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Greener pastures

This is the first in a weekly series of stories focusing on doctors and the medical malpractice climate in West Virginia.

CONCORD, N.C. — Dr. Joseph DeBord, 38, had planned to build a new home on an acre plot in Charleston’s South Hills.

But last year, he and his partner had several medical malpractice insurance scares. One insurance carrier left the state. Another company, Medical Assurance, didn’t tell the Charleston urologists that they would renew their insurance until three days before it was set to expire on Jan. 1, 2002.

Last month, DeBord, his wife and three children, ages 3, 6 and 9, moved into their new home. But it wasn’t into a house on a hillside in South Hills. Instead, he moved into a home 3 miles from Lake Norman, in North Carolina.

The former chief of urology at Charleston Area Medical Center joined a six-doctor practice at the Northeast Medical Center in Concord, outside Charlotte.

“To me, I was afraid this problem was going to turn into a lifelong problem that I didn’t want to deal with,” said the Huntington native on a recent afternoon.

In the past two years, DeBord was one of 30 Kanawha County doctors who left the state or retired early for reasons that included medical malpractice insurance. DeBord’s departure further thinned CAMC’s urology staff, which had been nearly cut in half in two years.

But doctors like DeBord didn’t just leave the state because their insurance premiums were too expensive or because their commercial carrier went bankrupt or left the state.

West Virginia’s poor economy discouraged young doctors from raising a family here. The state’s 10 percent taxation on doctors’ income coupled with decreasing reimbursement from governmental payers like Medicaid — health insurance for the poor and disabled — created an unattractive health-care climate, among other reasons, they said.

Here’s what the Sunday Gazette-Mail found after locating 80 of the 90 doctors who gave up their privileges at St. Francis Hospital, Thomas Memorial Hospital or Charleston Area Medical Center from January 2001 to October 2002:

  • One-third of the doctors said medical malpractice factored into their decision to leave the state or retire early.

  • Eleven doctors retired, but at least eight might still be practicing if it weren’t for problems such as medical malpractice and decreasing reimbursements.

  • Most of the doctors who retired early or left the state for reasons that included malpractice insurance were never involved in a settlement or lost a malpractice case. From 1993 to 2000, five of the 30 doctors had one case in which insurance companies reported a payout.

    Two of them — Drs. Henry Breland and Bruce Hoak — had two and three payouts, respectively, for a total of $1.2 million, according to board of medicine records.

    Usually, CAMC can at least match the number of doctors they’ve recruited with the number of physicians who have left the hospital, said Dr. Glenn Crotty, chief operating officer. But so far in 2002, 18 more doctors have left than have joined the CAMC staff, according to hospital records.

    ‘I don’t work as hard as I did in Charleston’

    DeBord joined a hospital about half of the size of CAMC. The 450-bed nonprofit medical center sits on a 60-acre, perfectly manicured campus in Concord — one of North Carolina’s fastest growing cities.

    The urologist said he moved from Charleston’s stagnant economy to a city 30 miles from Charlotte, one of the most quickly developing cities in the southeast.

    “In the long term, at least my kids will at least have the opportunity to find a job and stick around,” he said.

    DeBord left an area that was struggling to recruit specialists for a hospital in which the medical staff doubled in 10 years. He went from spending 100 to 120 hours a week practicing at CAMC’s three hospitals to working a 60- to 70-hour week, including time spent on-call at the Concord medical center’s Level III Trauma Center.

    “I was busier than I wanted to be [at CAMC],” he said. “Recruiting help wasn’t even an option, especially with the current malpractice environment.

    “There are more physicians here to take care of people.”

    DeBord’s wife, a Sissonville native, likes having her husband around more. “She was basically raising the kids by herself,” he said. DeBord’s 3-year-old daughter noted that, “Daddy doesn’t work anymore,” after he took a month of vacation to move and began working less than when he was in Charleston.

    What about his malpractice insurance? DeBord now has triple the coverage for a price that is half of what he paid in Charleston.

    Five urologists left CAMC in the last two years. One was recruited.

    “Not everybody is leaving the state,” Crotty said. “They’re reducing their burden of liability by restricting their privileges or restricting where they go for their burden of call.”

    This includes Drs. John Hannah and John Mani, he said. The urologists withdrew their privileges from CAMC to refocus their practice at Thomas Memorial, Crotty said.

    Forced to take early retirement

    Dr. Antonio Cafoncelli, 63, planned to retire in two years.

    But in December 2001, St. Paul Cos. sent a notice to the CAMC vascular and thoracic surgeon and more than 1,000 other doctors in West Virginia. The doctors would not have medical malpractice insurance as of Jan. 1, the notice said.

    St. Paul later rescinded the notices, giving a one-year extension to the doctors before the company would pull out of the national medical malpractice insurance market.

    But the damage was already done. Before receiving the rescinded notice, Cafoncelli announced his retirement.

    If the surgeon had to find another malpractice company, he would have had to pay St. Paul a tail, which is usually twice that year’s premium and covers them for any acts for which they are sued while they were with that company. But if he retired, he would not have had to pay a tail.

    Dr. Alberto Lee, a Charleston internist, said his satisfaction with practicing medicine had recently waned. He was tired of having to work 70 to 80 hours a week.

    “I have four grandchildren I want to play with,” he said. “I started to want to see them instead of going to the office.”

    Crotty said several doctors who’ve retired early — such as Dr. Ron Wilkinson of Ear Nose & Throat Associates of Charleston — wanted to work part-time or stop doing surgery, but couldn’t because they had to work enough to afford their malpractice insurance.

    That’s why Lee retired early in August 2001.

    “I was happy with what I was doing, until I started to feel burnt out,” said Lee, who first came to Charleston in 1969. “Most doctors go on until they are physically or mentally incapable of working.”

