Medical Professional Liability Insurance Research Articles

Reducing the Risk of Delayed Colorectal Cancer Diagnoses Through an Ambulatory Safety Net Collaborative

An estimated 12 million adults in the United States experience delayed diagnoses and other diagnostic errors annually. Ambulatory safety nets (ASNs) are an intervention to reduce delayed diagnoses by identifying patients with abnormal results overdue for follow-up using registries, workflow redesign, and patient navigation. The authors sought to co-design a collaborative and implement colorectal cancer (CRC) ASNs across various health care settings. A working group was convened to co-design implementation guidance, measures, and the collaborative model. Collaborative sites were recruited through a medical professional liability insurance program and chose to begin with developing an ASN for positive at-home CRC screening or overdue surveillance colonoscopy. The 18-month Breakthrough Series Collaborative ran from January 2022 to July 2023, with sites continuing to collect data while sustaining their ASNs. Data were collected from sites monthly on patients in the ASN, including the proportion that was successfully contacted, scheduled, and completed a follow-up colonoscopy. Six sites participated; four had an operational ASN at the end of the Breakthrough Series, with the remaining sites launching three months later. From October 2022 through February 2024, the Collaborative ASNs collectively identified 5,165 patients from the registry as needing outreach. Among patients needing outreach, 3,555 (68.8%) were successfully contacted, 2,060 (39.9%) were scheduled for a colonoscopy, and 1,504 (29.1%) completed their colonoscopy. The Collaborative successfully identified patients with previously abnormal CRC screening and facilitated completion of follow-up testing. The CRC ASN Implementation Guide offers a comprehensive road map for health care leaders interested in implementing CRC ASNs.

Medical professional liability insuarance

The aim of the study is to form an integrated approach to understanding the context and legal necessity of medical professional liability insurance.
 The methodological basis of the study is a set of scientific techniques and methods of scientific knowledge, including dialectical, historical-legal, logical-legal, system-structural, method of forecasting and comparative jurisprudence. Dialectical method has provided opportunities to analyze scientific positions regarding the content and development of medical professional liability insurance. Historical-legal method helps to study the genesis of the development of insurance in specific historical and legal situations, the development of theoretical scientific thought and legislation. The method of comparative law is used to study the legislative and regulatory acts of Ukraine and other countries in the world as well as to clarify the advantages and disadvantages of the mechanism of legal regulation the insurance of medical professional liability in various countries in the world. Systemic and structural methods have helped to clarify the content of the contracts connected with this kind of insurance. Formal-logical method has allowed analyzing the provisions of the legislation of Ukraine in the sphere of this type of insurance.
 Results. This study contains a comprehensive scientific analysis of modern problems of medical professional liability insurance. The elements of the medical professional liability insurance contract are defined, namely: subject matter, insured, beneficiary, insurance risk, insurance event, conditionals of insurance compensation payment. It is stipulated that medical professional liability insurance contract shall have separate grounds for refusal to pay insurance compensation, inherent only to this type of insurance. It is shown that this type of insurance helps to manage the risks in medical practice activities. The concept of this type of insurance has been researched. The conditions to terminate the medical professional liability insurance have been identified.
 Conclusions. Having considered the issues of medical professional liability insurance and examined the conditions of the medical professional liability insurance contract, it has been made a conclusion that it is necessary to introduce this type of insurance as mandatory for healthcare institutions and private practitioners. It has been proposed to introduce compulsory medical professional liability insurance by approving necessary alterations the valid legislation.

OBJECT AND SUBJECTS OF PROFESSIONAL LIABILITY INSURANCE OF DOCTORS

This article discusses constitutional guarantees, the object and subjects of medical professional liability insurance. The issue of the rights and obligations of subjects of medical professional liability insurance is also analyzed through research by domestic and foreign scientists.

DOCTOR’S PROFESSIONAL LIABILITY INSURANCE IN CIVIL LEGAL ORDER

This article talks about the importance and relevance of civil regulation of doctor’s professional liability insurance today. The economic, social and legal consequences of the lack of regulation of these relations are analyzed on the basis of statistical data and foreign experience. The level of regulation of medical professional liability insurance in the Republic of Uzbekistan and the analysis of regulatory legal documents are discussed.

