelligent health system which we believe will end health disparities in America in terms of the delivery of services.”

However, such a system would not improve disparities based on culture or ethnicity unless certain problems are addressed. For example, “diabetes is largely a cultural issue. How you treat diabetes is a medical issue, but how you avoid diabetes is a cultural issue.”

Since obesity plays a part in the development of diabetes, he urged audience members to push their home states to institute mandatory, 1-hour daily physical education in public schools and also to ban unhealthy foods from the schools.

After electronic health records are in place in hospitals and physicians' offices, the next step should be a “Personal Health Knowledge System,” Mr. Gingrich continued. The system would be accessible to patients online and would contain genetic profiles that might tell patients such things as whether they have a particular genetic makeup that puts them in the 10% of people who should not eat too many high-fiber foods because doing so could trigger colon cancer, he said.

“You should actually know your DNA before you go grocery shopping,” he said. “Within a decade, we'll have an expert system where you'll be able to punch in your health status and it will print out a grocery list.”

In fact, food purchases also can be used as an incentive: “If you want to truly help health disparities among the poor, you may want to give bonus points if you use food stamps for the right foods,” Mr. Gingrich said. “That sounds like micromanagement, but we've got to be practical about how to shift behavior patterns.”

An intelligent system also could help people maintain their health in other ways, he added. It would “tell you your health status, including weight, blood pressure, and blood sugar. And maybe it can be tied to your cell phone so it can remind you six times a day that you need to take a pill or check your blood sugar. We need to get people into a system that's supportive.”

WASHINGTON — Improving health information technology could go a long way toward eliminating disparities in health care, Newt Gingrich said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

“The challenge is not to be futurist but to bring health care up to the world of the last 20 years,” said Mr. Gingrich, former speaker of the House of Representatives and founder of the Center for Health Transformation.

He criticized a recently adopted Florida law that requires physicians to print legibly when they write prescriptions. “First, it's a fantasy to think legislation will convince doctors to print legibly. Secondly, it's the wrong direction for change,” he said. “Even a clearly printed prescription remains a paper prescription and misses all the opportunities for checking medication errors, checking other medications, and seeing if there are contraindications. In the long run, the future is an electronic prescription with an expert system to make sure you get the right medication.”

People will need to think more creatively, he continued. “Imagine that the medical profession went to major cell phone manufacturers and said, 'We want you to develop a camera capability on a cell phone sufficiently vivid that we could do emergency diagnostics by phone.'”

At the same time, the health care industry needs to find better ways to standardize itself and to disperse information about best practices in medicine, Mr. Gingrich continued. “It can take 17 years for a best practice to reach the average doctor,” he said. “We want to set a standard and migrate everybody to that standard.”

He gave an example of how electronic health records could improve the standard of care. “A friend's father went in for an MRI, and her mother went in with him. They filled out five paper forms before the MRI. The mother happened to go into the doctor's office as they were preparing to do the MRI, and she said, 'You did know he has a pacemaker?' They stopped right there.”

But if the patient had had an electronic health record, “that would have been obvious and automatic, and the expert system would check against it,” Mr. Gingrich said, noting that his center is trying to develop “a 21st-century intelligent health system which we believe will end health disparities in America in terms of the delivery of services.”

However, such a system would not improve disparities based on culture or ethnicity unless certain problems are addressed. For example, “diabetes is largely a cultural issue. How you treat diabetes is a medical issue, but how you avoid diabetes is a cultural issue.”

Since obesity plays a part in the development of diabetes, he urged audience members to push their home states to institute mandatory, 1-hour daily physical education in public schools and also to ban unhealthy foods from the schools.

After electronic health records are in place in hospitals and physicians' offices, the next step should be a “Personal Health Knowledge System,” Mr. Gingrich continued. The system would be accessible to patients online and would contain genetic profiles that might tell patients such things as whether they have a particular genetic makeup that puts them in the 10% of people who should not eat too many high-fiber foods because doing so could trigger colon cancer, he said.

“You should actually know your DNA before you go grocery shopping,” he said. “Within a decade, we'll have an expert system where you'll be able to punch in your health status and it will print out a grocery list.”

