Thousands of Georgia doctors lack malpractice insurance

Why we’re telling this story

The public needs to be protected from unscrupulous or dangerous doctors. Georgians rely on the state for that. Lawmakers establish how medical care can be administered, what information on doctors is made public and how malpractice cases can be filed. The state medical board licenses physicians, sets treatment standards and investigates complaints. Today, the AJC brings you the first in an occasional series of stories exploring Georgia’s physicians and how they are regulated.

Why we’re telling this story

The public needs to be protected from unscrupulous or dangerous doctors. Georgians rely on the state for that. Lawmakers establish how medical care can be administered, what information on doctors is made public and how malpractice cases can be filed. The state medical board licenses physicians, sets treatment standards and investigates complaints. Today, the AJC brings you the first in an occasional series of stories exploring Georgia’s physicians and how they are regulated.

More than 2,500 doctors in Georgia do not have malpractice insurance, and their ranks include dozens who have been disciplined by the state medical board for sexual misconduct, illegal drug use, patient deaths and other serious transgressions, an Atlanta Journal-Constitution investigation has found.

Experts in the fields of law and medicine called the number of uninsured doctors — just under 8 percent of those licensed in the state — surprising and disturbing.

“I know of no good way to understand that,” said Dr. Gerald Hickson, an authority on physician behavior who teaches at the Vanderbilt University School of Medicine. “I feel very strongly that it’s one of our professional duties to be prepared to do the right thing in the face of an adverse event.”

Practicing without insurance, known as “going bare,” makes doctors personally responsible for compensating patients if something goes wrong. That can put the doctors’ assets at risk — but it also can make them “judgment proof.” In costly cases where patients have died or must deal with life-long disabilities, that leaves patients or their families with little or nothing.

The AJC analyzed data compiled by the state medical board under a 2011 law requiring physicians to disclose to the board whether they have malpractice insurance. The analysis found that 2,536 of the more than 29,500 licensees who responded said they didn’t have insurance. The board could not provide responses from more than 3,000 other active licensees, in part because not all the data has been collected.

The data shows there are doctors in virtually every specialty without insurance. Moreover, 113 of the 2,536 have been sanctioned by the board for violating its regulations, including nine currently on probation. Some of the infractions are technical, but others indicate serious deviations from standard medical care.

Among the doctors without insurance are one with a $900,000 malpractice settlement, another sanctioned for performing a series of unnecessary surgeries and one barred from treating cancer patients after several were injured or died.

Numerous studies have found that preventable medical errors are a pervasive problem, each year killing or injuring hundreds of thousands of patients.

Longtime Atlanta medical malpractice attorney Tommy Malone said Georgia’s uninsured doctors “must be the luckiest doctors alive. The clock’s ticking on them, because they’re all humans, and humans make mistakes.”

Malone said he could not remember reviewing even a prospective case in 40-plus years of legal work in which the doctor didn’t have insurance.

“I cannot imagine any responsible physician not having at least $1 million worth of coverage,” he said.

It’s unclear from the data how many of the uninsured doctors are actively practicing medicine.

The AJC, checking randomly, found that some are in research, teaching or administrative positions, making it unlikely that they would see patients. Many others appear to be retired.

Among those without insurance is U.S. Rep. Paul Broun. The Athens physician, who was fined $500 in 2006 for briefly practicing after his license had expired, discontinued his insurance in 2002, spokeswoman Christine Hardman said. He made that decision because he had ended his hospital affiliation and was confining himself to house calls, she said. Since his election to Congress in 2007, he has declined to see patients, she said.

But the newspaper also discovered more than a dozen uninsured doctors treating patients — in some instances performing cosmetic surgery or using unorthodox procedures that have raised questions for the U.S. Food and Drug Administration and medical organizations.

In one case examined by the AJC, the death of a 56-year-old Atlanta woman while undergoing a controversial treatment at a Dunwoody clinic in 2002 turned into a long and contentious court fight that ended with frustration for her family because the doctor didn’t have insurance.

The woman, Susan Alexander, collapsed and died while undergoing chelation therapy, a procedure in which patients are intravenously administered drugs that remove heavy metals. Chelation is typically reserved for patients with severe lead poisoning, but in Alexander’s case, her physician, Viktor Bouquette, prescribed it for chronic fatigue, lack of concentration and other symptoms, according to an order from the medical board citing him for failing to follow “prevailing medical practice.”

Only after Alexander’s family sued Bouquette and others at the clinic, Progressive Medical Center, did they learn the doctor had no insurance. The family ultimately dropped the suit after receiving a relatively modest settlement from the physician’s assistant, who was insured.

“I was stunned to find out there are doctors who don’t have insurance,” said Edwin Alexander, the woman’s brother. “I assumed all of them did.”

A push for disclosure

Despite the widely-held notion that doctors are required to have malpractice insurance, only 18 states have laws making it mandatory or establishing other mechanisms for compensating patients who have been harmed, according to the American Medical Association.

In Georgia, acupuncturists are the only group of health care professionals required by law to have liability insurance.

Georgia’s law requiring physicians to disclose whether they have insurance was sponsored by state representative Ben Watson, a Savannah physician who won election to the Legislature in 2010. Watson said he considered proposing legislation making malpractice insurance mandatory, but he decided that public disclosure could be just as effective.

“It’s a piece of the puzzle,” he said. “If you think about a physician who doesn’t have malpractice (insurance), the question is why?”

