Insurance for obstetricians: Looming shortage of doctors to deliver babies

By Salma Khalik, Senior Health Correspondent, The Straits Times, 18 Feb 2015

SINGAPORE is facing another baby crisis - just as the number of babies born here rose by 2,000 last year from the year before, reversing a worrying decline. While more couples might be willing to have babies now, there could be fewer doctors willing to deliver them in the future.

This follows a change in the terms of doctors' insurance plans such that they will no longer be protected against lawsuits once they stop paying for coverage. Given the high cost of continued coverage, many feel it is not worthwhile to carry on.

A person has up to 24 years from birth to sue a doctor for any negligence or accident that caused permanent damage. Compensation can easily top the million- dollar mark.

Protection against such suits does not come cheap. Obstetricians now pay to the tune of $22,045 a year for coverage. To continue paying this amount for 24 years after retirement would mean stashing aside more than half a million dollars - and that is provided the fees do not rise.

Already, a quarter of obstetricians are saying they plan to stop delivering babies once their current coverage under the Medical Protection Society (MPS) is up for renewal - and that is within the next 11.5 months.

These are generally older and more experienced obstetricians who had expected to work for perhaps up to another decade.

One obstetrician said that for a doctor with five years or less of working life, "it really makes no sense" to continue, as "he could never earn enough to cover for the extra years of indemnity after he ceases all obstetric work".

Younger doctors, he said, can start charging patients more to accumulate enough to pay for continued protection after they retire. One doctor said he will likely have to double his fees to do so.

Unless this issue of protection for obstetricians can be resolved, and quickly, the baby boom could easily fizzle out, as young couples worry about the higher cost and the possible dearth of experienced obstetricians.

Perhaps the Ministry of Health (MOH) can step in to provide the post-retirement protection that will give obstetricians peace of mind - the same way it did for citizens with MediShield Life.

Offering such protection is not a commercially viable option, or London-based MPS would not have made the drastic change - not just in Singapore, but also in other places such as Hong Kong, Malaysia and South Africa. So trying to interest an insurance company is not likely to be the solution, given the small number of just over 300 obstetricians here.

In fact, 15 years ago, there were three organisations that doctors here could turn to for coverage. But one of them, Australia's United Medical Protection (UMP), went into provisional liquidation in 2002 when it was unable to meet the claims against the doctors it covered. The 1,500 doctors here whom it covered were left in the lurch. They had to scramble for coverage, not just for future cases, but also for any problems that had occurred in the past.

Most turned to MPS, even though at the time NTUC Income charged lower fees. It was because Income had a cap of $5 million on its payouts, so anything in excess would have had to be borne by the doctor. It is rare for payouts to exceed $5 million, but most doctors did not want to take the risk.

Today, MPS has cornered the market with coverage of more than 11,000 health-care professionals here. So, bringing in a commercial player to take on what the not-for-profit MPS has decided to drop is not likely to work.

In the national interest, MOH could provide tail cover for doctors who have retired by getting all practising obstetricians to contribute to a pool of funds yearly.

Last year, obstetricians each paid MPS $36,000 for coverage. With the reduced coverage, the fee has gone down to $22,045. At the very least, obstetricians should pay the difference into the MOH pool. But like MediShield Life, it should be used to cover only big bills. So doctors should be liable for a "deductible" - to be mutually decided on.

MOH will very likely have to contribute to this pool - but getting obstetricians to continue working without undue stress is in the best interest of the nation.

Some countries have legislated caps on compensations that can be paid to affected babies. Singapore might want to introduce this. But the amount has to be fair to the child.

An alternative solution is to let obstetricians raise their fees, and for the MOH to help less well-off families with a "delivery bonus" - much like the Baby Bonus to spur couples to have more children.

But going this route would work only for younger doctors, who have many more years to accumulate enough for the over 20 years of additional coverage they will need post-retirement. It will not stop those who are already in their late 50s from calling it a day.

A recent poll by the Obstetrical and Gynaecological Society of Singapore, in which 231 doctors took part, had 140 of the 311 registered obstetricians - almost half the practising obstetricians here - saying they will stop delivering babies within the next five years.

Of course, couples could turn to midwives instead. There were 1,385 registered midwives here at the end of 2013. Singapore can then maintain a core of obstetricians for problem births. Since they would deal largely with more complicated births, their fees would naturally be much higher.

Another scenario is to increase the number of foreign obstetricians practising here - who will leave the country when they retire. But this would mean babies delivered by them would not be able to seek redress should something go wrong during their delivery. That would certainly not be in Singapore's best interest.

Whatever the case, obstetricians should not be left to carry the baby on their own - it is a national crisis that requires a national solution.