In fact, food purchases also can be used as an incentive: “If you want to truly help health disparities among the poor, you may want to give bonus points if you use food stamps for the right foods,” Mr. Gingrich said. “That sounds like micromanagement, but we've got to be practical about how to shift behavior patterns.”

An intelligent system also could help people maintain their health in other ways, he added. It would “tell you your health status, including weight, blood pressure, and blood sugar. And maybe it can be tied to your cell phone so it can remind you six times a day that you need to take a pill or check your blood sugar. We need to get people into a system that's supportive.”

WASHINGTON — Improving health information technology could go a long way toward eliminating disparities in health care, Newt Gingrich said at a meeting sponsored by the Alliance of Minority Medical Associations, the National Association for Equal Opportunity in Higher Education, and the Department of Health and Human Services.

“The challenge is not to be futurist but to bring health care up to the world of the last 20 years,” said Mr. Gingrich, former speaker of the House of Representatives and founder of the Center for Health Transformation.

He criticized a recently adopted Florida law that requires physicians to print legibly when they write prescriptions. “First, it's a fantasy to think legislation will convince doctors to print legibly. Secondly, it's the wrong direction for change,” he said. “Even a clearly printed prescription remains a paper prescription and misses all the opportunities for checking medication errors, checking other medications, and seeing if there are contraindications. In the long run, the future is an electronic prescription with an expert system to make sure you get the right medication.”

People will need to think more creatively, he continued. “Imagine that the medical profession went to major cell phone manufacturers and said, 'We want you to develop a camera capability on a cell phone sufficiently vivid that we could do emergency diagnostics by phone.'”

At the same time, the health care industry needs to find better ways to standardize itself and to disperse information about best practices in medicine, Mr. Gingrich continued. “It can take 17 years for a best practice to reach the average doctor,” he said. “We want to set a standard and migrate everybody to that standard.”

He gave an example of how electronic health records could improve the standard of care. “A friend's father went in for an MRI, and her mother went in with him. They filled out five paper forms before the MRI. The mother happened to go into the doctor's office as they were preparing to do the MRI, and she said, 'You did know he has a pacemaker?' They stopped right there.”

But if the patient had had an electronic health record, “that would have been obvious and automatic, and the expert system would check against it,” Mr. Gingrich said, noting that his center is trying to develop “a 21st-century intelligent health system which we believe will end health disparities in America in terms of the delivery of services.”

However, such a system would not improve disparities based on culture or ethnicity unless certain problems are addressed. For example, “diabetes is largely a cultural issue. How you treat diabetes is a medical issue, but how you avoid diabetes is a cultural issue.”

Since obesity plays a part in the development of diabetes, he urged audience members to push their home states to institute mandatory, 1-hour daily physical education in public schools and also to ban unhealthy foods from the schools.

After electronic health records are in place in hospitals and physicians' offices, the next step should be a “Personal Health Knowledge System,” Mr. Gingrich continued. The system would be accessible to patients online and would contain genetic profiles that might tell patients such things as whether they have a particular genetic makeup that puts them in the 10% of people who should not eat too many high-fiber foods because doing so could trigger colon cancer, he said.

“You should actually know your DNA before you go grocery shopping,” he said. “Within a decade, we'll have an expert system where you'll be able to punch in your health status and it will print out a grocery list.”

In fact, food purchases also can be used as an incentive: “If you want to truly help health disparities among the poor, you may want to give bonus points if you use food stamps for the right foods,” Mr. Gingrich said. “That sounds like micromanagement, but we've got to be practical about how to shift behavior patterns.”

An intelligent system also could help people maintain their health in other ways, he added. It would “tell you your health status, including weight, blood pressure, and blood sugar. And maybe it can be tied to your cell phone so it can remind you six times a day that you need to take a pill or check your blood sugar. We need to get people into a system that's supportive.”

WASHINGTON — The term “prenatal care” should be rethought to include much more of a woman's life cycle, Dawn Misra, Ph.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

“We have to go beyond the [typical] prenatal period” of a few months before pregnancy, said Dr. Misra of the University of Michigan, Ann Arbor. When it comes to chronic illnesses that may affect pregnancy, for example, “we have to plan strategies to address these matters across the life course; if we want to fix them, we can't wait until pregnancy to [address] them.”

