Guide to Medical Indemnity for OGs

If there is one thing Singaporeans can learn from history – it is history repeats itself. The lesson here is the British will let you down.

Yes, just like how the Brits capitulated to the Japanese in the defense of Singapore in World War 2, how they also withdrew their Armed Forces prematurely in 1971 from Singapore, the MPS (A British organisation) has also now abruptly refused to continue incidence occurrence medical indemnity plans for our Obstetrician and Gynaecologists (OGs) in Singapore.

For those of us not familiar with the facts, here is a brief summary of the situation:

Until now, MPS has always offered incident occurrence (IO) plans. IO plans cover the doctor for events/claims that occurred in the past as long as the doctor had bought the IO plans from them then. For example, if you had bought a IO plan in 2005 and a claim was made against you in 2015 for a 2005 incident, you will be covered by the medical indemnity provider even thought in 2015 you are now buying a plan from another provider.

This is in contrast to claims-made (CM) plans – which is more akin to a car insurance scheme. To claim medical indemnity from a CM plan provider, you must remain in continuous membership with the CM Provider – from the date the incident occurred till the time you are aware a claim has been against you. There are also some extended reporting benefits(known as “tail cover”) that you can buy but here’s the rub – the tail cover offered here by MPS is only 5 years with no assurance of renewal or extension. And most of the time, it iscontinuous membership – which implies you cannot change provider. You are stuck with this organization for better or for worse.

This really sucks because for OGs (or for that matter anyone dealing indirectly with obstetrics or newborn, such as neonatologists and anaesthetists) because under Singapore law, the patient can sue you for up to 3 years upon turning 21. That means they can sue you until they’re 24. So a 5-year tail cover is plainly put – grossly inadequate. If you are covered under an IO plan, that’s OK, because the cover is forever as long as the incident occurred when you had bought the plan under MPS. So at least for now, the neonatologists and anaesthetists are OK since they can still buy IO plans. But for the OGs (both public and private sector), the writing is on the wall.

Since the OGs will not be able to buy IO plans once the current one expires, what’s the advice for OGs going forward?

If you are a resident training to be OGs –

Time to change specialty before its too late. Or make sure you get into an OG subspecialty that doesn’t do deliveries. Or train to be a medical indemnity lawyer. The sector is booming.

If you are a peri-retirement OG, in your mid to late fifties or older –

Time to quit altogether, retire or at the very least, drop obstetrics from your practice. MPS still offers IO plans for gynaecology ONLY. Many are already doing this as we speak. Many mothers have already been told by senior OGs that this is the last baby the OG is delivering and subsequent pregnancies will have to be managed by other OGs. There is a mass movement to retirement by many such experienced OGs, which is very unfortunate, both for the OGs and the patient.

If you are somewhere in between…

As the saying goes, the glass is either half empty or half full, depending on how you look at it. In places like Taiwan, there is no such thing as a medical indemnity provider and the doctor self-insures. In other words, the doctor sets aside a part of their earnings in preparation for the possibility that someone will sue them. You now have to set aside money enough for 24 years post-retirement. That’s probably when you are about 90 years old. All that has to be factored in when you charge your patient today. You have to probably raise prices because your costs have gone up. When you “self-insure” you do not enjoy the benefits of risk-pooling which indemnity organisations and insurance companies enjoy. Therefore costs go up. Delivering SG50 babies just got a lot more expensive.

The glass is half full because with the sudden retirement of many senior OGs, there is much less competition. You will probably get more deliveries per OG. Business will boom. If you are in your mid forties or younger, you probably have a long enough career runway before retirement to make enough money to fund your post-retirement tail-cover.

But do remember, when in doubt, please do an LSCS. No more mucking around with doulas, water deliveries, or even forceps or vacuums. Just get the baby out safe and sound as quickly as possible. To hell with giving your patient “a good birthing experience” when you want to avoid fully funding yourself a litigation experience later on. And do remember to order the full gamut of pre-natal testing to cover  yourself. Defensive medicine works when medical indemnity fails.

Other dark side ruminations….(The really useful/useless advice for OGs)

Plan A

Well, since there is only a 5-year tail cover available for you from MPS, you have to time your retirement and death carefully. You have to die within 5 years after your retirement. This can be achieved by working until you drop dead. Which is the usual case anyway for many doctors. Frankly, we should also consider legalising euthanasia for OGs. Then you can tell your favourite anaesthetist to give you a lethal injection because “my tail cover expires tomorrow”

Plan B

An easier or more palatable option is to transfer most of your assets to your spouse/mistress/boyfriend/children when you retire. Leave nothing much in your name so that the plaintiff cannot get a lot of money out of you even if he wins the suit. You may be made a bankrupt but it’s no big deal when you are a retiree and your beneficiary still takes good care of you. There are obviously certain risks to this plan. The person/beneficiary whom you leave the money to must be trustworthy. When in doubt, do not give your money to a Mainland Chinese travel agent. If the beneficiary runs away, please see Plan A’s option of lethal injection….

If you are the patient….

Your child gets to keep his/her right to sue the doctor that delivered him/her up to 24 years from birth. But otherwise,you are quite royally screwed.

Firstly, you have less choice because as aforesaid, OGs are running for the exits. They are retiring as fast as they can. It may even come to the point where midwives will be the ones delivering your baby. Provided we can even find them because as far as this Hobbit knows, we haven’t trained a midwife for at least 15 years and many of these (old) midwives haven’t performed deliveries on their own for many years. But perhaps midwives are the way forward because patients don’t usually sue nurses or midwives for the simple reason that you can’t get a lot of money out of them. It doesn’t do you much good financially to bankrupt a midwife and also get stuck with a large lawyer’s bill. Doctors can pay – that is why they get sued.

Secondly, because there is no adequate tail cover available, OGs has to raise prices to self-insure their own tail. You, the patient, are paying. Hopefully, the baby bonus will cover this increase in costs.

What does this all mean?

 

The first lesson we should glean from this is that we need to be independent and masters of our own fate. We have been independent for 50 years, yet for all intents and purposes we are still a British colony when it comes to the area of medical indemnity as this incident has demonstrated. A local provider needs to step up to the plate. This will not happen on its own because medical indemnity as a business is simply not very profitable compared to other areas of insurance and indemnity. In other words, the market will not sort itself out. Government needs to lean on someone….

The second lesson is that the law is meant to protect the people and their rights but there are limits to this protection before it backfires on the people. This is a clear example. The confluence of the law and the withdrawal of IO plans for OGs has worked together to undermine the patient’s and public interest. Everyone is a loser here – the OG and the patient. And probably the patient is the bigger loser than the OG. The law needs to be changed to balance the rights of the patient and the doctor for a win-win situation rather that the current lose-lose one. Again, the law will not change by itself. Changing laws is the prerogative of parliament and the government. For a start, look at the 24 years of tail. Do we really need to give the patients or their parents such a long period to sue the doctor? Can we also limit the amount of damages payable?

The third lesson is that this is only the tip of the iceberg. Any specialists or specialty that deals with the newborn and young will suffer from a long tail of potential litigation. After OG, which specialty is next? Will it come to the point where all specialties can only purchase CM plans with no adequate tail cover or worse, self-insure? Costs will escalate sharply when this happens. This has already happened in other countries. But this is not inevitable if all stakeholders make the correct decisions now.

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