    In the last several years, for example, Lee said his overhead jumped from 40 to 50 percent of his gross income because of continued insurance increases. Twenty percent of that was his $18,000 yearly insurance premium — 17 percent more than what it was in 2000.

    Other factors also influenced his decision to retire: for instance, patients who don’t take responsibility for their own care; or the increased amount of paperwork mandated by HMOs, Medicare, Medicaid and PPOs.

    Gone after only one year in West Virginia

    Out-of-state Drs. Jason Chiappetta and Gregory Joy, both ophthalmologists, lasted one year in West Virginia. As young doctors who had just finished their residency, they went elsewhere because they wanted to start their careers in a state that has a stable economy or more insurance options.

    Chiappetta’s then-fiancée is a doctor and West Virginia native. In 2001, the couple moved to Charleston after finishing their residency in Charlottesville, Va.

    “I didn’t realize what was going on in the state,” he said. “I didn’t think to look into it.”

    He didn’t seriously consider leaving until his own insurer, St. Paul, threatened to immediately pull out of the malpractice business. St. Paul did grant a one-year extension, but where was he going to get insurance after that?

    “I was at the beginning of my career and thought I should find a place that was a little more stable,” Chiappetta said. “I didn’t want to practice medicine wondering if I was going to lose my insurance or not.

    “My fiancée and I broke off our engagement,” he added. “She wanted to stay there. She was more willing to overlook the problem and wait the storm out.”

    He is now working in Richmond, Va.

    Joy, who had worked at the Eye and Ear Clinic, left West Virginia not because of malpractice insurance, but because the area economy limited the clinic’s ability to make a profit, he said. He relocated to Syracuse, N.Y.

    In New York, doctors are having some of the same malpractice problems. “The insurance is getting so high that doctors are having difficulty affording it,” he said.

    Some high-risk specialists like obstetricians/gynecologists, for example, are reducing the scope of their practice and have stopped delivering babies.

    Joy had come to West Virginia because he liked the idea of filling a position at an established clinic and hospital whose doctors were near retirement and where there was already a large base of patients.

    “But then I realized that the medical practice may not be worth what it used to be,” he said. They were losing staff and money, reimbursements were terrible and Medicaid barely covered the clinic’s overhead, he said.

    The Eye and Ear clinic had lost money four years in a row, although officials there have said they made a slight profit in 2001.

    Almost half of West Virginia hospitals lost money in 2000. Officials have blamed the Balanced Budget Act of 1997, which cut federal payments to health-care providers.

    Also, in the last five years, Medicaid has cut state doctor fees by 15 percent, according to a report by the National Conference of State Legislatures. Nationwide, West Virginia has one of the top five largest percentages of people on Medicaid, said John Law, state Department of Health and Human Resources spokesman.

    “I liked Charleston and West Virginia quite a bit,” Joy added. “I’m an outdoorsman, the people were very friendly, and I would have stayed if it was just about the clinical practice of medicine [rather than] economics.”

    Saving $18,000 a year working out of state

    Family practice Dr. Charles Mitchell enjoyed working with his partners at South Charleston Primary Care, but he wanted to spearhead his own practice.

    He would have done this in Kanawha County if weren’t for the creeping malpractice insurance cost, too many taxes and the economy of the area, he said. To run a profitable business, Mitchell figured he would have to either cut his overhead or jack up the number of patients he treated until he was seeing a different patient every 3 to 5 minutes.

    Mitchell attributed increases in overhead and declining reimbursements for cutting his income in half the last four years. Overhead is the expense associated with running a business, including rent, utilities and malpractice insurance.

    Mitchell didn’t want to cut time with patients, so he worked to decrease his overhead. In December 2001, the Ripley native and Marshall University graduate opened his own practice in Manning, S.C.

    “I didn’t have to stay here,” he said. “I can do my craft someplace else.”

    He moved his office into a renovated National Guard Armory on the one-block campus of the 34-bed Clarendon Memorial Hospital.

    Now he could control his overhead, which in South Charleston was 60 percent of his income. Instead of spending $17 for every square foot of office space, he was dishing out $7. He spends $6,000 a year on malpractice insurance instead of the $24,000 he was paying in West Virginia.

    And he doesn’t have to give 1.8 percent of his annual income to the state. [State officials use provider tax money to match federal Medicaid funds.]

    “When you can save $18,000 a year by not doing anything, that’s a pretty good motivator,” he said.

    At CAMC, more family practice doctors joined the staff than left the hospital from Jan. 1, 2001 to October 2002. This is not the same for specialists like anesthesia, plastic surgery and urology, according to CAMC records.

    Four anesthesia doctors, for example, joined the staff at CAMC, but 10 left. “They can get more money elsewhere,” said Dr. Alan Snider, a doctor at General Anesthesia Services.

    Most of the departing doctors were cardiac anesthesiologists. CAMC may schedule eight or 10 heart surgeries on a certain day instead of the standard 12, Crotty said. Last year, CAMC gave GAS a $350,000 “performance bonus” to help pump up their salaries and help offset insurance costs.

    Almost all of the doctors said medical malpractice wasn’t the only motive behind them leaving the state or retiring early. But Dr. Ron Grandia, a general surgeon who used to work at Thomas, St. Francis and CAMC, said that was his only reason.

    In the fall of 2001, Grandia started to work at the Holzer Clinic in Ohio. His insurance dropped from $80,000 to $35,000 a year.

    And he never had to leave his home. Grandia still lives on his Mason County farm, which is about 30 minutes from his new employer. In Ohio, there is no provider tax and Medicare reimbursements are better.

    “It’s been better than expected,” he said. “Financially, it’s much better.”

    To contact staff writer Joy Davia, use e-mail or call 348-1254.


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