Report: OB services in region near crisis point

By JO CIAVAGLIA
Bucks County Courier Times
http://www.phillyburbs.com

In the Philadelphia region, more hospitals are closing obstetric units and fewer OB-GYN doctors are practicing at a time when more low-birth-weight babies are being born and fewer expectant mothers are starting early prenatal care.

Those are among the key findings in a new report that foresees a looming OB care crisis in the state and specifically the Philadelphia area unless the state and federal government take dramatic legislative, regulatory and operations actions soon.

“It is real,” said Ken Braithwaite, director of the Delaware Valley Health Care Council, which compiled the report for its OB Services Task Force that was released Friday.

The report outlines the decline of obstetric and gynecological services in the state and region and proposes a plan for reversing the trend that includes incentives to attract doctors, boost provider care reimbursement rates, and reform medical malpractice laws.

Since 1994, the Philadelphia region has seen 13 hospitals end OB services, resulting in a 28 percent drop in licensed beds and the loss of six neonatal intensive care units that provide special care to premature and medically fragile babies.

Additionally, the region has lost nearly one-third of its practicing OB-GYN doctors since 2001. Since 2003 alone, almost 70 percent of the specialty doctors in the Philadelphia tri-state area have limited their practices or increased the use of so-called “defensive medicine,” such as performing more Caesarean sections, because of the lack of affordable or available malpractice insurance.

The situation here is being seen across the state, as more hospitals are closing costly obstetric units, according to the report.

Over the last decade, 33 hospital OB units have closed statewide. Since January alone, four more Pennsylvania hospitals have announced plans to stop delivering babies, including Jeanes Hospital in Northeast Philadelphia, which is closing its unit at the end of this month.

What makes the issue so critical is that adequate access to appropriate prenatal, obstetrical and postpartum care is essential to the health of mothers and their newborns.

Low reimbursements and high medical liability costs top the list of contributing factors to the OB shortage in the state and region, according to the task force findings. The cost of professional liability insurance for Pennsylvania hospitals has doubled since 2000, with obstetricians and gynecologists experiencing some of the largest increases, the report said.

Medical assistance pays for one in every three births in the state, and 40 percent of births in the Southeast section, but it reimburses hospitals only 80 percent of hospital stay costs and 54 percent of outpatient costs. Inadequate insurance coverage for undocumented-immigrant, expectant mothers through emergency Medicaid is also causing access and payment problems.

Commercial insurer reimbursement rates are better, the report said, but still fall far short of the levels necessary to maintain a financially viable practice.

Among the task force recommendations is legislation to protect OB and maternity services by providing “adequate” hospital reimbursement for providers including a “disproportionate” share payment for hospitals serving high volumes of Medicaid maternity patients.
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Two Pennsylvania lawmakers in the House and Senate are sponsoring a bill that seeks improved government funding for hospitals with high volumes of obstetric and neonatal intensive care for mothers with Medicaid insurance.

Health officials say they’re already seeing problems related to the doctor shortage, especially among poor women who have the biggest challenge accessing health care, according to the report.

While statewide the birth rate has remained stable in recent years, the percentage of low birth weight babies (5 pounds, 8 ounces or less) needing more specialized care increased 15 percent from 1996 to 2004.

In Philadelphia and its suburbs, the percentage of infants born at very low birth weight — under 3.3 pounds — has increased 10 percent to 60 percent since 1998, according to the report. Bucks County saw about a 10 percent increase from 1.4 percent to 1.5 percent of births, while neighboring Montgomery County saw about a 20 percent increase, from 1.3 percent to 1.6 percent.

Managed care companies are increasingly concerned about the adequacy of obstetric service provider networks based on monitoring of expectant mothers’ wait time for appointments and later entry into prenatal care, the report said.

Statewide the percentage of women starting prenatal care in their first trimester has been dropping, with Philadelphia having especially low rates. Low-income, undocumented-immigrant expectant mothers become eligible for Medicaid after they go into labor. These women face greater challenges accessing the prenatal care.

Releasing the report is considered the first step in raising public awareness of the situation for the task force, whose members include Philadelphia area doctors, hospitals, insurers and health departments, Braithwaite said.

“It’s not an easy issue to address,” he said.

Among the strategies hospitals are using now to attract and keep doctors is to put them on the hospital staff, which could cover their malpractice insurance costs, he said.

The big loss of doctors is particularly distressing for Patrick Knaus, vice president of strategy and business development at St. Mary Medical Center in Middletown.

“Where is the next generation coming from? It is really impossible almost to recruit OB doctors into Southeastern Pennsylvania,” he said. “It’s a really difficult situation.”

Overall deliveries at the Middletown hospital are up 21 percent for the first quarter of this year, compared with last year, he said. At Mother Bachmann Maternity Center, the hospital’s charity clinic in Bensalem, deliveries are up about 24 percent so far this year.

Knaus believes that addressing the malpractice situation and raising reimbursements for Medicaid deliveries, which are typically $1,500, are critical to bringing doctors back into the area.

“If a doctor has a $100,000 medical liability premium, he’d have to deliver an awful lot of babies at $1,500 before he pays his staff and rent and brings something home for himself,” he said.
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