Taking on the Medical Director Role: Risk Management Considerations

Back to table of contents Previous article Next article Government & LegalFull AccessTaking on the Medical Director Role: Risk Management ConsiderationsGloria Umali, R.N., M.S., C.P.H.R.M.Gloria UmaliSearch for more papers by this author, R.N., M.S., C.P.H.R.M.Published Online:25 Feb 2023https://doi.org/10.1176/appi.pn.2023.03.3.18AbstractBeing a medical director as well as a treating psychiatrist may be an exciting career move, but it raises a number of liability issues that you need to think through before accepting the position.iStock/SinenkiyIt is not uncommon to hear of psychiatrists taking on a medical directorship role while providing direct care to their own patients. Psychiatrists have many reasons for assuming this role; however, the passion to serve, loyalty to and a strong connection with an organization, and financial freedom are often cited as the main motivators.While being a medical director is undoubtedly rewarding, there are aspects of the role that psychiatrists need to consider from a medical malpractice standpoint. It is imperative that psychiatrists understand the legal, regulatory, and professional liability coverage issues associated with being a medical director. Although the role of a treating psychiatrist and the role of a medical director both fundamentally require clinical training and competency, each role may differ. Psychiatrists performing a dual role may believe that the coverage from the existing professional liability insurance policy automatically extends to their role as a medical director without realizing that certain arrangements compound their liability exposures and therefore leave an unintended gap in coverage.Furthermore, what it means to be a medical director and how to acceptably stay within the agreed-upon scope of responsibilities can be confusing and tricky to navigate. To decrease the risk of practicing outside of scope, psychiatrists need to understand the usual responsibilities of a medical director and take the time to thoroughly review the scope of responsibilities outlined in their specific contract. A medical director’s typical responsibilities include administrative duties such as management of medical staff matters, development of organizational policies, oversight of clinical operations and compliance with regulatory requirements, and quality improvement activities. Depending on the arrangement, it may not be easy to discern that a medical director might also be held accountable for everything that happens in the facility.If you are thinking about taking on a medical directorship role, here are some points for your consideration:Ensure you have insurance coverage for the dual role as a medical director and treating psychiatrist.Identify duties and responsibilities not covered under your basic professional liability coverage agreement to delineate the coverage necessary for the medical directorship role.Do not assume that your medical professional liability insurance policy covers your actions as a medical director. Notify your medical malpractice carrier if considering a medical directorship position to review possible changes in the current coverage.Confirm that the duties and responsibilities outlined in the contract are within your scope of practice and expertise.Delegate and oversee only those medical tasks and clinical operations that are consistent with your scope of practice and specialty.Verify that your contractual arrangements do not violate state or federal laws.Conduct proper due diligence by performing research on the facility’s quality rating, care standards, and performance before accepting the position.Ensure resources are available to adequately fulfill and execute your assigned duties and responsibilities. Being a medical director is both an honor and a privilege. It gives psychiatrists the perfect opportunity to satisfy the passion for serving their patients while fulfilling civil community responsibilities. However, performing the dual role as a psychiatrist and a medical director requires due diligence to avoid needless risk and liability exposures. ■This information is provided as a risk management resource for Allied World policyholders and should not be construed as legal or clinical advice. This material may not be reproduced or distributed without the express, written permission of Allied World Assurance Company Holdings, Ltd, a Fairfax company (“Allied World”). Risk management services are provided by or arranged through AWAC Services Company, a member company of Allied World. © 2023 Allied World Assurance Company Holdings, Ltd. All Rights Reserved.Gloria Umali, R.N., M.S., C.P.H.R.M., is assistant vice president of the Risk Management Group of AWAC Services Company, a member company of Allied World. Risk Management services are provided as an exclusive benefit to insureds of the APA-endorsed American Professional Agency Inc. liability insurance program. ISSUES NewArchived

