In need of a medical miracle

Southern Maryland population growing; number of doctors shrinking

Friday, Nov. 14, 2008

Click here to enlarge this photo Staff photo by DARWIN WEIGEL Dr. Robert Schlager talks with patient Casey Mitchell of North Beach recently at the Twin Beaches Community Health Center in North Beach. Schlager spends Monday, Thursday and half a day Friday at the clinic seeing patients and spends the rest of the week working as the vice president of medical affairs at Calvert Memorial Hospital in Prince Frederick. E-Mail This Article | Print This Story

Charlene Letchford spent 12 years studying to be a doctor. A dream of opening her own practice was the fuel that kept her struggling toward the future.

Letchford, 43, realized her dream 11 years ago when she opened her private internal medicine practice in La Plata, but on July 1 she shaved back the time she sets aside to care for patients at the practice to only one or two days a week to begin working at Calvert Memorial Hospital in Prince Frederick.

The mother of two said that the skyrocketing cost of medical malpractice insurance coupled with the dwindling value of medical insurance reimbursements and the high overhead of running a full-time private practice forced her to join a group of doctors at Calvert Memorial.

The decision was a difficult yet practical one to make because the hospital picks up the tab for her medical malpractice insurance — a bill that recently jumped from $11,000 to $16,000 a year, Letchford said. In addition, Calvert Memorial tangles with a patient's medical insurance companies for reimbursement payments that she said are decreasing and getting more and more difficult to obtain.

"In my private practice I work very hard and get paid very little," she said. "Although sometimes I would work 60 to 65 hours a week I didn't always get the bills paid. I have a single-income household and I've got kids heading toward college. If I hadn't made this career change, I would be in the poorhouse."

Struggling for a solution

Letchford's fate is a common one among physicians, particularly internal medicine doctors, obstetricians and gynecologists. A real and severe shortage of doctors in Southern Maryland and elsewhere in the state is the driving force behind legislation passed during this year's Maryland General Assembly in Annapolis to form a task force to study the problem and come up with recommendations on how to curb it. The shortage only promises to get worse when baby boomers begin to require more medical care.

Sen. Thomas "Mac" Middleton (D-Charles) sponsored the bill to form the Task Force to Review Physician Shortages in Rural Areas. The senator chairs the 15-member group that meets regularly in Annapolis to review the problem.

Another group, the Task Force on Health Care Access and Reimbursement, has also been formed to study the situation. Both groups are comprised of doctors, elected officials and hospital administrators from Southern Maryland, Western Maryland and the Eastern Shore — the regions hit hardest by the physician shortage, Middleton said.

The panels must come up with recommendations in December to present to Gov. Martin O'Malley (D), Middleton said.

"Southern Maryland leads the state with the most significant shortage of doctors, especially in primary care," he said. "I didn't realize the extent of the problem in Southern Maryland. We need to look at the entire issue and find some solutions."

Southern and Western Maryland and the Eastern Shore fall significantly below national averages in active practicing physicians, according to a study released early this year by the Maryland Hospital Association and the Maryland State Medical Society (MedChi).

Southern Maryland has critical shortages in 25 of the 30 physician categories, including primary care, cardiology, obstetrics, gynecology, surgery, emergency medicine, infectious diseases and neurology, according to the study.

It is a crisis that has to be addressed immediately, Middleton said.

"We're taking a very serious look at this," he said. "The doctor shortage in Southern Maryland is just off the charts."

Christine Stefanides, president and chief operating officer of Civista Medical Center in La Plata, chairs a subcommittee of the rural areas task force that is addressing the issues of recruitment and retention of doctors in rural parts of the state. There are several options the group is studying that could make a dent in the shortage, including having young physicians pay back their student loans by working in a rural hospital.

"When young physicians come out of school they're burdened with debt," she said, adding that several states have instituted similar programs with success. "Ten to 14 years of college is very expensive. With a loan payback program, the doctor could pay back the loans by working in a rural underserved community and the debt would be forgiven. That would be very attractive to many young doctors."

Stefanides said obstetric care is particularly difficult to find in Southern Maryland because of the higher malpractice insurance costs. In answer to that problem, Civista Ob Gyn Associates was established in Waldorf about a year ago that has four doctors and a nurse practitioner to attend to patient needs.

"Civista takes all of the risks," she said. "The overhead is the hospital's problem, not the doctors.' This just shifts the burden to the hospital. … It's going to become a burden that is going to be untenable over a period of time. It's a big thorny problem."

Fighting the odds

Michael Hotchkiss has practiced obstetrics and gynecology for 31 years and has delivered almost 5,000 babies in Southern Maryland. Last year, Hotchkiss said that he closed his longtime Waldorf practice to join the Civista Ob Gyn Associates group at Pembrooke Square.

Hotchkiss said that medical malpractice insurance for ob/gyn doctors tips the scales at $150,000 a year — 10 times what Letchford pays, even with her increase. Like most other physicians across the country, particularly obstetricians and gynecologists, he said he has to deal with medical malpractice lawsuits.

"A lot of doctors have decided that obstetrics is not the way to go," he said. "It's fraught with liability and the hours are terrible. It's a difficult lifestyle."

The skyrocketing cost of medical malpractice insurance, which increases with the number of lawsuits filed against a doctor whether or not she is found liable for damages due to malpractice, is driving many doctors out of business, Hotchkiss said.

"There's not an obstetrician or gynecologist who hasn't been impacted," he said, adding that there are hidden costs that insurance carriers have to pay to defend a medical malpractice case. "Somebody has got to defend the case so the insurance carrier has to hire an attorney to defend me and that costs money. … You can say that it's a frivolous case, but it's very difficult to prove it. You lose, even if you win the case."

