Quotes of the Day
Dr. Alexander Sosenko is proud of his skills, but these days they don't seem to be the ones he needs to keep his medical practice going. A pulmonologist for 19 years, he knows just about everything there is to know about the lungs and is cherished by patients for his concerned, direct manner. But by his own admission, he's not great at lobbying. And, unfortunately, that's how Sosenko, 49, has lately been spending much of his time — circulating petitions at the local hospital, pleading with politicians for help. He has spent sleepless nights worrying that he may have to uproot his wife and three children from their home in Joliet, Ill., or else give up the profession he loves — all because he can't find affordable malpractice insurance.
A few months ago, Sosenko and the five other doctors at the practice he founded, Midwest Pulmonary Consultants, learned that their malpractice insurer, American Physicians Capital, would not be renewing their policy when it expired at the end of March. They weren't exactly shocked. Over the past two years, insurers of doctors in Illinois, worried by a rise in malpractice awards by juries in the state, have dwindled in number from more than two dozen to six. But then it got personal. Sosenko and his partners discovered that their insurer was not leaving Illinois entirely but was limiting its exposure. Although Sosenko and his colleagues had not lost or settled a single lawsuit over the years — an impressive record in this litigious age — they are named in a couple of cases that have been grinding through the courts since the late 1990s. Sosenko and his colleagues have denied all the allegations and refuse to settle.
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When the doctors started looking for an insurer to replace APC, none of the mainstream malpractice insurers offered coverage. One smaller firm came up with a package for nearly $100,000 a doctor (up from about $14,000 only two years earlier), plus $500,000 a year for "tail" coverage, to insure the practice for any suits that might arise from care provided before the new policy took effect. The doctors couldn't afford it. So after one of them left the practice to try to go it alone, the rest enlisted their state senator, who persuaded their original carrier to give them an extension — which expired at the end of last week. What next? Will they change specialties? Will they change addresses to a less litigious state? And what of their 6,000 patients, who would have to drive an hour to the nearest lung specialist, in Chicago? "We doctors can move on," says Sosenko, tilting back in his office chair. "But our patients can't."
Like Sosenko's patients, millions across America might turn up for an appointment one day soon and find the doctor is out — for good. Thousands have already lost their doctors to a malpractice crisis that, while concentrated for now in certain states and specialties, is spreading. Doctors are being handed malpractice-insurance bills that are double those of a couple of years ago, forcing many of them to move from high-premium states — like Florida, Nevada and Pennsylvania — to more affordable venues like California and Indiana. The crisis is compelling some doctors and medical students to switch from lawsuit-magnet specialties like obstetrics, neurology and pulmonology to "safer" ones like dermatology and ophthalmology, or to refuse to perform high-risk procedures like delivering babies and operating on spines.
While there is no evidence that the total number of physicians in the U.S. has declined, some veteran practitioners in states with sky-high malpractice premiums are quitting medicine. Even in states where malpractice insurance remains relatively affordable, doctors are increasingly practicing more "defensive medicine," trying to gird themselves against possible lawsuits by ordering unnecessary tests and thereby driving up health-care costs.
In one 6,000-sq.-mi. expanse of Arizona, high malpractice premiums have prompted six obstetricians to stop delivering babies. Many women now have to drive an hour or more to reach a hospital with a delivery room, forcing several, like Melinda Sallard, 22, to give birth in the car en route to the hospital. Seniors in parts of Pennsylvania travel an hour or two to see a neurosurgeon, and one orthopedic surgeon from Philadelphia commutes every week to see patients in the Midwest, where malpractice-insurance costs are lower. Emergency rooms from Orlando, Fla., to Belleville, Mo., report that rising insurance premiums are making it difficult for them to employ the trauma specialists needed to treat car-accident victims. In protest, doctors from New Jersey to Washington State are taking to the streets and engaging in work slowdowns and strikes. Nearly 100 physicians in and around Jacksonville, Fla., have stopped performing elective surgery, making the county activate an emergency response system that it typically uses to deal with natural disasters like hurricanes.
The system is clearly broken, and there is no quick fix in sight. To doctors like Sosenko, the main problems are frivolous lawsuits and multimillion-dollar judgments awarded for tragic but sometimes unavoidable outcomes. (A banner at a rally read SICK? CALL A LAWYER) The waiting room at Sosenko's Midwest Pulmonary these days looks almost like a campaign headquarters. Banners declaring WE HAVE A CRISIS! hang alongside lists of politicians' names and phone numbers. Sosenko's patients have signed petitions calling on politicians to make malpractice reform a top priority.