Features of medical professional liability insurance

This article analyzes the features of professional liability of a medical worker as a type of property liability and determines its specifics,taking into account the experience of Italian legislation. Professional liability is the property liability of specialists of various professions, whoseinsufficient qualifications, errors and omissions as a result of imprudence or negligence can cause damage to the client. Professional responsibility isinextricably linked with the categories «profession», the personality of a specific natural person who possesses the necessary special knowledge andqualifications, experience and business qualities and characteristics. Professional liability insurance of a medical worker is intended for insurance protection of doctors against adverse financial consequences arising from legal harassment, detection by a third party (victim) in connection with the occurrence of damage (damages) caused as a result of an error, negligence committed by a doctor in the process of execution him of medicalprofessional duties. Taking into account that in Ukraine, when a medical worker causes damage, we refer to Part 1 of Article 1172 of the Civil Codeof Ukraine, which states that a legal entity or an individual shall compensate for the damage caused by their employee during the performance of his work (official) duties. Problems arise with proving the guilt of a medical worker. Of course, it is necessary to prove the composition of the offense, however, it has long been known that the courts decide this issue at their discretion, and the amounts of compensation for material and especially moral damage are still ridiculous, but it is difficult to prove in the plane of cause and effect. We believe that a rather significant problem is that neither commercial organizations,nor state or communal enterprises consider it necessary to offer a compromise solution to the victims without a trial at all, because they are sure that the case will last a long time and in the worst case the compensation will be insignificant or not at all will be assigned. It is also a problemthat in most medical cases, witnesses are medical workers who have been connected by employment relations with the defendant, or are even friendswith the medical worker. In particular, according to Art. 1172 of the Civil Code of Ukraine, in most cases, the medical institution is responsible for the material and moral damage caused by the medical worker as a result of failure to perform his duties to the patient. Thus, the situation in Ukraine willnot change without the introduction of medical worker liability insurance.

Legal Review Doctor’s Professional Liability Insurance To Patients

Legal Review Doctor’s Professional Liability Insurance To Patients

Medicaid coverage expansions and liability insurance

AbstractDo changes in the population covered by health insurance affect liability insurers, who compensate billions of dollars in medical claims each year? We examine this question by exploiting the selective rollout across states of Medicaid expansions under the Affordable Care Act. Using data on insurer losses across a range of insurance lines, and employing a triple‐difference research design that contrasts states, years, and lines of insurance, we demonstrate that coverage expansions reduce auto liability and workers’ compensation outlays by 6–11 percent, but do not measurably impact other lines of insurance. Our analysis provides some of the first evidence regarding the use of the tort system particularized to the low‐income population and is the first to consider the impacts of health insurance on medical professional liability and commercial auto insurance claims.

Clinical safety and professional liability claims in Ophthalmology

Abstract Introduction Patient safety is an international public health priority. Ophthalmology scientific societies and organizations have intensified their efforts in this field. As a tool to learn from errors, these efforts have been linked to the management of medical professional liability insurance through the analysis of claims. Material and methods A review is performed on the improvements in patient safety, as well as professional liability issues in Ophthalmology. Results There is a high frequency of claims and risk of economic reparation of damage in the event of a claim in Ophthalmology. Special complaints, such as wrong surgery or lack of information, have a high risk of financial compensation and need strong efforts to prevent these potentially avoidable events. Studies focused on pathologies or specific procedures provide information of special interest to sub-specialists. The specialist in Ophthalmology, like any other doctor, is subject to the current legal provisions and appropriate mandatory training in the medical-legal aspects of health care is essential. Conclusions Professionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical–legal aspects in the routine clinical practice can help to pave the way toward a satisfactory and safe professional career, and help in increasing patient safety. The aim of this review is to contribute to this training, for the benefit of professionals and patients.

Seguridad clínica y reclamaciones por responsabilidad profesional en Oftalmología

IntroductionPatient safety is an international public health priority. Ophthalmology scientific societies and organisations have intensified their efforts in this field. As a tool to learn from errors, these efforts have been linked to the management of medical professional liability insurance through the analysis of claims. Material and methodsA review is performed on the improvements in patient safety, as well as professional liability issues in Ophthalmology. ResultsThere is a high frequency of claims and risk of economic reparation of damage in the event of a claim in Ophthalmology. Special complaints, such as wrong surgery or lack of information, have a high risk of financial compensation and need strong efforts to prevent these potentially avoidable events. Studies focused on pathologies or specific procedures provide information of special interest to sub-specialists. The specialist in Ophthalmology, like any other doctor, is subject to the current legal provisions and appropriate mandatory training in the medical-legal aspects of health care is essential. ConclusionsProfessionals must be aware of the fundamental aspects of medical professional liability, as well as specific aspects, such as defensive medicine and clinical safety. The understanding of these medical-legal aspects in the routine clinical practice can help to pave the way towards a satisfactory and safe professional career, and help in increasing patient safety. The aim of this review is to contribute to this training, for the benefit of professionals and patients.

