Charles Silver

Did Texas Lose Physicians in 2006? Is Tort Reform to Blame?

Tort reformers argue that Texas lost physicians before it curtailed patients’ rights in 2003 and gained them rapidly thereafter. The Texas Alliance for Patient Access (TAPA) and the Texas Medical Association (TMA) have asserted this repeatedly, as has Republican Senator Kay Bailey Hutchison.

Statistics compiled by the Texas Department of Health (TDH) do not support their claims. TDH’s numbers show that Texas’ physician population grew more slowly in 2004 and 2005 than in the years before tort reform. They also show that Texas lost 514 direct patient care physicians in 2006. The 2006 decline is the first in 17 years. Given the eagerness with which tort reformers take credit for every new doctor who arrives in the state, it is tempting to chalk up this reversal of fortunes to them as well. Texas enacted tort reforms; Texas lost physicians; tort reforms reduced patients’ access to care. QED

Who has the better case, the tort reformers or TDH? Although they reach diametrically opposing conclusions, both sides use data collected by the Texas Medical Board (TMB). The short explanation for the conflict is that they slice the data in different ways.

When doctors register with TMB, they indicate a practice setting (military, VA, public health service, HMO, hospital-based, solo, partnership/group, other, and “no answer”). They also indicate a practice type (direct patient care, medical teaching, administrative medicine, research, not in practice, resident fellow, and “no answer”). When counting Texas physicians, TAPA and TMA include all doctors, regardless of practice setting or practice type. TDH is more selective. It wants to measure the number of physicians who treat patients in the general Texas population, so it counts only doctors whose practice setting is HMO, hospital-based, solo, or partnership/group. TDH also excludes doctors whose practice type is anything but direct patient care. The glowing assessment of the post-reform growth rate offered by TAPA and TMA is driven by doctors in the categories TDH excludes.

TAPA and TMA should not count these physicians. When members of the public want obstetrical care or surgery, they see direct patient care physicians. They don’t see medical researchers or administrators. Similarly, if the issue is whether access is affected by the liability climate, one should exclude physicians who don’t have any malpractice exposure, such as physicians who work for the military and the VA. Finally, military physicians don’t choose where they practice. Because they count the doctors TDH excludes, TAPA and TMA provide misleading information.

One puzzle remains: Why did TDH’s count of direct patient care physicians fall in 2006? A reporting glitch appears to be responsible. In 2006, 1,222 doctors previously counted as direct patient care physicians reclassified themselves as “military.” The reason for this is unknown, but a contact at TDH thinks the “military” classification is erroneous. If that is right, TDH will eventually report that Texas added about 700 direct patient care physicians in 2006. Even then the annual post-reform growth rate (2%) will be lower than it was pre-reform.

By claiming credit for every new doctor in the state, TAPA and TMA exaggerate the impact of the 2003 reforms. Texas’ supply of direct patient care physicians grew almost every year before 2003. It would have grown thereafter too, even without the reforms. TAPA and TMA should net out the predictable growth rate when discussing the impact of the 2003 reforms. If they persist in taking credit for all physicians, they’ll deserve every bit of blame they receive for the 2006 “loss.”

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Posted at 12:00 PM, Nov 30, 2006 in
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I wonder why tort reformers portray the tort system as the single biggest consideration doctors have about where to practice. Isn't it possible that doctors, like every other American, take some of the following factors into consideration when deciding where to live and work:

Proximity to family and friends;
Salary and work opportunities;
Cost of living;
Cost of real estate;
School systems;
Quality of life.

Yes, I'm sure doctors take the tort system into consideration when deciding where to practice. But I can't imagine a doctor saying, "I'm going to move to Dullesville to practice. My salary will be low, I won't be challenged in my job, the crime rate is high, the tax rate is higher, I'll be thousands of miles away from my family, and it has just the sort of harsh winters I swore I'd never endure again. But it's nearly impossible for patients to sue me, so my malpractice insurance rates will be low."

Posted by: Justinian Lane | November 30, 2006 12:41 PM

At a recent forum on medical malpractice tort reform, the Harvard Researchers working with Common Good noted that doctors are particularly worried about liability, even though it's based more on misperception than fact.

I was disappointed, though not surprised, that Common Good's people seem less concerned with countering these misperceptions than building off of them.

Of course, as a later panelist noted, "If you don't have a crisis, you have to manufacture one."

Posted by: Seth | November 30, 2006 2:08 PM

"If you don't have a crisis, you have to manufacture one."

This sounds like a job for the National Association of Manufacturers and their leader, John Engler!

Posted by: Justinian Lane | November 30, 2006 3:28 PM

The Texas Department of Insurance has addressed the misclassification issue I identified above and posted new numbers. Its view is that Texas had 36,450 direct care physicians in 2006, an increase of 639 over 2005. The growth rate is therefore 1.8%, slightly lower than I predicted and considerably lower than the rate of growth before Texas enacted sweeping tort reforms in 2003.

Posted by: Charles Silver | December 4, 2006 12:05 PM