It's easy to see why they want to help. Sosenko is a native and a favorite son of Joliet, a middle-class town about 45 miles southwest of Chicago. The child of Ukrainian immigrants who fled a displaced-persons camp in Germany after World War II, Sosenko grew up in Joliet watching his father, Roman, serve the town as a family doctor. He wanted to do the same for his friends and neighbors, treating people suffering from diseases such as asthma, bronchitis, emphysema and lung cancer.
Over the years, Sosenko and his colleagues at MPC have earned a reputation as not only capable but also unusually attentive. Phone calls are promptly returned, day or night, and doctors make house calls when necessary. "It's such a relief, just knowing he's here," says Pat Falkenberg, 48, a patient of Sosenko's who is battling pulmonary fibrosis and awaiting a lung transplant. During a stay in the hospital, Falkenberg says, Sosenko stopped by her room so many times that she "often wondered if he ever went home."
A math whiz with almost total recall, Sosenko is legendary around the office for remembering practically every one of the several thousand patients he has seen — and details of their conditions — even if it's been 15 years between visits. He personally coordinates most of his patients' care, calling other specialists for tests and appointments. "Any wheezing? How about panting?" Sosenko asks Richard Escherick, 61, during an office visit. In his blunt but friendly style, Sosenko quizzes the man about his nighttime cough. "Is it like this?" he asks, making a hacking sound. "Or like this?"--and he rattles his throat, sounding like a tom turkey. Sitting on a round stool, with his legs crossed, and peering over the top of his reading glasses, Sosenko gives his patients as much time as they need to ask questions and voice concerns. These days, their worries often go beyond what medication to take. When Sosenko tells Richard Tea, 73, that he wants to see him again in three months, Tea's wife Mary Ellen nervously asks, "Are you going to be here in three months?"
Sosenko's petition drive generated more than 1,000 letters to Illinois' congressional delegation in Washington and to state legislators in Springfield. It got the attention of state senator Larry Walsh, a Democrat from Joliet. Concerned about the availability of medical care in his hometown, Walsh persuaded Midwest Pulmonary's original carrier to give the practice a special two-month extension — albeit a pricey one, costing about $35,000. Walsh has reason to be worried. Sosenko's practice isn't the only one in Joliet that is perilously close to shutting down. The area's last remaining neurosurgeon, after learning he would have to pay $468,000 a year for insurance, up from $180,000, is considering moving to South Dakota or quitting for good. And a local group of 16 cardiologists — as well as 60 general practitioners — may lose their insurance at the end of this month.
Soon after he got the two-month extension of his group's insurance, Sosenko thought he might have found a more permanent solution, courtesy of the local Provena Saint Joseph Hospital. Surgeons like to have a pulmonologist standing by when they perform a complicated procedure like open heart surgery. So the hospital offered to hire Sosenko and his colleagues as staff physicians and cover them under its liability insurance. However, Provena's insurance company wouldn't cover the doctors if they continued to see patients outside the hospital, even part time. "Maybe it was silly to take the two-month extension," says Dr. Gregg Cohan, 41, one of Sosenko's partners. "Maybe all we did was prolong the death."
The insurers blame rate hikes and policy cancellations on what they describe as a rising tide of lawsuits and $1 million — plus jury awards. Their solution (which many doctors, including Sosenko, support): caps of $250,000 on noneconomic damages awarded for pain and suffering. President Bush and other Republicans, whose campaigns are supported by doctors and insurance firms, endorse such legislation, and the House of Representatives has passed a bill along those lines. But plaintiffs' lawyers, who contribute heavily to the campaigns of Democrats, are lobbying their friends in the Senate, and national "tort reform" may remain more of a rallying cry than a real prospect.
The states could step in. Sosenko would love to see Illinois politicians ride to his rescue — and at the very least require a panel of qualified medical experts, rather than one hired gun, to sign off on a suit before it can go forward. But he doesn't hold out much hope. Twice in the past two decades, the state legislature has passed caps on noneconomic jury awards only to have them struck down as unconstitutional by the state supreme court. (Courts in other states, including California, have upheld similar caps.) Many state politicians are more than happy to hand the thorny issue off to Congress. State senator Walsh says some of his colleagues believe that the crisis eventually "will just work itself out." Sosenko says with disgust, "Talking to politicians is like hitting your head against a wall."