Insurance of Medical Personnel Professional Responsibility as a Form of Legal and Social Responsibility

Medical professionals are not protected from patients` action in the case of medical negligence or mistake. Anytime patient can file a medical malpractice claim against medical professional. Nowadays medical negligence claims and mistakes are increasing. The progress of medical law shows, that patients more often use the rights and legal options to protect their interests and fundamental rights. The scope of the freedom of medical professionals is limited. They have to act in accordance with certain standards or an artificially created frame and in the best interests of their patients and protect constitutional rights of each patient. In case when medical professionals make mistakes and the patients are harmed due to that claims can be brought. Medical professionals must have insurance or indemnity to protect themselves, but patients also need it. Patients' rights and possibility to compensate damage depends on how good and qualitative the medical professional liability insurance or indemnity is. Furthermore, medical professional's mistake is his or her own ethical, prestige and social responsibility in front of the patients' issue. In order to protect medical professionals and patients the medical professional insurance system has to cover healthcare practice and provide professional protection against the financial consequences of legal liability, as well as possible moral compensation. The objective of the paper is to present a summary of medical professional insurance system in Latvia. The article will provide information about what legal mechanisms shall be improved in order to optimize medical professionals` insurance system and patients' rights to receive compensation. DOI: 10.5901/ajis.2016.v5n3s1p320

La gestión de la responsabilidad profesional médica desde el colectivo de la profesión médica y enfocada a la seguridad clínica

The medical professional liability insurance system must cover optimally and effectively potential defects of medical praxis, promote improvements in clinical safety and help preventing the situation of «malpractice crisis» reported in abroad.We review the medical professional liability system and propose a direct management model, according to the principles and values of the medical community. It has advantages such as data analysis to identify risk areas and guide clinical safety actions (clinical-practice-guidelines, quality-programs…).Faced with traditional models, the model implemented in Catalonia, applicable in other settings, brings undeniable improvements achieved by focusing on good medical practice, which is the main objective of physicians colleges. This ensures an appropriate response to society in case of errors, based on experience, excellence and professionalism in handling and defense, caring for the involved physician, comprehensively covering assistance and learning from errors.

The Impact of Defense Expenses in Medical Malpractice Claims

The objective of this study was to take a closer look at defense-related expenses for medical malpractice cases over time. We conducted a retrospective review of medical malpractice claims reported to the Physician Insurers Association of America's Data Sharing Project with a closing date between January 1, 1985 and December 31, 2008. On average a medical malpractice claim costs more than $27,000 to defend. Claims that go to trial are much more costly to defend than are those that are dropped, withdrawn, or dismissed. However, since the overwhelming majority of claims are dropped, withdrawn, or dismissed, the total amount spent to defend them surpasses that spent on claims that go to trial. Defense attorney expenses account for the majority of defense-related expenses (74%), while expert witness expenses and other expenses split the remaining 26%. A strong association was also found between the average indemnity payment and the amount it costs to defend individual claims by specialty. Our study found that defense-related expenses for medical malpractice claims are not an insignificant cost. As state and federal governments debate how to repair the malpractice system, addressing the high cost of defending claims should not be ignored.

The Impact of Malpractice Liability Claims on Obstetrical Practice Patterns

This paper examines whether malpractice claims have any impact on obstetrical practice patterns (C-section rates) and physician delivery volume. Secondary data from the 1992-2000 Florida Hospital Inpatient Discharge File, the Florida Medical Professional Liability Insurance Claims File, and the American Medical Association's Master File on physician characteristics. The effects of malpractice claims on C-section rates and physician delivery volume were estimated using panel data and a fixed-effects multivariate model. Variables were constructed from each data source and merged into a single panel dataset using consistent physician identifiers. Principal Findings. I did not find evidence that physicians changed their practice patterns by increasing C-section rates in response to malpractice claims. However, physicians performed six fewer inpatient deliveries 3 years after the closing of a malpractice claim, after controlling for individual- and market-level characteristics. Physicians with high malpractice awards of U.S.$250,000 or more performed 14 fewer deliveries on average. Malpractice claims led to a small reduction in physician delivery volume, but they did not have a significant impact on C-section rates.

