Can someone tell me why only the left of half the comments on this page appears on my screen?

1) Silver’s data in the main trendline aggregates all doctors; when one breaks out the high-litigation-risk categories, as I did above, the post-2003 and pre-2003 comparisons are considerably more dramatic, though Silver is correct that there may be confounding factors other than tort reform that explain the change in trends.

2) It would be extraordinarily surprising if small changes in Texas GDP had a larger impact on doctor location decisions than large changes in medical malpractice insurance expenses, but that is what Silver’s model is effectively asking us to believe.

Mr. Schuelke:

Previously, you had stated that “the number of docs per capita has been trending upward well before the 2003 tort-reform legislation was passed at approximately the same rate it’s going up now.”

It’s unclear what you mean when you say that doctor per capita growth was “trending upward” before reform at “the same rate it’s going up now.” Is it possible for a rate to trend upward while continuing at the same rate? Or perhaps to you mean to say that the *rate of change* of per capita doctors is accelerating? (I would love to see those statistics backing that up).

In any event, Mr. Frank responded:

“Texas had a net loss of obstetricians in 2001-2003, and has gained 186 obstetricians since then. Texas had a net loss of orthopedic surgeons in 2000-2003, and has gained 156 since then. The statewide total of pediatric intensive care, pediatric emergency medicine and pediatric infectious disease specialists will double this year since pre-reform; the population hasn’t doubled.”

Showing a loss of a segment of doctors pre-reform, and showing a net gain since then, refutes your claim that the “rate” of doctor growth was tending toward that direction on its on inertia. Thus, for you to claim you’re not “refuted” by this is…perplexing.

Further, showing that the number of doctors have grown 16% *since 2003* while the population has grown 13% *since 2003* is absolutely meaningless for your claim that the rate of doctor growth was growing *before reform* i.e., pre-2003. You’ve traded in your original position — that the number of doctors was growing anyways and reform had nothing to do with it — to the new position that it’s population that has caused the admittedly high doctor growth in recent times.

And you’ve sprinkled in an argument that, even if reform has contributed to doctor-growth, it’s not where the doctors are needed most. The corollary to this argument is that if we can’t get doctors to the rural areas, then having more doctors is useless. Many call this “the perfect being the enemy of the good.”

In sum, this is why Mr. Frank referred to you as a “moving target.” If you think you’re being “met with distortions” then it’s most likely because you can’t decide what you’re trying to say.

Nothing in your stats refuted what I said. The TMB stats show that Texas had 50,549 docs as of 5/03 (the last count taken before the 9/03 effective date of tort reform) and 59,042 as of 3/08 (the last availabe). That’s a 16.8% growth rate, which is approximately in line with our population growth. The last census data (2000-2006) shows a 13% population growth. I don’t have time to look up any stats, but I can virtually guarantee that the growth in the last two years has outpaced those numbers with our booming economy here. That was one of my original premises and I stand by it. The fact that the TMA lobbyists can go pick and choose what specialties and counties they want to use to present the benefits of tort reform doesn’t refute the overall numbers.

Second, I put the Texas Observer article in my orignal comment with a synopsis saying that if there are new doctors (from tort reform or other sources) they’re not getting to the high need areas. And given that tort reform was sold to Texans on the basis that all of these rural areas didn’t have doctors, that’s relevant. Who cares if the D/FW metroplex or Austin or Houston have more doctors? We already have plenty.

I have tried to contribute to a civil discussion on this issue, and all I’m met with is distortions. I can have those type of discussions with the pro-tort reform crowd here in Texas. I thought this site was beyond that.

As the Nixon article (and a recent McQuillan study) demonstrates, there have been billions of dollars of benefits to “all of us” from tort reform. Texas doctors are largely insured by mutual companies; thus, when “insurance companies” benefit, the proceeds go directly to the policy-holders. The only losers have been trial lawyers.

Since you’re not in Texas, I’ll give you the benefit of the doubt and assume that you don’t know that the Texas Medical Assoc, from whom you pull your stats, is the doctors’ lobbying group, and one of the primary backers of tort reform. Their pulling of statistics is very selective.

The Texas Medical Board is the licensing agency for the state. They keep detailed records of the number of docs in Texas and the number of doctors and specialists in each county.