* Insurance for obstetricians: MOH replies

WE REFER to the letters by Dr Wong Mun Tat ("Private obstetricians contribute a lot to healthcare"; last Thursday), Dr Yik Keng Yeong ("Open up docs' insurance to more players"; last Friday) and Dr Chew Shing Chai ("Not reasonable for Govt to provide blanket cover"; Forum Online, last Friday), concerning the insurance coverage for obstetricians in private practice, in response to the report on April 13 ("MOH to cover obstetricians in retirement").

Our public healthcare institutions have already been covering the medical indemnity insurance of all doctors under their employment as part of their provision of medical services to the public.

With the change in terms for insurance coverage for obstetricians offered by the Medical Protection Society (MPS), the public healthcare institutions will continue to ensure that doctors under their employment remain covered, and are in the process of working out the administrative details.

This has been communicated by the respective hospitals' management to their obstetricians, and should enable obstetricians in the public hospitals to practise without the anxiety of future indemnity cover once they retire.

Doctors in private practice can opt to be covered under the terms offered by the MPS or NTUC Income, the two main insurers in Singapore for medical indemnity.

While the MPS cover for obstetrics practice has changed from occurrence-based to claims-made, the NTUC Income scheme remains occurrence-based.

There is still indemnity cover, even though the terms going forward have been changed for one insurer.

MOH will continue to work with the obstetrics fraternity, including the Obstetrical and Gynaecological Society, of Singapore to address the issues for both private and public institutions.

We appreciate the important and responsible role of our obstetricians in pregnancy care and childbirth in Singapore.

We will need to work together to ensure that Singaporeans have access to appropriate and affordable maternity care.

Lim Bee Khim (Ms)
Director
Corporate Communications
Ministry of Health
ST Forum, 23 Apr 2015

* MOH to cover obstetricians in retirement
Public hospitals will ensure insurance protection for them against lawsuits
By Salma Khalik, Senior Health Correspondent, The Straits Times, 13 Apr 2015

PUBLIC sector doctors who deliver babies need not fret about a lack of insurance protection against lawsuits after they retire, despite a change that had left them vulnerable.

The Ministry of Health (MOH) said it will continue to provide these doctors with full coverage even after they retire.

An MOH spokesman told The Straits Times last week: "The public hospitals are committed to covering their retiring obstetricians but will require time to sort out the details and other issues. This has been communicated to their obstetricians."

The issues include what happens should the obstetrician move to the private sector instead of working until retirement in public hospitals.

Of the 311 obstetricians here, 91 work in public hospitals, with more than 200 in private practice.

Many of these doctors had expressed worry after The Straits Times reported in February that the London-based Medical Protection Society (MPS), which provides insurance coverage for most obstetricians here, was changing the way it protects these doctors, starting this month.

With the change, obstetricians are now covered by the MPS only for incidents reported while they are members.

As most usually stop subscribing to the MPS on retirement, this leaves them with no insurance protection if they are sued after retirement.

This is a risk, given that babies have 24 years from the time they are born to lodge a complaint against their doctor.

While such cases are rare, they can cost a doctor millions of dollars if he loses the lawsuit. Even an unsuccessful suit can set the doctor back by tens of thousands of dollars in legal fees.

The MPS, whose change of policy also affects obstetricians in other countries, has offered five years of post-retirement coverage for no higher than 1.75 times the highest annual subscription they have paid - which currently stands at $36,000.

But some obstetricians are concerned about whether the not-for-profit society will continue covering them, and at what cost, for the next 18 years or so.

Meanwhile, in response to the change, some obstetricians have raised their fees, from a few hundred to several thousand dollars, while others have switched their insurance coverage to NTUC Income from the MPS.

Several older private practice obstetricians, in their 60s and even early 70s, have opted to call it a day, raising concerns about whether there will be enough such doctors here.

In response, the MOH spokesman said that obstetrics is the third-largest speciality here, so there are enough doctors "to take on the load of retiring obstetricians".

She added: "We also have a significant number of trained registered midwives - 1,337 in total, with 572 working in the public sector as of Dec 31, 2014 - to enable continued access to obstetric services by the public."

Obstetricians offered more cover, but still seek fuller protection
By Salma Khalik, Senior Health Correspondent, The Straits Times, 19 Feb 2015

OBSTETRICIANS who were left without insurance coverage after they retire have been given a short lifeline by the Medical Protection Society (MPS) - an additional five-year coverage at a higher rate than the annual premium.

But these doctors say the latest offer is still not enough for their peace of mind. That is because they need to be covered for as long as 24 years after they have delivered their last baby.

MPS said that, while claims by children can normally be made up to three years after they become adults at the age of 21, "where permanent disability has been caused, or in cases of mental incapacity, the period may even be longer".

Premiums for obstetricians have gone down from their recent level of $36,000 to $22,045 from this month, but their coverage has been reduced.

Up till now, obstetricians were given the same protection as other doctors - that is, they were covered for all suits against them for any professional mishap that occurred while they were members of the not-for-profit MPS.

But with this change in rules, they are covered for legal fees and compensation only for complaints made against them while they remain members of MPS.