Medicare Part B: Physician Participation Options

Orthopaedic surgeons in the United States have recently been facing the challenge of caring for their patients in the face of rising costs and declining reimbursements. While medical practice expenses and professional liability insurance rates have been increasing, the average Medicare reimbursement rates for the twenty-five most frequently performed orthopaedic surgical procedures (Table I) have declined 28% since 1992, after adjustment for inflation with use of the Consumer Price Index1,2. For the last several years, physicians have been subject to what has become a familiar scenario: projected Medicare physician reimbursement decreases are met by last-minute congressional action that either temporarily freezes or marginally increases reimbursement without keeping pace with the inflation rate. None of these congressional stopgap measures revise the formula (the sustained growth rate formula, or SGR) that has mandated, and will continue to mandate, annual decreases in physician reimbursement. Furthermore, since these congressional reimbursement measures escalate Medicare spending beyond the budget mandated by the sustained growth rate formula, the formula will automatically call for even deeper future Medicare budget targets to offset this increased spending. View this table: TABLE I The Twenty-five Most Commonly Performed Inpatient Orthopaedic Surgical Procedures According to the 2005 National Hospital Discharge Survey For the orthopaedic surgeon, Medicare Part B plays an important role as it covers inpatient and outpatient physician services, for example, reimbursement for operations, clinic visits, and consultations. There are three options for physicians under Medicare Part B: participating, nonparticipating, and private contracting (i.e., opting out). These three scenarios are described in this article. We integrate and organize a variety of primary documents and organizational updates that address this topic to present a comprehensive review of the physician participation options3-7. Prior to 1920, the practice of medicine in the United States was quite rudimentary, and therefore the chief …

Multicenter Medical Malpractice Risk Reduction Study for Medical Students, Trainees & Practicing Physicians Using Short Burst [Ssb] E-Mailed Seminars

Purpose: The purpose of this multicenter study was to evaluate the use of medical malpractice risk reduction seminars in the form of short bursts of e-mailed seminars [SBS]. Methods: SBS to teach medical malpractice reduction strategies [1] were designed for hospital trainees and practicing physicians at several institutions and private practices centers in the Northeast, Southeast & West coasts of the U.S. SBS was e-mailed to coordinators in gastroenterology, internal medicine, psychiatry & other specialties who targeted their audience of students, trainees and practicing physicians. The target audience, performed the sequence of pre test, seminar, post test, and returned the testing on an anonymous basis to the coordinators. One answer on the post-test required a short written response to a medical malpractice case study. Pre and post-tests were graded by the change of post-test answer scores compared to pre test total scores. Results: Post-test scores showed significant improvements & documented the benefits of an e-mailed medical malpractice/risk reduction seminar. SBS was well accepted by medical students, gastrointestinal trainees and practicing physicians. Residents [2] and department chiefs learned how to teach medical malpractice reduction techniques which provides a potential pool of new teachers. Actual medical malpractice cases were useful as documented by responses given to a case study. Conclusion: SBS: 1. Offers more convenience, reduces time away from patient care, schedules learning around busy schedules, and can be an ongoing resource to refresh seminar knowledge retention when filed in each participant's e-mail folder. 2. Can be provided in a consistent fashion and specifically tailored to certain levels of training for each specialty. 3. May be delivered in each specialty either as online CME or in a classroom setting by medical schools, teaching hospitals, & medical professional liability insurance companies. 4. Teaches how to teach medical malpractice/risk reduction. 5. More easily connects physicians with risk management specialists with short turn around time to customize contemporaneously in changing risk areas of hospitals and/or different clinical specialties. 6. A medical malpractice case history increases seminar lesson retention. [1] Hookman P. “Medical Malpractice Expert Witnessing: Introductory Guide for Physicians and Medical Professionals” (Hardcover) 592 pages Publisher: CRC; Boca Raton, Fl. ISBN-10: 1420058959; Price $239.95 [2] Aiyer M. et al. “Change in Residents Perceptions of Teaching: Following a One Day Residents as Teachers” [RasT] Workshop, Southern Medical Journal 2008 101[5]:485

