'Rural' no more?
A legislative proposal would end malpractice insurance subsidies for doctors in communities like Ashland, with obstetricians among those most affected
By Bill Kettler
Lucinda Kolo came to Ashland to deliver babies, but the Oregon Legislature may force her to change her mind.
The Legislature is deliberating a bill (SB 183) that would change the definition of “rural” to eliminate Ashland physicians from a four-year-old program that subsidizes the malpractice insurance premiums of rural doctors. Kolo and other Ashland physicians who still deliver babies say they would be hard-pressed to continue doing obstetrics if their malpractice relief disappears.
“I’d have to deliver 32 babies a year just to make my malpractice premium,” said Kolo, 38, who lives in an 800-square-foot apartment and drives a 10-year-old Ford Escort. “That’s just to pay the premium, not to pay my employees.”
Kolo pays $53,000 a year for malpractice insurance that includes obstetric coverage, and the state picks up 60 percent of the tab. If she were to stop delivering babies altogether, her annual malpractice premium would fall to just $12,000.
With an 18-month-old toddler of her own to raise, Kolo said if she loses state support, she’ll have to “balance the good I’m doing my family with the good I’m doing my community. One night a week I’m up all night (delivering a baby).”
The Legislature decided to revise the program after discovering that its loose definition of rural had allowed millions of dollars in malpractice relief to go to hundreds of physicians in communities such as Bend and Ashland that were perceived by many people as distinctly not rural. The law also drew criticism because it provided malpractice relief to all physicians, including specialists such as plastic surgeons and eye doctors, who practiced in rural areas.
SB 183, which is scheduled for a hearing Wednesday before the Senate’s health and human services committee, uses a U.S. Census Bureau definition of rural to define eligibility for the program. That definition would disqualify physicians in Ashland and other “urbanized” areas such as Albany and Independence from the program.
The bill would also reduce malpractice subsidies for rural physicians who do not deliver babies, and require physicians who participate to see patients covered by Medicare and Medicaid, which traditionally pay physicians much less than private insurance.
Under the new definition, Grants Pass would still qualify as a rural area, even though it is a larger community than Ashland and has a larger hospital. Three Rivers Community Hospital staffs 115 patient beds, while Ashland Community Hospital has just 37.
“It’s Ashland’s proximity to Medford that makes it ineligible” under the new proposal, said Scott Ekblad, director of the state Office of Rural Health. He notes it’s barely 10 miles on Interstate 5 from Ashland to Medford, but about 25 freeway miles from Grants Pass to Medford.
Ashland also has more physicians per thousand residents than Grants Pass. According to statistics from the Office of Rural Health, Ashland has 3.2 physicians per 1,000 residents, while Grants Pass has 1.8 physicians per 1,000 residents, Ekblad said. Oregon overall has 2.4 physicians per 1,000 residents. In urban areas as a whole, the state average is 3.0 physicians per 1,000 residents; for all rural areas, it’s 1.3 per 1,000.
Those numbers alone don’t tell the whole story, however, says Dr. John Delgado, who has been delivering babies in Ashland for 16 years. Delgado says Ashland has many specialists but not nearly enough primary care doctors. He said the number of physicians attending births has dropped from 16 when he started to just five today.
Delgado said attending births is “the heart and love” of his practice, but he would probably have no choice but to drop obstetrics if the state subsidy ends.
Dr. Jani Rollins, another Ashland doctor who delivers babies, said the real issue is who will deliver Ashland’s babies if she and the other four doctors who still do obstetrics decide to drop out. Rollins said Ashland Community Hospital provides an environment that supports natural childbirth and procedures such as water birthing that are favored by many women.
“We have a specific service here, and our community would be lost without it,” she said.
If no Ashland physicians chose to deliver babies, Ashland Community Hospital could be forced to close its birth center, said Mark Marchetti, hospital administrator. Marchetti said Ashland is perceived as a privileged community, but in fact 60 percent of the hospital’s 350 annual births are low-income mothers who qualify for the state/federal Medicaid program.
Rollins said that physicians receive about $1,700 for a Medicaid pregnancy (which includes prenatal care and delivery) compared to about $3,600 for private insurance.
“We love what we do,” she said, “but if we’re going to lose money doing OB, we’re not going to do it.”
Administrators at Medford’s two hospitals said their birth centers could handle an influx of as many as 350 new births per year.
State Sen. Alan Bates, D-Ashland, said amendments are being drafted for SB 183 that would extend some malpractice relief to Ashland physicians and gradually end their subsidy over the next four years. Bates said the subsidy program would be re-examined again in 2009 to determine whether it’s working.
“It’s always hard to draw a line,” he said, “but you’ve got to draw a line somewhere. If Ashland were 20 or 30 miles away from Medford it would be different.”