Road to Resolution
By Kara Nuzback Texas Medicine May 2014

Rural Doctors Fight to Retain OB Privileges

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Law Feature — May 2014

Tex Med. 2014;110(5):51-53.

By Kara Nuzback

No one knows the challenges of a rural practice better than family physician Jeff Alling, MD, who delivered babies for 18 years at a hospital that later stripped him of his obstetric privileges. 

Following the closure of their physician-owned hospital in Bridgeport, Dr. Alling and three of his partners in Decatur found themselves in a struggle to retain their obstetric privileges at the sole remaining hospital in Wise County, the nonprofit Wise Regional Health System (WRHS), 40 miles north of Fort Worth.

Dr. Alling started practicing family medicine in Decatur in 1990 and delivered babies at WRHS. As the years passed, Dr. Alling says he and other members of his group practice, Wise County Medical and Surgical Association, felt they could better care for their patients at their own hospital. They left WRHS in 2008 to practice at the newly built, physician-owned North Texas Community Hospital (NTCH), a nonprofit, 35-bed institution in Bridgeport, 10 miles west of Decatur.

NTCH hired a management company to oversee daily operations. Dr. Alling says the company did a "very poor job." The hospital went bankrupt just four years after it opened.

WRHS purchased the Bridgeport facility in early 2013. The maternity ward at NTCH closed just prior to the hospital switching hands, and the only place doctors could deliver babies was at WRHS in Decatur. 

That's when, Dr. Alling says, officials at WRHS dropped a bombshell: The family physicians coming from Bridgeport — Dr. Alling; Lara Pierce, MD; Shawn White, MD; and Brad Faglie, MD — could no longer deliver babies at the Decatur hospital.

With help from the Texas Medical Association and the Texas Academy of Family Physicians (TAFP), the family doctors ultimately regained their obstetrical privileges. But the road to resolution was rocky, and the parties narrowly avoided an expensive legal battle.

"It was not a fun experience," Dr. Alling said. "But banding together and fighting for each other, it was worth it."

Family Bond

Dr. Pierce, who joined the practice in 2012, says after WRHS bought NTCH, she learned in a meeting with WRHS Chief Executive Officer Stephen Summers that the hospital's policy allowed only board-certified obstetricians to deliver babies.

Kevin Reed, an Austin attorney representing WRHS, explains the medical staff recommended the policy to the hospitals' board of directors.

"For a period of time, there were no family practitioners practicing at Wise," he said.

Mr. Reed says in 2009, while Dr. Alling and his associates practiced only in Bridgeport, WRHS adopted the policy that mandated physicians complete a residency in obstetrics and obtain a board certification to deliver babies. 

Dr. Pierce says she was caring for about 15 pregnant patients at the time, whose babies she could no longer deliver. 

"I was pretty mad," Dr. Pierce said. "All of a sudden … everything we had worked for and had been doing didn't mean anything."

Dr. Alling says he did not understand why WRHS suddenly thought he was incapable of practicing obstetrics. 

"I've delivered 2,500 babies," Dr. Alling said.

He says delivering babies is an important part of his practice, noting 15 to 20 of the babies he delivered in more recent years are the children of mothers he delivered early in his practice. 

"That's a very special relationship," he said. "They almost feel like my grandchildren."

Besides getting personal fulfillment from the practice, Dr. Alling says his Medicaid patients in the more rural town of Alford, about 10 miles north of Decatur, depend on him for care. 

"Basically, there's not anybody between Decatur and Wichita Falls who delivers babies," he said. "It was really important for us to keep that going."

He says if WRHS did not allow him to practice obstetrics, his patients at Alford Medical Clinic may not have received any prenatal care, thus increasing their risk of preterm deliveries and complications during labor.

The percentage of family physicians practicing maternity care in the United States dropped from 23 percent in 2000 to less than 10 percent in 2010, according to a 2012 study published in the Journal of the American Board of Family Medicine.

"We really need more family physicians doing obstetrics," Dr. Alling said. 

The role of a family doctor is important and rewarding, Dr. Alling says, but he acknowledges it's hard to convince doctors to move to rural areas.

TMA recognizes the lack of physicians in rural areas of Texas and offers several programs to give recent graduates and seasoned professionals some incentive to work in underserved areas. 

Grazing Litigation

Mr. Reed says after pushback from the affected doctors, the medical staff at WRHS recommended the board of directors waive the WRHS board certification policy for only the family physicians coming from Bridgeport. The policy should stand for all physicians in the future, the staff recommended. 

"The board felt like you should have a policy that works appropriately for everybody across the board," Mr. Reed said. 

In response, Dr. Alling says, the family physicians hired Addison attorney Russ Lambert and threatened to sue the hospital. 