The issue is not number of docs. We have plenty of physicians in the metropolitan areas (and even a glut if you listen to my doctor friends). The issue is getting doctors to rural areas. If you go through the TMB reports you can selectively pull the data to support whatever conclusion you want. The Texas Observer article (admittedly using their own selections) notes that as of Sept 2007, the number of counties without an OB remains unchanged after tort reform and the number of counties without a physician at all actually increased from 20 to 21.

There may be random gains here and random losses there, but overall, you will find that the new doctors aren’t getting to where they need new docs (and I think even the stats you cited above about Houston, San Antonio, and El Paso support that).

You also can’t look at tort reform in a vacuum. Texas has also adopted incentives (ironically funded by the state’s tobacco money) to encourage doctors to go to the underserved areas. We have also had a population explosion in many major metropolitan areas of the state.

Unfortunately, there is not a good solution for getting docs to underserved areas. Texas is just a huge state with very large, sparsely populated areas. I can drive south from San Antonio on IH 35 for four plus hours before coming to Laredo, the next town of any significance. And in West Texas or the Panhandle, you can drive further than that. There simply isn’t a population base in most Texas counties to support more than one or two GPs and certainly not any specialists.

And finally, I have my own criticisms about the data pulled by the TMA. For example, they cite the increased number of OBs. The Texas Observer article looked at those numbers. 94 of those new OBs went to 5 wealthy counties. Around the rest of the state, some counties gained a few, some lost a few, and 2/3 remained the same. The article looked at the neurosurgeons and orthos (which you cited) and the same pattern exists. I also thought it was funny that they cited Corpus Christi and Beaumont as underserved areas. Corpus is the home to the Christus Spohn hospital chain cited by Joe Nixon, and Beaumont is, in essence, a wealthy suburb of Houston (ironically driven by oil and trial attorneys — several tobacco firms are based there).

My point of all this? Maybe you can marginally say that tort reform has led to some of the new doctors. But the one thing I think is clear is that there have not been huge increases that you can track to tort reform and certainly not huge increases to traditionally underserved areas. And given the substantial rights that Texas gave up in tort reform, I think we should expect huge benefits for all of us and not just the insurance companies.

This is simply not true.

Texas had a net loss of obstetricians in 2001-2003, and has gained 186 obstetricians since then. Texas had a net loss of orthopedic surgeons in 2000-2003, and has gained 156 since then. The statewide total of pediatric intensive care, pediatric emergency medicine and pediatric infectious disease specialists will double this year since pre-reform; the population hasn’t doubled.

In 2003, Texas was 48th in doctors per capita. That’s now up to 42nd.

Texas licensed a record number of new doctors in 2007.

# The physician growth rate in El Paso is 76 percent greater than pre-reform.
# The physician growth rate in San Antonio is 55 percent greater than pre-reform.
# The physician growth rate in Houston is 36 percent greater than pre-reform.
# Jefferson, Nueces and Victoria counties saw a net loss of physicians in the eighteen months prior to tort reform. They’re now gaining doctors again.

More data at the Texas Medical Association site.

Next, look at the stats. The only data he cites is the one number quoted by Ted. And frankly, most I know take those numbers with a grain of salt. When touting the benefit of reform, Christus is always the example given, and they certainly have not opened their books to prove the accuracy. Why not present any argument based on any of the other large chains in the state?

Next, to address Ted’s response to Turkewitz, I know that Ted is knowledgeable enough to know that it’s not as simple as saying there are more doctors now. You can certainly manipulate the stats, but the number of docs per capita has been trending upward well before the 2003 tort-reform legislation was passed at approximately the same rate it’s going up now.

Finally, two other stories to consider (and I apologize in advance for the long links):

Last week the D/FW Fox Affiliate ran its own story looking at the need and effectiveness of the med mal reforms. Unlike Nixon’s article that’s all rhetoric and no data, it actually cites some data in support of its conclusions. It’s available here: http://www.myfoxdfw.com/myfox/pages/Home/Detail;jsessionid=9FDF916BD433B871BDFDC87132D64F84?contentId=6552986&version=7&locale=EN-US&layoutCode=TSTY&pageId=1.1.1&sflg=1

And the Texas Observer has recently run a story finding that most of the state’s new doctors are practicing in urban areas where there never was a doctor shortage (I apologize if that story has been discussed on this site): http://www.texasobserver.org/article.php?aid=2607

For the most part, a good thread of comments (though, to comment #4, we don’t have a state income tax).