By Christina Frangou
San Diego—Texas’ 2003 tort reform legislation was associated with an upsurge in actively practicing physicians in the state, with physician population growth outstripping regular population growth and increasing the per capita number of physicians in 20 of 22 trauma service areas, a new study shows.
“Tort reform is associated with a very significant increase in the number of Texas physicians relative to the Texas population,” said lead author Ronald M. Stewart, MD, professor and chair of surgery, University of Texas Health Science Center, San Antonio.
Dr. Stewart presented the study at the 2012 annual meeting of the Society for Surgery of the Alimentary Tract, part of Digestive Disease Week 2012.
Dr. Stewart measured the changes in physician population in Texas after tort reform was implemented, and compared the results with overall population data and hospital survey data for the next 10 years. To count the number of physicians in the state, they used data from the Texas Medical Board and included all in-state licensed physicians who were actively practicing.
Results showed that the population of Texas grew by 21% between 2002 and 2012. Over the same period, physicians practicing in the state increased by 44%, or 15,611, resulting in an additional 30 physicians per 100,000 residents of the state.
OB/GYN, obstetricians/gynecologists; PCPs, primary care physicians
The change was most pronounced in metropolitan areas, which received the bulk of population growth for both physicians and the overall population. The population of the state’s metropolitan residents rose 23%, but was outpaced by a 46% increase in physician migration to these areas. Non-metropolitan areas had no per-capita growth in physicians.
The study findings challenge a controversial 2011 report from the consumer advocacy group, Public Citizen. In it, the group claimed that the rate of new doctors in Texas actually fell after the state’s $250,000 noneconomic damages cap was enacted in 2003. The report also argued that health care in Texas became more expensive and less accessible after the malpractice caps took effect.
Doctors and other tort reform advocates immediately took issue with Public Citizen’s report, arguing that it underestimates the physician manpower in the state by omitting all physicians who list research time and all physicians at academic medical centers.
Andrew Warshaw, MD, the W. Gerald Austen Distinguished Professor of Surgery at Harvard Medical School and surgeon-in-chief emeritus at Massachusetts General Hospital, both in Boston, said the new study demonstrates that tort reform can improve health care by reducing the economic and human costs associated with malpractice litigation.
“The number of malpractice suits fell substantially; liability premiums declined for doctors and hospitals; and the number of licensed physicians adjusted for rising population increased significantly after the passage of tort reform.”
But, he said many important questions remain unanswered, questions such as: Is the resulting quality of care better? Are any of the health care savings passed along to patients?
Most importantly for critics of tort reform, the report does not prove causality, a fact acknowledged by the study authors. Other factors, particularly the state’s strong economic growth in the post-tort reform era, could have spurred some of the physician migration to the state after 2003.
For nearly every year after 2000, the rate of Texas job growth was a full percentage point or more above the national average. The state’s population, too, grew at a pace far above the national average.
Although the state economy certainly attracts some physicians, it is not likely the sole driver of the increased numbers of actively practicing physicians, said Dr. Stewart. The economic situation for Texas physicians isn’t all rosy, he pointed out: Reimbursements have fallen, and the payer mix is unfavorable compared with other states.
Dr. Stewart said he believes physicians are attracted at least in part by reduced insurance premiums and lessened litigation risk. “A fivefold reduction in lawsuits with significant reduction in litigation, as we showed in a previous paper, is not trivial.”
The study also showed that the increases varied by specialty. Overall, the number of surgeons practicing in the state increased by 1,557, or 4% per capita. That figure largely represents subspecialist surgeons; surgeons who identified as general surgeons fell over the 10-year time period. Primary care physicians increased by 15% in per-capita representation, whereas OB/GYN physicians increased by 3% per capita.
It’s a surprise that more OB/GYNs did not move to the state following tort reform, as they were the specialists most targeted by malpractice suits, said Dr. Warshaw.
The investigators also compared their data with hospital survey results in an attempt to see how tort reform and the subsequent increase in physicians played out in hospitals.
Results indicate that tort reform legislation has resulted in liability savings for hospitals, money that was redirected at least in part to programs for patients.
In the 2008 survey, 58% of hospitals reported that they expanded patient safety programs, and 69% said they were able to grow or maintain services. Eighty-five percent of hospitals reported that they found it easier to recruit physicians after tort reform legislation was implemented.
This is the third study from Dr. Stewart and colleagues to examine changes in the Texas practice environment after tort reform. A study published in the Journal of the American College of Surgeons in April found that the total number of complaints, investigations, disciplinary decisions, license revocations or surrenders, and financial penalties from the Texas Medical Board significantly increased (2012;214:567-571). A study published in 2011 showed that implementation of tort reform in Texas was associated with a significant decrease in the prevalence and cost of surgical malpractice lawsuits at one academic medical center (JACS 2011;212:463-467).
Chad Hoover, 48" x 48", oil on canvas.
The Ephemera Series comments on humankind's struggle against mortality. Becoming more than a record of history, Mr. Hoover's work captures the point of view of a surgeon in action. For more information, contact the artist by e-mail at
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