Mr. Lambert says the four family physicians applied for obstetric privileges, which the WRHS Medical Ethics and Credentialing Committee tentatively approved. In a March 20, 2013, letter to the WRHS Board of Directors, Mr. Lambert says when the committee met to confirm the approval in a final vote, none of the committee members voted in favor of granting obstetric privileges to the doctors.

In the letter, Mr. Lambert asked the board to reconsider its policy to avert the disruption of care for 43 expecting mothers in the community.

"Preserving women's right to choose their own physician to continue maternity care and avoid the duress of changing physicians in the middle of their pregnancy, and to the future mothers' care, is the right decision medically and ethically for these patients," Mr. Lambert wrote.

In the letter, he added that if the board denies the four family doctors obstetric privileges, he would recommend they pursue immediate legal action against WRHS. Mr. Lambert also contacted TMA and TAFP for assistance. 

TMA staff reviewed the case and invited the parties to attend a TMA Patient-Physician Advocacy Committee meeting during the association's TexMed 2013 meeting in San Antonio. 

The TAFP president and general counsel as well as attorneys for the four family physicians and WRHS attended the meeting, during which each side presented its position to the committee.

"We were able to listen to both sides of the conflict," said committee Chair Susan Pike, MD. Afterward, Dr. Pike says, the committee recommended the parties begin mediation and offered financial assistance to get the ball rolling.

"We provided a list of known medical mediators, successful ones," she said. "Mediation played a significant role in resolving this conflict."

TAFP Chief Executive Officer and Executive Vice President Tom Banning says the organization promised to support the physicians legally and financially if the situation escalated to a lawsuit. TAFP also reached out to state and national media outlets. June 2013 articles in The New York Times and The Texas Tribune helped tip the public's opinion in favor of the family doctors, Mr. Banning says.

"It allowed them to tell their story," he said. "That made a huge difference."

Dr. Alling says mediation talks were not successful at first. TMA then arranged for the physicians to meet with Kim Van Winkle, deputy chief of the Consumer Protection Division in the Texas Attorney General's Office. That, Dr. Alling says, got the attention of the WRHS Board of Directors, whose members were now more amenable to reaching a compromise.

"It's a tough fight when you're fighting a big hospital system," Dr. Alling said. He says it helped to have TMA working to resolve the issue because it showed the hospital "they were going to have to fight somebody bigger than just a small town practice." 

Mr. Reed says the mediators urged the WRHS medical staff to revisit the hospital's policy on obstetrics and its recommendation to its board of directors.

"When it did that, the medical staff took it back through its committee process," he said. 

Making a Deal

Dr. Alling says he and the other family physicians met with WRHS obstetricians, and together they came up with a new policy that suited everyone, including the WRHS Board of Directors. 

WRHS now requires family doctors without a board certification in obstetrics who wish to deliver babies to demonstrate they have previously served as the primary physician for 100 vaginal deliveries and 50 cesarean sections.

Dr. Alling says the new policy mirrors a recommendation made by the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists that hospital privileges in rural communities be based on training, experience, and competence. According to the 1998 statement, "Provisional privileges in primary care, obstetric care, and cesarean delivery should be granted regardless of specialty as long as training criteria and experience are documented."

The WRHS Board of Directors approved the new policy last July. Dr. Alling says the situation at the hospital has improved for him and his colleagues. 

"We've pretty much ironed it out," he said.

Mr. Reed says the resolution pleased the board of directors, especially because it had the approval of the WRHS medical staff. He says the board approved the new policy because it treated everyone fairly, and the medical staff felt they put in place a high standard for obstetric care at WRHS.

"In the end, it worked out to be something that was ultimately beneficial to the community," he said. 

Dr. Alling says that he and Drs. White and Faglie regained their obstetric privileges. Dr. White is now practicing in Gainesville. Dr. Pierce had to make other arrangements.

"She had just come out of residency," he said. "She was just a little bit short on the numbers."

Dr. Pierce says at the time WRHS approved the resolution, she had acted as the primary physician for 80 to 90 vaginal deliveries. 

"I had 50 total C-sections for sure, but I wasn't primary on 50," she said. "When they came to that decision, there was no way that I could have privileges."

Dr. Pierce remains a member of Wise County Medical and Surgical Association, and she now delivers babies in Jacksboro. She says she is not sure whether she will reapply to WRHS when she reaches the standard set by the hospital because she enjoys working in Jacksboro and "would like to see it continue to grow." 

"Disease is a very formidable opponent all by itself, much less having to fight insurance and administration and everything else," Dr. Alling said. "If you're practicing good medicine, and someone interferes, stay strong; get help from other physicians; get help from TMA."

Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.

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