But the legal system is not the only culprit in the malpractice mess. Critics say soaring premiums are less the result of lawsuits than of insurers rushing to make up for their losses in underpriced premiums and poorly performing investments. An independent study by Weiss Ratings to be released this week shows that states with caps on malpractice damages have not enjoyed much relief in malpractice-insurance premiums but have instead seen insurers shore up profits. Sosenko's anger at the insurers moved him to join several hundred other Illinois physicians at a rally in the state capital earlier this year, calling on legislators to freeze malpractice premiums for six months and investigate the industry's pricing practices. "These companies pretty much have a free hand to do what they want," he says.
However, physicians themselves deserve at least part of the blame. "Doctors," says Dr. John Walsh, 46, one of Sosenko's partners, "haven't sold themselves as a self-policing group." The vast majority of conscientious physicians have been forced to subsidize the higher insurance costs of a few incompetents. Consider this: between September 1990 and March 2003, just 5% of the doctors who have made medical malpractice payments accounted for a third of all the money paid out, according to the Federal Government's National Practitioner Data Bank.
Sosenko's crash course in law and politics is taking an emotional toll on him and his family. An avid windsurfer and science-fiction buff whose favorite books are The Hobbitt and The Lord of the Rings, Sosenko hasn't been able to enjoy himself much for the past several months. He hardly has the time or energy to play video games with his son Nick, 10. For the first time in recent memory, he has missed some of his 12-year-old daughter Teresa's afterschool volleyball games, though he still manages to take the kids to their classes at the Ukrainian cultural center on Saturdays. (The family speaks Ukrainian at home.) Sosenko has always been a bit moody. His office is littered with Tasmanian-devil toys given to him by his family, an inside joke alluding to his occasional temper. But nowadays he is regularly depressed and irritable. "Alex takes everything to heart," says his wife Maria, 46, a rheumatologist (whose malpractice premiums nearly doubled this year, from $8,592 to $15,472). "He's frantically searching for help."
With Medicare, Medicaid and HMO reimbursements falling and malpractice premiums steadily rising, Sosenko's income has dropped 40% over the past five years, to about $200,000 last year. That might sound like a lot, until you consider the 13 years he studied after high school, the debts he built up, the nights and weekends he works. As his colleague Cohan says, with only a little exaggeration, "Our income is completely controlled by the government, but we have no control on our expenses." Both men are bracing for a potentially bigger pay cut. Sosenko has put off indefinitely any major expenditures, including having the house repainted. But while his colleagues and even his wife have considered moving across Illinois' eastern border to Indiana, where malpractice premiums are lower, Sosenko can't imagine cutting his ties to his hometown. Not only would he have to take his kids away from their school and friends, but he would have to relocate his wife's elderly parents, whom he and his wife recently moved to Joliet. "I don't want to leave here. I'm too old to start from scratch," Sosenko says.
Early retirement is an equally unattractive prospect for Sosenko, a driven perfectionist who avidly reads medical journals to stay current with his specialty and holds his children to his exacting standards. If necessary, Sosenko says, he would "probably work without insurance," a dangerous gamble for any doctor these days but one that some physicians, particularly in Florida, are now taking. Another option he's exploring is work as a cardiopulmonary trainer and tester for fire fighters and others who must have good respiratory fitness for their job. As for the career plans of his children, Sosenko probably won't encourage his oldest son Alexander, 18, to follow in Dad's or his grandfather's footsteps. "I want him to be successful," Sosenko says. "I'm not sure [anymore] that the doctor has job security."
That has been painfully clear to Sosenko in recent weeks. After the collapse of their talks with Provena Hospital, the doctors of MPC, who had pledged to stick it out together, suddenly fractured. The three who haven't been named in either of the lawsuits pending against the practice — Drs. Walsh, Visvanatha Giri and Phillip Leung — created a separate partnership and secured malpractice insurance. Sosenko is planning to take the next couple of weeks off now that his policy has run out and then try to find a new medical group to join. Even so, he says, there are no hard feelings against his former colleagues. He's too busy for that. There are too many patients to treat. And too many people to lobby.
- Daniel Eisenberg and Maggie Sieger/Joliet