Dr. Misra gave hypertension as an example. “There really is no good treatment for hypertension once you're pregnant,” she said. “You can do some things to try to moderate its effects and lessen its impact, but you can't fix it. So [instead] we could prevent women from having hypertension and entering pregnancy with hypertension.” This involves addressing such chronic health problems in the preconception period as well as between pregnancies.

She gave several reasons why providers haven't taken this approach. “Public health and medical professionals are wedded to the notion that prenatal care is fundamental,” she said. “There have been a lot of successes with prenatal care, but I would like to take a step back and think about how prenatal care is not the only answer.”

The health care financing system has encouraged this model of prenatal care by the way it reimburses for care, she continued. As a result, “very few women get no prenatal care, yet we haven't achieved much improvement in terms of infant outcomes.”

Changing this system of care would also mean increasing involvement by providers outside the specialty of ob.gyn., such as pediatricians, Dr. Misra said. “Pediatricians are taking care of future mothers. They could spend time from that perspective thinking about chronic illnesses, keeping [these patients] well, and thinking about what future concerns might be.”

Some of these changes might be fostered by improving medical school training. In addition, people from outside the medical profession such as coaches and personal trainers could be involved in these types of issues, she said.

Pediatricians could also help provide better record transfer, Dr. Misra noted. “We have young girls moving from the pediatrician to the ob.gyn. or the nurse-midwife. A lot is lost when young girls move to those providers, and we need to find better ways to relay their health history.” This is a challenge that needs to be met, especially in the wake of a study showing that 25% of pregnant women have a chronic health condition, Dr. Misra added.

On a broader level, public health officials need to rethink their method of separating chronic disease care from maternal and child health programming, Dr. Misra said. “This may require thinking about how future [pregnancy] outcomes are dependent on preventing these kinds of illnesses.”

One audience member commented that although she liked the speaker's message, “The women's health movement has been struggling for a long time to get away from thinking about women's health merely in terms of maternity and reproduction,” she said. “I think we need to reword language like 'preconceptional.' When we're sitting in this room, we know what we're talking about, but many people out there still think of women as reproductive machines.”

WASHINGTON — The term “prenatal care” should be rethought to include much more of a woman's life cycle, Dawn Misra, Ph.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

“We have to go beyond the [typical] prenatal period” of a few months before pregnancy, said Dr. Misra of the University of Michigan, Ann Arbor. When it comes to chronic illnesses that may affect pregnancy, for example, “we have to plan strategies to address these matters across the life course; if we want to fix them, we can't wait until pregnancy to [address] them.”

Dr. Misra gave hypertension as an example. “There really is no good treatment for hypertension once you're pregnant,” she said. “You can do some things to try to moderate its effects and lessen its impact, but you can't fix it. So [instead] we could prevent women from having hypertension and entering pregnancy with hypertension.” This involves addressing such chronic health problems in the preconception period as well as between pregnancies.

She gave several reasons why providers haven't taken this approach. “Public health and medical professionals are wedded to the notion that prenatal care is fundamental,” she said. “There have been a lot of successes with prenatal care, but I would like to take a step back and think about how prenatal care is not the only answer.”

The health care financing system has encouraged this model of prenatal care by the way it reimburses for care, she continued. As a result, “very few women get no prenatal care, yet we haven't achieved much improvement in terms of infant outcomes.”

Changing this system of care would also mean increasing involvement by providers outside the specialty of ob.gyn., such as pediatricians, Dr. Misra said. “Pediatricians are taking care of future mothers. They could spend time from that perspective thinking about chronic illnesses, keeping [these patients] well, and thinking about what future concerns might be.”

Some of these changes might be fostered by improving medical school training. In addition, people from outside the medical profession such as coaches and personal trainers could be involved in these types of issues, she said.

Pediatricians could also help provide better record transfer, Dr. Misra noted. “We have young girls moving from the pediatrician to the ob.gyn. or the nurse-midwife. A lot is lost when young girls move to those providers, and we need to find better ways to relay their health history.” This is a challenge that needs to be met, especially in the wake of a study showing that 25% of pregnant women have a chronic health condition, Dr. Misra added.

