Changing patterns of obstetric practice in Washington State: the impact of tort reform.

Rapidly rising malpractice premiums have profoundly altered patterns of obstetrical practice. In the summer of 1986, the state of Washington enacted major tort reform legislation intended to stabilize the costs of liability insurance. Following passage of the legislation, we surveyed obstetricians, family physicians, and midwives in the state to assess the likely impact of tort reform on future practice patterns. Largely because of malpractice concerns, 40% of family physicians, 15% of obstetricians, and 27% of midwives had discontinued obstetrical practice. Although obstetrical participation has decreased most dramatically for family physicians, the mean number of deliveries per physician has increased to the extent that the proportion of deliveries attended by family physicians has remained stable at about 30%. However, as fewer family physicians practice obstetrics, the availability of care has diminished in rural areas. The passage of tort reform legislation has induced one-third of those respondents currently practicing obstetrics to at least temporarily continue to practice obstetrics. Despite tort reform, however, the majority of respondents either do not provide or ration care to the medically indigent. The major deleterious social impact of the professional liability problem is reduced access to care in rural areas and a severe curtailment of care to the medically indigent. Tort reform alone will not solve these problems.