"Even if the case is dismissed the lawsuit still counts against you with the insurance carrier," said Barry Aron, an ob/gyn doctor who has a private practice in La Plata. "It's a losing situation. Even if a doctor wins a case the insurance company still pays out money.

"It's all a game to the lawyers involved," he added. "It's kind of a shame. The way the system works is that pain and suffering brings in a lot of money."

But, Wayne Willoughby, president of the Maryland Trial Lawyers Association in Baltimore, said that medical malpractice lawsuits are on the decline in Maryland.

"Frivolous lawsuits aren't a problem in Maryland," he said. "A lawyer has to make certain that there has been medical negligence and you have to have medical expert testimony lined up."

Hotchkiss said that he has been able to continue to care for his patients at Pembrooke without the worry of medical malpractice rates, insurance reimbursements or high overhead to staff an office.

"Civista has really stepped up to the plate so that I can continue the relationship with my patients that I've had over the years," he said. "It's the best of both worlds."

The price of growth

Aron continues alone in private practice. He opened the practice in 1998 and currently is not seeing any new patients.

"Trying to recruit new doctors to the area isn't easy," he said. "One of the problems is that new doctors are looking for metro areas to work. Southern Maryland, in particular, is at the bottom for reimbursement and the highest for malpractice insurance. The ceiling is low and the floor is high. Doctors can typically make more money in other areas."

The doctor shortage dilemma in Southern Maryland needs to be fixed sooner rather than later, Aron said.

"The worst-case scenario is that more and more patients will have to leave the [area] for care," he said. "Ultimately, if the situation doesn't improve, people are going to die."

Aron said that he is glad that the state legislature is beginning to study the problem.

"At least the state is looking at it," he said. "I would like to see some productive things come from it. They are recognizing that there is a problem."

Joyce Neal and Valinda Nwadike have an ob/gyn practice in Charlotte Hall and Leonardtown.

The practice is still accepting new patients, but the doctor shortage and problems associated with it are very much a reality in their business, Nwadike said.

Nwadike began practicing as an ob/gyn doctor with Neal seven years ago. The 43-year-old said that she and her husband, Bruce, moved to the area from Pennsylvania because of the skyrocketing cost of medical malpractice insurance premiums in that state.

"I trained in Philadelphia, but Pennsylvania has a severe medical malpractice problem," she said. "I wanted to get out of Pennsylvania because of the liability issues. Doctors get sued a lot. … Once I got here, I realized that this isn't a great place to work, either."

Nwadike said that she has not been directly involved in a malpractice lawsuit as a physician, but as a resident she was named in lawsuits that involved other people.

"Medical malpractice definitely impacts how long that I plan to stay in this profession," she said. "Sometimes I feel like I've got a bull's-eye on my back. It's stressful. It's getting harder and harder to make ends meet."

Robert Schlager has practiced family medicine in Prince Frederick in Calvert County since 1978.

He also serves in a part-time role as Calvert Memorial Hospital's vice president for medical affairs.

Schlager devotes some of his time as a family medicine doctor at the Twin Beaches Community Health Center in North Beach.

Schlager said that he is well aware of all of the problems plaguing physicians and that the situation is going to reach a crisis level if something is not done to address it.

"The doctor shortage is greatly impacting our area," he said. "Many patients are having difficulty getting appointments within a reasonable amount of time."

Population growth in Southern Maryland is far outweighing the number of physicians who are available to treat patients, Schlager said.

"Charles, St. Mary's and Calvert [counties] have had a significant growth rate, but there's no corresponding increase of physicians coming to our counties," he said. "Calvert Memorial [Hospital] is trying to respond to the problem with urgent care centers that are open late in the evening when appointments aren't available in doctor's offices."

Schlager said that the difficulty that doctors have in trying to get medical insurance reimbursement is actually a larger problem to deal with than the rising cost of medical malpractice insurance. Reimbursement rates in Maryland are significantly lower than in Virginia, Washington, D.C., Delaware and Pennsylvania.

"The bottom line is that reimbursement rates are less in Maryland," he said. "It started many years ago. We only have two or three main insurance carriers in Maryland. There's not a lot of competition."

The malpractice issue is somewhat stabilizing in Maryland, Schlager said.

The perfect storm

Seventy-eight million baby boomers are due to reach age 65 by 2011, at a time when many doctors are aging and closing their practices.

Coupled with a lack of interest in young doctors to practice in rural areas, this is a disaster waiting to happen, said Nancy Friedler, MHA spokeswoman.

In Maryland, 9.9 percent of all clinical physicians are 65 or older and 33.4 percent are 55 or older, according to the MHA and MedChi study. By 2015, 32 percent of the workforce is expected to retire.

"Doctors are retiring and a lot of baby boomers are going to be in greater need of health care; that's not a great mix at all," she said. "It's sort of the perfect storm."

"With baby boomers retiring during the next several years it's only going to get worse," said Chinnadurai Devadason, Charles County's health officer. "This issue is a real one and there are no simple solutions to fix this. Any solution that is proposed won't happen immediately. It's time to act now."

Letchford said that her decision to cut back her private practice to work with an internal medicine group at Calvert Memorial was a sound one that will keep her financially stable into the future.

"It was a very tough decision; it left my patients with very little choice of where to go for care," she said. "I'm there one to two days a week to see the sickest people … I sacrificed 12 years of education to end up where I am. I really didn't have a choice. I'm enjoying my job at Calvert. I work 14 hours a day and for the most part it's rewarding.

"I feel appreciated and I get paid."

nmcconaty@somdnews.com