On a broader level, public health officials need to rethink their method of separating chronic disease care from maternal and child health programming, Dr. Misra said. “This may require thinking about how future [pregnancy] outcomes are dependent on preventing these kinds of illnesses.”

One audience member commented that although she liked the speaker's message, “The women's health movement has been struggling for a long time to get away from thinking about women's health merely in terms of maternity and reproduction,” she said. “I think we need to reword language like 'preconceptional.' When we're sitting in this room, we know what we're talking about, but many people out there still think of women as reproductive machines.”

WASHINGTON — The term “prenatal care” should be rethought to include much more of a woman's life cycle, Dawn Misra, Ph.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

“We have to go beyond the [typical] prenatal period” of a few months before pregnancy, said Dr. Misra of the University of Michigan, Ann Arbor. When it comes to chronic illnesses that may affect pregnancy, for example, “we have to plan strategies to address these matters across the life course; if we want to fix them, we can't wait until pregnancy to [address] them.”

Dr. Misra gave hypertension as an example. “There really is no good treatment for hypertension once you're pregnant,” she said. “You can do some things to try to moderate its effects and lessen its impact, but you can't fix it. So [instead] we could prevent women from having hypertension and entering pregnancy with hypertension.” This involves addressing such chronic health problems in the preconception period as well as between pregnancies.

She gave several reasons why providers haven't taken this approach. “Public health and medical professionals are wedded to the notion that prenatal care is fundamental,” she said. “There have been a lot of successes with prenatal care, but I would like to take a step back and think about how prenatal care is not the only answer.”

The health care financing system has encouraged this model of prenatal care by the way it reimburses for care, she continued. As a result, “very few women get no prenatal care, yet we haven't achieved much improvement in terms of infant outcomes.”

Changing this system of care would also mean increasing involvement by providers outside the specialty of ob.gyn., such as pediatricians, Dr. Misra said. “Pediatricians are taking care of future mothers. They could spend time from that perspective thinking about chronic illnesses, keeping [these patients] well, and thinking about what future concerns might be.”

Some of these changes might be fostered by improving medical school training. In addition, people from outside the medical profession such as coaches and personal trainers could be involved in these types of issues, she said.

Pediatricians could also help provide better record transfer, Dr. Misra noted. “We have young girls moving from the pediatrician to the ob.gyn. or the nurse-midwife. A lot is lost when young girls move to those providers, and we need to find better ways to relay their health history.” This is a challenge that needs to be met, especially in the wake of a study showing that 25% of pregnant women have a chronic health condition, Dr. Misra added.

On a broader level, public health officials need to rethink their method of separating chronic disease care from maternal and child health programming, Dr. Misra said. “This may require thinking about how future [pregnancy] outcomes are dependent on preventing these kinds of illnesses.”

One audience member commented that although she liked the speaker's message, “The women's health movement has been struggling for a long time to get away from thinking about women's health merely in terms of maternity and reproduction,” she said. “I think we need to reword language like 'preconceptional.' When we're sitting in this room, we know what we're talking about, but many people out there still think of women as reproductive machines.”

WASHINGTON — Despite claims to the contrary, there is still more work to do to reduce maternal morbidity and mortality in the United States, Cynthia Berg, M.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

Throughout the 20th century, maternal mortality in the United States gradually went from 900 deaths per 100,00 live births to about 10, noted Dr. Berg, who is a medical epidemiologist at the Centers for Disease Control and Prevention, Atlanta. “But in the past 20 years, there hasn't been a meaningful drop.”

As a result of this slowing in decline, “some people believe that the United States has reached an irreducible minimum,” she continued. “However, I would say there are a few pieces of evidence that would refute this claim.”

For one thing, there are large racial and ethnic disparities in the risk of pregnancy-related death. For example, “the risk for black women is four times that for non-Hispanic white women, and that is one of the largest gaps in reproductive health treatment in the United States,” Dr. Berg said. “Hispanics, Asian/Pacific Islanders, and Asian women also have a 50%–70% higher rate of pregnancy-related mortality than non-Hispanic white women.”