Under the law, the medical board is responsible for collecting the information from doctors when they renew their licenses every two years. The board is then required to post it online on the physicians’ public profiles.

However, three years after the bill was signed into law, the profiles have yet to be updated to include that information.

LaSharn Hughes, the board’s executive director, said the board can only collect the data at this point. It cannot add the information to the online profiles without an appropriation of money from the Legislature because an upgrade of the entire web site is required, she said.

“When this is funded, probably next year at this time, the site will be up and running,” she said.

Watson said he understands the board’s predicament and hopes public attention to it will spur the Legislature to make the necessary funds available.

The board provided its data to the AJC in response to an open records request. The newspaper then compared the data with the board’s database of all licensed physicians, which includes their specialties and whether they had been disciplined.

Medical, legal and insurance organizations queried by the AJC said they had no data showing how many doctors nationally lack malpractice insurance.

However, experts in those fields said they assume the greatest percentage have insurance because it’s usually required for hospital privileges.

“One would hope patients would be savvy enough to recognize they are taking a chance by going to someone who doesn’t have malpractice insurance,” said Mark Rothstein, who holds the Herbert F. Boehl chair of law and medicine at the University of Louisville. “Actually, two chances. One, what kind of doctor would not have it? And, two, if something goes wrong, they are left without much of a remedy.”

`There’s always a risk’

Doctors contacted by the AJC who are practicing without insurance cited cost as the main reason for not having it. In Georgia, premiums can range from nearly $13,000 a year for general practitioners to $44,000 for surgeons and $65,000 for obstetricians. And the costs go up for doctors who have been sued or have board orders against them

Dr. Rajae Janho, founder and director of a cosmetic surgery center in Lawrenceville, said he dropped his insurance when he switched to his current practice from emergency medicine 10 years ago. Because he’s not board certified in plastic surgery, he was quoted a rate of $42,000, which he considered unworkable, he said.

“It’s like driving a car, there’s always a risk,” he said. “But you’re careful. You select your patients correctly, explain to them what you’re doing, who you are.”

Janho said he tells patients he doesn’t have insurance and, if there are issues, they can be worked out through arbitration.

“It really helps me understand my patients, where their focus is,” he said. “Is their focus beauty, the improvement of their well-being? If a patient is litigious and questioning all these things, we will tell them who we are honesty and let them decide.”

Dr. Jack Heneisen said he hasn’t had insurance since opening his storefront clinic in Rincon seven years ago. He started the clinic after serving eight months in federal prison for illegally writing prescriptions for the painkiller OxyContin and destroying evidence, and that made the premium he was quoted, $35,000, double what he paid before his incarceration, he said.

“They wanted it all up front,” he said. “If I had to pay, I couldn’t have gotten this place open.”

Heneisen, widely known as “Dr. Jack,” said his lack of insurance is noted on the forms patients fill out detailing their medical histories as well as their bills

“I have mixed feelings about it, of course,” he said. “It puts me at risk. (Patients) could come after everything if they wanted to, or what little I’ve got, since I live in a double-wide trailer and drive an eight-year-old car.”

Five years in court

In a case that played out over five years in court in DeKalb County, Bouquette’s lack of insurance became an issue as Alexander’s family sought answers for her death.

Shortly after starting chelation, Alexander tried to maneuver with her IV to the restroom and collapsed. The medical examiner said the cause of death was heart disease stemming from small blood vessels and an abnormal valve.

Although the medical examiner didn’t tie Alexander’s death directly to the therapy, evidence uncovered as part of the lawsuit found that Bouquette was 20 miles away listening to then-President George W. Bush speak when she died and that there was no crash cart or other emergency equipment at the clinic.

In a ruling issued in 2011, three years after the suit was settled, the medical board ordered Bouquette to obtain 30 hours of continuing medical education and pay a $7,500 fine.

The board said Bouquette’s treatment of Alexander was substandard in a variety of ways, including using an unreliable urine test to diagnose lead poisoning. It also noted that, instead of treating Alexander with a safe oral chelating drug, Bouquette used one that’s known to have serious potential side effects such as hypotension, renal failure and dangerously low blood levels of calcium, magnesium and potassium.

Bouquette strenuously denied that he was at fault in Susan Alexander’s death when he appeared before the board and he did so again during a recent interview.

“That lady … had small (blood) vessel disease,” he said. “She could have dropped dead in a Wal-Mart parking lot.”

Bouquette, who continues to practice at the clinic, said he dropped his insurance 14 years ago when he left emergency medicine and began practicing integrative, or alternative, medicine. By not having insurance, he’s shielded from baseless lawsuits, a label he believes applies to the Alexander suit, he said.

“In any practice, there are opportunities for mistakes,” he said. “But the more I looked at the way litigation works, the more I realized it’s really about the money. If (patients) figure out you’ve got malpractice insurance, then they’re going to pursue frivolous cases. Often, the insurance companies will force doctors to settle, just because they don’t want a long litigation.”

Edwin Alexander said Bouquette initially offered to pay $10,000, but the offer was rejected because it was believed — erroneously it turns out — that such an amount would allow the doctor to avoid reporting the settlement to the medical board.

“I guess it turns out we should have taken the $10,000,” he said. “But we weren’t really out for the money. We were more interested in stopping things like this from happening.”

That the settlement came from the physician’s assistant is ironic, the brother said, because, while Bouquette was listening to Bush, the assistant was administering CPR in an attempt to save Susan’s life.

“It hardly seemed fair,” he said. “The physician’s assistant paid and the doctor just walks away.”