Doctors usually stop paying the subscription fee when they retire, which means they will not be protected against any new complaints brought against them.

It is unclear if MPS will provide doctors with coverage beyond the first five years of their retirement, and if so, how much it will charge.

Dr Tony Tan, an obstetrician in private practice, said: "The five-year tail cover is inadequate. Though it'll cover the majority of cases, it will not cover all cases.

"We need peace of mind when we retire, like any other doctor."

Because of this, many of the senior doctors have indicated that they plan to stop delivering babies.

Dr Chua Yang said that if senior doctors stop delivering babies because of this change, it would put a strain on younger doctors, and that "an inability to get senior colleagues to help in dire situations will in fact make the practice more at risk".

Those who continue practising will also have to charge more, she said, adding: "There is no real outcome in this that actually benefits patients. That's a very sad turn."

Another obstetrician said the tail cover should be for at least seven years, so that the child would have been screened by the school health service and most problems, if any, would have come to light.

The vast majority of doctors here are protected by MPS. Those who opted for NTUC Income continue to enjoy incidence-based coverage, capped at $5 million.

The MPS limit is $15 million per case.

The Obstetrical and Gynaecological Society of Singapore, to which 294 of the 311 registered obstetrics and gynaecology specialists here belong, has asked the Health Ministry for help.

Professor Benjamin Ong, the ministry's director of medical services, said: "We are meeting interested parties, including MPS, and looking at other jurisdictions' approach."

He added that the cheaper subscription to be paid from this year can be "set aside for extended cover at the end". But he said whether this is enough will "depend on the runway to stopping work".

Obstetricians up in arms over new protection limits
By Salma Khalik, Senior Health Correspondent, The Straits Times, 17 Feb 2015

OBSTETRICIANS here are in an uproar, with more than one in four saying they plan to stop delivering babies within the year.

This comes in the wake of changes to their protection plans that will leave them to fend for themselves against lawsuits from patients once they retire.

Unlike most other medical specialities where there is usually a three-year time limit, a baby has up till three years after turning 21 - or 24 years from birth - to file a lawsuit against the doctor.

Until last month, obstetricians who paid the Medical Protection Society (MPS) $36,000 a year were covered for suits against them, no matter when the complaint was made. So those who have retired remain protected for the rest of their lives.

With the change, the renewal fee drops to $22,045 a year from this month. But the doctors will be covered only for complaints made while they are members of the London-based MPS.

They could remain covered by paying fees to the not-for-profit MPS for 24 years after their last delivery.

Historically, there have been claims made many years after the delivery, and settlements run into hundreds of thousands, or even millions, of dollars.

MPS told The Straits Times that such limited coverage is practised in many countries, including the United States.

This way, it can "price subscriptions for obstetric risks more accurately and fairly since it can be difficult to predict long-term obstetric risk".

MPS told the doctors that many factors can have an impact on the final value of the claim, "such as a change in legislation, the claims environment or increased consumer willingness to make a claim".

It said the alternative was to either raise the annual fees "significantly", or stop covering them altogether. Fees have already gone up by more than $10,000 over three years for obstetrics.

The Obstetrical and Gynaecological Society of Singapore (OGSS) did a survey among its 294 members after being notified of the change.

Of the 311 obstetricians and gynaecologists registered here, 231 responded, with 79 saying they plan to stop delivering babies when their membership is up for renewal.

Another 61 said they plan to stop within five years.

Some have already stopped accepting new expectant patients, preferring to concentrate on gynaecology, or the treatment of women's diseases.

Almost all said they feel "pressured to raise patients' fees" to cope with the extended premiums they might need to pay, and hoped that the Health Ministry (MOH) would cap payouts to patients the way Australia does.

Dr Abdul Aziz, who delivers about 400 babies year, said he will continue to deliver babies, but might have to double the fees.

If that results in a big drop in patients, he might stop as it "would not be worth taking the risks".

Dr Tony Tan, president of OGSS, said the society is in talks "with various stakeholders" to try to find a solution.

Professor Benjamin Ong, director of medical services at MOH, said the ministry is aware of the situation and is "working on the potential implications to our doctors".

Doctors sued years after child's birth
By Salma Khalik, The Straits Times, 17 Feb 2015

CLAIMS can be made against obstetricians up to three years after a baby turns 21 years old.

Lawyer Charles Lin of MyintSoe & Selvaraj said parents here are well- informed and would check with their own doctors to see if a problem might have been caused by something during delivery.

Mr Lin is in the midst of a civil suit which was brought against a doctor when the child involved was five years old.

In other countries, suits can be raised many years after birth.

The Supreme Court in New South Wales awarded A$14 million (reduced to A$11 million on appeal) to Ms Calandre Simpson, aged 22 in 2001, for cerebral palsy caused by 15 to 20 minutes without oxygen at her birth.

In France, two 20-year-old girls are suing the hospital where they were born for accidentally switching them at birth.