BY SARAH STEPHEN
Australia is facing a shortage of working medical specialists. Almost 10% of Australia's obstetricians abandoned the profession last year, and in June the Royal Australian College of Obstetricians and Gynaecologists released a study showing 40% of obstetricians plan to leave the profession over the next 10 years. This will bring the national workforce of 700 down to 420.
An article in the May 29 Sydney Daily Telegraph highlighted the dire situation. It noted that there is a growing reluctance by trainee obstetrician-gynaecologists to deliver babies. Graduates are increasingly choosing careers in private gynaecology and IVF/fertility. The Telegraph cited the example of 36-year-old Amanda Dennis, who planned to abandon obstetrics in June after just four years on the job.
"Dr Dennis, who works in public and private hospitals in western Sydney, said she delivered about 200 babies a year, and was run off her feet. She has decided to move into a private gynaecology practice and perform a small number of public deliveries.
"'I'm tired', she said. 'I get called out of bed two nights a week, last week it was four and I can't cut down on the number of deliveries I do because it's not cost effective. I got married 12 months ago and it's very hard on my husband if every second week I'm on call.' Each patient Dennis sees adds about $500 to her medical indemnity insurance, which was around $100,000 last year.
Andrew Foote, a Canberra obstetrician, told ABC news on July 1: "Three new colleagues who started in town have ... only become gynaecologists, and not taken obstetrics. So my concern is that services are going to suffer, as [insurance] premiums rise people are going to walk away."
The medical insurance crisis is a big part of why so many obstetricians are leaving their profession and why many medical specialists and GPs are retiring early. The crisis reached a crescendo at the beginning of October, as wave after wave of doctors and medical specialists threatened to stop working in public hospitals across New South Wales.
The threat of a mass walkout was triggered by news that the 60% of the country's doctors who are covered by United Medical Protection would have to pay a hefty levy by November 1. The "incurred but not reported" levy (IBNR) is supposed to cover doctors against future claims made by past patients. The annual levy, to be paid for 10 years, will establish a fund to meet future unfunded liabilities of UMP, which the government estimates could be in the order of $460 million.
UMP is a doctor-run not-for-profit insurance company. It was hit by the HIH collapse, a blow-out in malpractice claims and rising re-insurance costs and went into provisional liquidation in 2002.
UMP's failure sparked a national crisis, and the government was forced to, in effect, underwrite it until the end of this year in order to ensure doctors kept working. The levy was proposed as part of the rescue package.
The levy for a surgeon was calculated at around $20,000 per year on top of their average premium of $59,000; $35,000 for an obstetrician on top of a $110,000 premium, and $8000 for an anaesthetist in addition to a $30,000 premium. For GPs who do no procedural work, the levy was set at $1000-$1800, in addition to their average premium of $7000.
The appointment of former minister for union bashing Tony Abbott as health minister gives the Coalition's key tough guy the job of negotiating away the bad publicity. On October 3, he proposed a "solution" — an 18-month moratorium on IBNR levies of more than $1000. On October 7, he extended the moratorium to cover the whole levy.
Doctors have not responded well to Abbott's "solution", not only because it rather conveniently postpones the levy problem until after the federal election, but also because the levy is only a small part of the much bigger problem of medical insurance.
The day after Abbott's announcement, more than half of the 40 ear, nose and throat surgeons in Queensland offered their resignations to the state's public hospitals. Another 55 specialists from Sydney's Royal Prince Alfred Hospital reportedly voted to resign on October 7, along with at least one paediatric neurosurgeon from Westmead Hospital.
Australian Medical Association president Bill Glasson called Abbott's proposal "an olive branch with thorns on it". He told ABC radio's The World Today on October 8: "The moratorium, on its own, is worth nothing unless we can come up with a major structural change to the way indemnity is handled in this country."
Doctors' anger was further fuelled by the news on October 8 that the federal government had got its sums wrong, inflating the amounts that doctors were levied, because it failed to consider the effect of recent changes to negligence law in many states which limit the number and size of negligence claims.
Skyrocketing insurance premiums have been hitting doctors hard, particularly in the past two years.
In 2001, a doctor not carrying out seriously risky procedures was required to pay around $1000 a year to an insurance company in order to be covered if sued by a patient for negligence. Doctors involved in delivering babies or major surgery paid more than $10,000. Since then, these costs have increased dramatically: the base rate is $2500, and delivering babies costs a doctor at least $100,000 in insurance.
An emergency doctor from Tasmania posted a comment on the AMA's web site, pointing out the frustrating contradiction that "hospital medicine has never been as safe; obstetrics and neurosurgery (to mention two) have outstanding outcomes, yet insurance does not reflect it".
Doctors who were trained in the simple procedure of inserting Implanon (the new long-lasting contraceptive) into a woman's arm are now having their insurance premiums increased by $5000 a year. Many doctors are deciding to no longer offer this service. Soon a woman will only be able to get Implanon from a specialist gynaecologist.
Some doctors are stopping the work they do in public hospitals, which is often done as an adjunct to private practice, because it doesn't generate enough money to help pay their insurance premiums. Many GPs are no longer doing procedural work, such as minor surgery, in order to keep their premiums down. Increasing numbers of doctors are retiring early.
AMA president Bill Glasson told ABC Radio on September 12: "We have lost more general practitioners in the last 12 months than we've lost proportionately in the last 10 years. So the GPs are leaving the system and I can tell you the specialists are leaving in even greater numbers."
Why have insurance claims been rising?
The AMA argues that a culture of litigation is the reason the cost of doctors' insurance premiums has escalated. But increased litigation is not just a product of the activities of lawyers. Alone, it doesn't explain the explosion in claims and record pay-outs.
In a speech on April 9, chair of the AMA Medical Professional Indemnity Task Force Committee Dr Michael Sledgley told a Sydney doctors' rally: "In 1996 an award of $9 million was the largest medical compensation award on record. By 2001, Calandra Simpson's $19 million (including costs) broke the record". He pointed out: "The future care costs of a severely injured patient form the greatest part of the large claims."
Many of those seriously injured during a medical procedure can only get enough compensation to treat their injuries by suing a specialist doctor (this system does not apply to public hospital doctors, who are covered by the government). Many are forced to sue doctors in order to get enough money to pay for a lifetime of medical bills and sustain a decent quality of life, because the social system doesn't provide that care.
The present system needs to be replaced with one which recognises that necessary care for the seriously injured is a public responsibility. Some are calling for the government to look at implementing a "no fault" insurance scheme, where all patients injured during medical procedures or in hospitals could be compensated. Separate criminal or civil proceedings for malpractice could be taken against incompetent doctors.
If the government pumped sufficient funds into Medicare, they could ensure that bulk billing covers all the costs of a general practice, including insurance (which is one of the biggest costs).
Such measures would be a step forward, but what needs to underpin a comprehensive solution is a universal health care system and societal support that ensures all the injured are cared for, have a decent income and a shot at a decent life — irrespective of how their injuries are caused. Doubling the disability pension and putting serious resources into support services for the injured and disabled would go a long way to solving the "indemnity crisis".
From Green Left Weekly, October 15, 2003.
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