Disparities also appear if both race and birthplace are taken into account. Although Hispanic and Asian women born in the United States have mortality rates similar to native-born white women, Hispanic and Asian women born outside the United States have a much higher mortality risk, according to Dr. Berg.

Although maternal mortality is often the focus of research, maternal morbidity deserves more attention than it is getting, said Stacie Geller, Ph.D., director of the University of Illinois at Chicago National Center of Excellence in Women's Health. “Clearly, studying morbidity itself is important, but it also is another way to try to reduce maternal mortality.”

One study by Dr. Berg and her associates found that 43% of women experience some form of maternal morbidity, based on data from the National Hospital Discharge Survey for women giving birth between 1993 and 1997. The most common condition was obstetric trauma such as a third- or fourth-degree laceration or hematoma (10.6%), followed by infections such as amnionitis (8.4%). Rare and serious complications like hemorrhage or pulmonary and amniotic embolisms occurred in less than 0.1% of the study group.

Dr. Geller cited three factors that placed women at higher risk of adverse outcomes during their pregnancies: lack of health insurance, particular clinical diagnoses, and preventable events.

“Most [preventable events] were due to provider issues,” she said.

Dr. Geller cited a study she and her colleagues had done, which found that a woman who died from a pregnancy-related cause was two times more likely to have had a provider-related preventable event, compared with her counterpart with severe morbidity. “It's not good news, but it means we can do something about it by changing provider behavior.”

Dr. Geller recommended more use of departmental and institutional review committees to study maternal morbidity and mortality cases. She also recommended that statewide maternal death review committees expand their scope to include near-miss morbidity cases.

Some audience members disagreed with Dr. Geller's approach. “If you continue to say some of these deaths are provider related versus system related, that propagates the continuation of individualized blame for adverse outcomes in the health care system,” said Michele Curtis, M.D., of the department of obstetrics and gynecology at the University of Texas at Houston Health Science Center. “The aviation industry has demonstrated profoundly to us, as has the specialty of anesthesia, that we can, if we choose to use a system-based analysis and get away from the blame game, make much more progress on a population level.” n

WASHINGTON — Despite claims to the contrary, there is still more work to do to reduce maternal morbidity and mortality in the United States, Cynthia Berg, M.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

Throughout the 20th century, maternal mortality in the United States gradually went from 900 deaths per 100,00 live births to about 10, noted Dr. Berg, who is a medical epidemiologist at the Centers for Disease Control and Prevention, Atlanta. “But in the past 20 years, there hasn't been a meaningful drop.”

As a result of this slowing in decline, “some people believe that the United States has reached an irreducible minimum,” she continued. “However, I would say there are a few pieces of evidence that would refute this claim.”

For one thing, there are large racial and ethnic disparities in the risk of pregnancy-related death. For example, “the risk for black women is four times that for non-Hispanic white women, and that is one of the largest gaps in reproductive health treatment in the United States,” Dr. Berg said. “Hispanics, Asian/Pacific Islanders, and Asian women also have a 50%–70% higher rate of pregnancy-related mortality than non-Hispanic white women.”

Disparities also appear if both race and birthplace are taken into account. Although Hispanic and Asian women born in the United States have mortality rates similar to native-born white women, Hispanic and Asian women born outside the United States have a much higher mortality risk, according to Dr. Berg.

Although maternal mortality is often the focus of research, maternal morbidity deserves more attention than it is getting, said Stacie Geller, Ph.D., director of the University of Illinois at Chicago National Center of Excellence in Women's Health. “Clearly, studying morbidity itself is important, but it also is another way to try to reduce maternal mortality.”

One study by Dr. Berg and her associates found that 43% of women experience some form of maternal morbidity, based on data from the National Hospital Discharge Survey for women giving birth between 1993 and 1997. The most common condition was obstetric trauma such as a third- or fourth-degree laceration or hematoma (10.6%), followed by infections such as amnionitis (8.4%). Rare and serious complications like hemorrhage or pulmonary and amniotic embolisms occurred in less than 0.1% of the study group.

