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Fri August 2, 2013
Texas hospital lifts ban on non-specialists delivering babies
The Wise Regional Health System will no longer require doctors at its hospitals to have a three-year residency in obstetrics and gynecology before letting them deliver babies, a shift that will give privileges back to certain family physicians practicing in the area.
The policy change, approved by the system's board of directors on July 29, will instead require doctors seeking to deliver babies to have performed 50 C-section deliveries and 100 vaginal deliveries. In accordance with the change, the board agreed to return admitting privileges to the three Wise County family physicians who were in mediation with the system over the specialists-only policy.
When Dr. Jeff Alling, a family physician, moved to Wise County more than 20 years ago, he was one of only two doctors in the rural North Texas community qualified to deliver babies. Since then, he has delivered more than 2,000.
“I’ve got 12 little babies that I delivered their mothers 18 or 20 years ago, so I’m kind of on my second generation,” he said.
But Alling no longer has a place to deliver babies in the county. The community hospital in Bridgeport that he helped found in 2008 merged its obstetrics unit with the Wise Regional Health System in Decatur in March. That hospital, where Alling delivered babies before he left for Bridgeport, instituted a policy in 2009 that allowed physicians to deliver babies only if they had undergone a three-year residency program specializing in obstetrics and gynecology.
“The purpose of that was looking ahead to the potential in the growth of our market,” said Steve Summers, the chief executive of Wise Regional.
For more than a decade, Summers has worked to shift Wise Regional toward a “specialist model.” He said it was an effort to meet the quality-of-care standards set by its urban affiliate, the Baylor Health Care System, which operates hospitals nearby that also allow only qualified obstetricians to deliver babies.
Although he acknowledged that family physicians usually receive a rotation of obstetrics training during their residency, Summers said the hospital board decided not to allow exceptions to its policy.
As a result, Alling and three other family physicians were denied obstetric privileges at Wise Regional and are in legal mediation with the hospital. They estimate that 50 to 100 pregnant patients, the majority of whom live in rural areas and are covered by Medicaid, have been affected by Wise Regional’s refusal to grant them obstetric privileges. Those patients now have three options: they could transfer their care to one of three doctors with obstetric privileges at Wise Regional; continue to see their current doctor and go to the emergency room when they are in labor; or travel roughly 30 miles to Jacksboro, where a community hospital has granted those family doctors obstetric privileges.
The situation in Wise County illustrates how many family physicians are caught in a growing divide between rural and urban health care markets. With a shortage of medical providers nationwide, one that is particularly acute in remote corners of Texas, rural regions continue to rely on family physicians to provide an array of services. While some urban hospitals allow qualified family doctors to deliver babies, the practice has become less common, in part because patients with more provider options often choose medical specialists.
“You can’t chalk it up to any one thing but the underlying reason — it’s money,” said Dr. Brad Faglie, one of the family physicians denied obstetric privileges at Wise Regional. Specialists “make more money on these bills.” Moreover, he said, “Maybe rural life is losing out to urban life.”
A 2012 study by the Journal of the American Board of Family Medicine found that the number of family physicians providing maternity care declined to 9.7 percent in 2010, from 23.3 percent in 2000. The study attributed the decline to “malpractice costs, lifestyle concerns, lack of institutional and community support of family physicians delivering babies” and changes to family medicine residency requirements.
In a written response to that study, Dr. Howard Blanchette, the chairman of the obstetrics and gynecology department at New York Medical College, suggested that there was “growing evidence that the adequacy of prenatal care for women in rural and medically underserved areas is deteriorating.”
Faglie said that nearly 90 percent of his obstetric patients, whom he sees at a rural health clinic in Alvord, northwest of Decatur, are on Medicaid. He continues to receive new obstetric patients, he said, many of whom do not want to change doctors before delivery, or who have difficulty transferring to Wise Regional because those doctors are booked.
He said the situation had endangered some patients, especially those with high-risk pregnancies, because it has been difficult for him to coordinate patient care with a specialist.
“I have patients that I’m seeing to term, and when they go into labor, they go to the ER,” Faglie said. “That is a poor standard of care.”
Summers disputed the assertion that the hospital’s obstetric privileges policy was created for financial gain. He said he expected that the family physicians would continue caring for patients in the region, and simply transition their obstetric services to the community hospital in Jacksboro.
“We are opting for a higher level of quality over all,” he said, “and actually turning away from the potential benefit financially by having the increased business come here.”
Summers chalked up some coordination-of-care challenges to communication. He said some of the family physicians’ patients who wanted to deliver at Wise Regional did not transition their prenatal services to admitted physicians far enough in advance.
Wise Regional said the assertion that women were delivering in emergency rooms was false. The hospital has had 17 pregnant patients transferred from family physicians to obstetricians since March, all but one of whom were receiving Medicaid. None of the family doctors' patients have delivered babies in the emergency room, the hospital said. Instead, patients were moved to the labor and delivery unit.
A spokeswoman for Baylor Health said the system’s policies governing hospital privileges were recommended by medical staff based on “clinical assessment of the skills and experience necessary to perform the privilege sought.” She said the obstetrics policy had been in place “for many years.”
But Dr. Jeffrey Cain, president of the American Academy of Family Physicians, said that while local hospitals may set varying criteria for granting physicians hospital privileges on the basis of training and competence, it was “bad for patient care to deny family doctors the ability to practice cooperatively with obstetricians.” Tom Banning, the chief executive of the Texas Academy of Family Physicians, said that Wise Regional is the sole hospital in the area and, as a result, has the power to set administrative policies that interfere with patient care.
“It’s incumbent upon the family physicians and OB-GYNs to work collaboratively to provide that care,” he said, “because there’s just not enough of them in those communities.”
Shefal Luthra contributed to this story.
This story originally appeared in The Texas Tribune at http://www.texastribune.org/2013/08/02/policy-keeps-some-rural-doctors-delivery-room/.