February 1999 Bulletin

Removing the barriers to volunteerism in U.S.

'We need a way to create some immunity for retired volunteer physicians.'

By Sandra Lee Breisch

For years, Owen B. Tabor, MD, has been providing orthopaedic health care to an uninsured Memphis, Tenn. community-without reimbursement. "At the end of the year, what I get out of it is a very nice 'thank you' letter from the general internist who runs the Church Health Center Program," he says proudly.

But after retirement, he acknowledges that he'd have to "reconsider" volunteerism. As Dr. Tabor puts it, "You have to blend the milk of human kindness with a little of the ice cubes of reality. As long as you're going to see patients, you need to have insurance. I would not be purchasing insurance so that I could do pro bono work."

His sentiments ring true for other orthopaedists whose practices are slowing down or they're retired. Many orthopaedic surgeons enjoy volunteering their service in other countries through organizations such as Orthopaedics Overseas. It gives them an opportunity to teach and use their skills in a new, sometimes exotic culture, free from the paperwork hassles and threats of lawsuits in the U.S.

They might enjoy volunteering their services in the U.S., too, but may not know where there are opportunities to volunteer. A bigger barrier is the need to have malpractice insurance. In today's litigious society, orthopaedic surgeons don't want to risk their retirement assets in a lawsuit that arises out of a free medical service.

Simply put: It's easier to volunteer medical services in Mexico City or Africa than Los Angeles or Appalachia.

Surveys disclose that many orthopaedic surgeons are thinking about retiring early because of the intensifying pressures from the controls and paper work of managed care, reduced reimbursements and increasing competition in a marketplace with surplus orthopaedists. Yet, it's also clear that orthopaedic surgeons really want to continue to treat patients.

There is certainly a need for orthopaedic surgeons to provide volunteer services in the U.S. and as the population grows and ages. The Academy recognized this and formed the Task Force on Volunteer Orthopaedic Care. Their mission included: to identify existing volunteer health care programs to serve the underserved and noninsured population, determine new volunteer opportunities, determine the liability exposure of volunteers and identify methods to legally protect orthopaedists while doing volunteer work.

"As we explored the problems with volunteerism in orthopaedic care, we recognized two areas where the Academy could potentially help," said John J. Callaghan, MD, task force chairman. "One was providing a clearinghouse for the opportunities available to those wishing to volunteer, and the other was determining potential discounted insurance possibilities."

Currently, there are 3,000 Academy emeritus members. "There's a large number of people available," says Mohinder A. Mital, MD, task force member. "I've no question in my mind that if physicians were unshackled by the problems of liability, they would do what they're best suited for-using their knowledge and hands."

Yet, coverage for professional liability is high. The average annual premium for an orthopaedic surgeon in full-time clinical practice is $33,500. Fifty-one percent have premiums under $30,000; 8 percent have premiums of $60,000 and over, according to the Academy's biennial survey, Orthopaedic Practice in the U.S. 1996/97.

"We can't expect retired physicians to purchase malpractice insurance in order to volunteer-unless it's dirt cheap, but we're not going to get it dirt cheap," says Thad C. Stanford, MD, a task force member whose charge was to look at liability factors. "We need a way to create some immunity for the retired volunteer physicians."

Tort immunity for uncompensated care providers has made some progress in state legislatures. But, says Dr. Stanford, "even though there are Good Samaritan statutes in some states, it doesn't mean people still can't be sued."

There are some limited protections buried in the 1996 Kennedy-Kasselbaum bill: Sec. 194, Volunteer Services Provided by Health Professionals at Free Clinics. However, although there is authorization for an appropriation of $10 million for each fiscal year for paying judgments against the U.S. from the acts or omissions of free clinic health professionals, the Secretary of Health and Human Services has not established a fund. "There are still some complex issues to be resolved especially by physicians who are performing surgical procedures versus nonsurgical procedures," says Nicholas Cavarocchi, director of the Academy's Washington office.

William W. Tipton Jr., MD, Academy executive vice president, suggested to David Satcher, MD, U.S. Surgeon General, the possibility of establishing a separate classification for orthopaedic surgeons to provide nonreimbursed health care services as "government employees" so that federal liability coverage could be extended to these individuals.

Edward A. Rankin, MD, a task force member who investigated volunteer opportunities, both locally and nationally, noted that many physicians aren't aware of organizations that provide volunteer opportunities. "Also, in many communities where there are medical schools and teaching hospitals or clinics that are understaffed, they could use additional attendees," says Dr. Rankin. "Those are the kind of things that are traditionally done, but people aren't necessarily aware that they're available."

As Dr. Mital puts it, "All agencies need to be identified on a regular basis and offered to the fellowship as a whole." However, Dr. Stanford says, "There needs to be some cohesiveness in pro bono care and federal programs. It's hard to do volunteerism if you've got 50 different state programs; you're going to run into 50 different problems."

George L. Lucas, MD, of the task force, explored the possibility of approaching national foundations such as the Robert Wood Johnson Foundation or the Commonwealth Fund to underwrite malpractice coverage for volunteer physicians. "This is a consideration, but a temporary means of providing indemnification," he says.

Dr. Lucas surveyed 150 program directors of residency programs to determine if residents were interested in volunteerism. He received 50 responses and found that the majority cited a lack of manpower-residents-to serve the parent institution, concerns about malpractice liability and that the Residency Review Committee wouldn't allow time away from the parent organization.

"I think it's important that the notion of volunteer service in whatever capacity needs to get started early" Dr. Lucas stresses. "It is a little bit amazing today that the idealism and volunteerism that is expressed in medical applications for residency spots, seems to disappear as the residency training period continues."

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