Dr. Geller cited three factors that placed women at higher risk of adverse outcomes during their pregnancies: lack of health insurance, particular clinical diagnoses, and preventable events.

“Most [preventable events] were due to provider issues,” she said.

Dr. Geller cited a study she and her colleagues had done, which found that a woman who died from a pregnancy-related cause was two times more likely to have had a provider-related preventable event, compared with her counterpart with severe morbidity. “It's not good news, but it means we can do something about it by changing provider behavior.”

Dr. Geller recommended more use of departmental and institutional review committees to study maternal morbidity and mortality cases. She also recommended that statewide maternal death review committees expand their scope to include near-miss morbidity cases.

Some audience members disagreed with Dr. Geller's approach. “If you continue to say some of these deaths are provider related versus system related, that propagates the continuation of individualized blame for adverse outcomes in the health care system,” said Michele Curtis, M.D., of the department of obstetrics and gynecology at the University of Texas at Houston Health Science Center. “The aviation industry has demonstrated profoundly to us, as has the specialty of anesthesia, that we can, if we choose to use a system-based analysis and get away from the blame game, make much more progress on a population level.” n

WASHINGTON — Despite claims to the contrary, there is still more work to do to reduce maternal morbidity and mortality in the United States, Cynthia Berg, M.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

Throughout the 20th century, maternal mortality in the United States gradually went from 900 deaths per 100,00 live births to about 10, noted Dr. Berg, who is a medical epidemiologist at the Centers for Disease Control and Prevention, Atlanta. “But in the past 20 years, there hasn't been a meaningful drop.”

As a result of this slowing in decline, “some people believe that the United States has reached an irreducible minimum,” she continued. “However, I would say there are a few pieces of evidence that would refute this claim.”

For one thing, there are large racial and ethnic disparities in the risk of pregnancy-related death. For example, “the risk for black women is four times that for non-Hispanic white women, and that is one of the largest gaps in reproductive health treatment in the United States,” Dr. Berg said. “Hispanics, Asian/Pacific Islanders, and Asian women also have a 50%–70% higher rate of pregnancy-related mortality than non-Hispanic white women.”

Disparities also appear if both race and birthplace are taken into account. Although Hispanic and Asian women born in the United States have mortality rates similar to native-born white women, Hispanic and Asian women born outside the United States have a much higher mortality risk, according to Dr. Berg.

Although maternal mortality is often the focus of research, maternal morbidity deserves more attention than it is getting, said Stacie Geller, Ph.D., director of the University of Illinois at Chicago National Center of Excellence in Women's Health. “Clearly, studying morbidity itself is important, but it also is another way to try to reduce maternal mortality.”

One study by Dr. Berg and her associates found that 43% of women experience some form of maternal morbidity, based on data from the National Hospital Discharge Survey for women giving birth between 1993 and 1997. The most common condition was obstetric trauma such as a third- or fourth-degree laceration or hematoma (10.6%), followed by infections such as amnionitis (8.4%). Rare and serious complications like hemorrhage or pulmonary and amniotic embolisms occurred in less than 0.1% of the study group.

Dr. Geller cited three factors that placed women at higher risk of adverse outcomes during their pregnancies: lack of health insurance, particular clinical diagnoses, and preventable events.

“Most [preventable events] were due to provider issues,” she said.

Dr. Geller cited a study she and her colleagues had done, which found that a woman who died from a pregnancy-related cause was two times more likely to have had a provider-related preventable event, compared with her counterpart with severe morbidity. “It's not good news, but it means we can do something about it by changing provider behavior.”

Dr. Geller recommended more use of departmental and institutional review committees to study maternal morbidity and mortality cases. She also recommended that statewide maternal death review committees expand their scope to include near-miss morbidity cases.

Some audience members disagreed with Dr. Geller's approach. “If you continue to say some of these deaths are provider related versus system related, that propagates the continuation of individualized blame for adverse outcomes in the health care system,” said Michele Curtis, M.D., of the department of obstetrics and gynecology at the University of Texas at Houston Health Science Center. “The aviation industry has demonstrated profoundly to us, as has the specialty of anesthesia, that we can, if we choose to use a system-based analysis and get away from the blame game, make much more progress on a population level.” n