Do not remove this shingle under penalty of the law

I left clinical practice some three years ago (in order to become Rabble-Rouser-in-Chief for this fine website,) but apparently I am still on the physician's mailing list for the state of Pennsylvania.  For this reason I was honored to receive the notice sent to all Pennsylvania physicians on December 20, 2002 by Mr. C. Michael Weaver, the (lame duck) Secretary of the Commonwealth. The letter expressed the Secretary's extreme sympathy for us PA docs regarding the escalating crisis over malpractice insurance premiums. 

Mr. Weaver assured us that he and the rest of the current state administration (which will be leaving office very shortly) have been doing everything humanly possible to alleviate the malpractice crisis, and he's sure the problem will be solved eventually.  By the next guys, I guess.

He went on to say that he knows the malpractice crisis may be driving many of us docs to seriously consider leaving the state, or going into early retirement, and that many of us are planning to do so as early as January, 2003 - when the massive insurance increases take effect. Leaving practice or moving out of state are drastic actions, he realizes, though they might be understandable given the magnitude of the malpractice problem.

However, as Secretary of the Commonwealth is is his duty to mention that, if we do leave our practices to move to Alaska or to sell pickles (or to run not-for-profit websites,) the state may choose to interpret that action as "patient abandonment."  The clear implication - and indeed the whole point of the letter - is that any doctor choosing not to practice any longer in Pennsylvania may be prosecuted (as reluctant as the state would be to do so, and as sympathetic as the administration may be, etc., etc.)

DrRich comments:

Sometimes I'm sorry not to be practicing medicine any more, but Mr. Weaver's letter makes me especially glad I got out when I did.  I did not realize that the decision to practice in the state of Pennsylvania could render me an indentured servant, obligated to continue toiling within state borders until such time as the government says I can leave.  But that is clearly the message of Mr. Weaver's extraordinary letter to Pennsylvanian physicians.  Faced with the very real prospect of seeing a whole lot of doctors quitting the state in very short order, the government has chosen to threaten prosecution. 

The notion that they would actually do so is clearly ridiculous, of course. The main significance of this threat - aside from angering all the doctors in Pennsylvania - is that it demonstrates that the lawyerly class realizes they might have overplayed their hand, just a mite, this time. The lawyers are thinking: Instead of treating our docs like a beef farmer treats his herd - culling off just the right number to keep your source of income going strong from year to year - have we been treating them more like Buffalo Bill treated the great buffalo herds? "By God!" you can almost hear the litigators (and their brothers the legislators) saying, "They're actually quitting!"

Doctors fancy themselves as humanitarians, but they also are necessarily businesspeople. And when expenditures become higher than revenue, you've got a bad business model. (I suppose one must forgive some in government for being slow to recognize this fact, as happy as they are to operate in a chronic deficit mode.)  In more and more instances, due to skyrocketing malpractice premiums combined with an inability to raise their prices, the only realistic options for some Pennsylvania doctors are to leave the state, limit services, or quit practice. 

This state of affairs now seems to be unacceptable.

So, some Band-aid will have to be applied to push the crisis back below the surface, where it belongs.  And sure enough, Mr. Weaver's letter was followed a few days later by an announcement by Ed Rendell, the Governor-elect, to the effect that rapid and effective measures will be taken immediately to assure that doctors in Pennsylvania will be able to afford their premiums. Those rapid and effective measures, it seems, will be to confiscate "surplus" dollars from health insurers within the state (chiefly Blue Cross/Blue Shield) to subsidize doctor's 2003 insurance premiums.  We'll worry about next year some other time.

This malpractice crisis all sounds like a great mess, but it actually makes a lot of sense, considered in light of the Grand Unification Theory of Health Care.  For, if your chief mode of rationing health care is to drive a wedge between the interests of doctors and the interests of their patients, patients (not being quite the stupid ciphers of most health policy theory) are going to start to get pissed off.  They are going to become more litigious, over and above the general increase in litigiousness of our society.

Truth to tell, there's plenty to sue about. The frivolousness of most malpractice actions is merely a reflection of the lack of medical sophistication of many malpractice attorneys, and the fact that you can't sue HMOs or the feds.  And since patients can't sue the HMOs or the government, the the only ones left are the docs. 

Indeed, one can view the growing malpractice crisis as part and parcel of, not to mention as a measure of the success of, the systematic destruction of the doctor-patient relationship.  The specter of doctors and patients, allied in common cause, sitting alone in a private office, deciding - just the two of them - on how much of society's money to spend, is not nearly as threatening to insurers or the feds as it was just a few years ago. So, once they succeed in calming down the docs a bit, those of the Clintonian persuasion (i.e., those who ultimately want government to control health care,) can find much to like about the malpractice crisis.

For one thing, as mentioned, the crisis reflects that the underlying strategy is a working.  In addition, the malpractice crisis drives the doctors deeper into the arms of the government.  Not only is government seen seen as acting forcefully to diffuse the crisis and "save" doctors' practices, but also the "solution" to the malpractice crisis makes doctors more dependent on the protection of the government than they have ever been before. And finally, at least in Pennsylvania, that "solution" takes a big step toward making the big insurers insolvent.

So, while Mr. Weaver's letter to Pennsylvania's physicians was perhaps ill-considered, it merely reflects a moment of panic. Docs aren't going anywhere, not if the state plays its strong hand well.

January, 2003

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