Association Between Rising Professional Liability Insurance Premiums and Primary Cesarean Delivery Rates

To estimate the association between changes in Illinois professional liability premiums for obstetrician-gynecologists and singleton primary cesarean delivery rates. Data from the National Center for Health Statistics were used to identify all singleton births between 37 weeks and 44 weeks of gestation occurring in Illinois from 1998 through 2003. Primary cesarean delivery rates for women delivered between 37 weeks and 44 weeks of gestation per 1,000 gravid women eligible to have a primary cesarean delivery were calculated for each Illinois county. The annual medical professional liability premium for each county in Illinois was represented by the reported professional liability insurance rate charges (adjusted to 2004 dollars) from the ISMIE Mutual Insurance Company. Separate analyses were conducted for nulliparous and multiparous women. The independent association between county-level primary cesarean delivery rates and the previous year's insurance premiums was evaluated using linear regression models. During the study period, 817,521 women were eligible for inclusion in the analysis. The county-level mean primary cesarean delivery rate increased from 126 to 163 per 1,000 (P<.001) eligible women, whereas the mean annual medical professional liability insurance premiums also rose significantly (from $60,766 in 1997 to $83,167 in 2002, P<.001). Multivariable analyses demonstrated that for each annual $10,000 insurance premium increase, the primary cesarean delivery rate increased by 15.7 per 1,000 for nulliparous women. This association also was evident for multiparous women, who had an increase in cesarean deliveries of 4.7 per 1,000 for every $10,000 increase. Higher rates of primary cesarean delivery are associated with increased medical professional liability premiums for obstetrician-gynecologists in Illinois. II.

Medical Professional Liability Insurance and its Relation to Medical Error and Healthcare Risk Management for the Practicing Physician

Medical Professional Liability Insurance and its Relation to Medical Error and Healthcare Risk Management for the Practicing Physician

Medical Professional Liability Insurance and its Relation to Medical Error and Healthcare Risk Management for the Practicing Physician

To review the history and current issues surrounding medical professional liability insurance and its relationship to medical error and healthcare risk management. Focused literature review and authors' experience. Medical professional liability insurance issues are reviewed in association with the occurrence of medical error and the role of healthcare risk management. The rising frequency and severity of claims and lawsuits incurred by physicians, as well as escalating defense costs, have dramatically increased over the past several years and have resulted in accelerated efforts to reduce medical errors and control practice risk for physicians. Medical error reduction and improved patient outcomes are closely linked to the goals of the medical risk manager by reducing exposure to adverse medical events. Management of professional liability risk by the physician-led malpractice insurance company not only protects the economic viability of physicians, but also addresses patient safety concerns. Physician-owned malpractice liability insurance companies will continue to be the dominant providers of insurance for practicing physicians and will serve as the primary source for loss prevention and risk management services. To succeed in the marketplace, the emergence and importance of the risk manager and incorporation of risk management principles throughout the professional liability company has become crucial to the financial stability and success of the insurance company. The risk manager provides the necessary advice and support requested by physicians to minimize medical liability risk in their daily practice.

Impact of the Medical Professional Liability Insurance Crisis on Access to Care in Florida

Almost half of the US states face serious problems with professional liability insurance (PLI). Despite this, little is known about how this crisis is affecting access to care, particularly in rural areas. We surveyed physicians practicing in rural Florida in 2003. The primary assessment was on changes in health care delivery by service type and specialty. Secondary outcomes included changes in PLI premiums and the effect of changes in premiums on service delivery and practice satisfaction. Four hundred eleven (52.6%) of 781 physicians decreased or eliminated health care services during the past year. Overall, 73 (61.3%) of 119 decreased or eliminated vaginal deliveries; 60 (52.6%) of 114, cesarean sections; 186 (51.7%) of 360, hospital-based surgical procedures; 209 (46.4%) of 450, emergency department coverage; 103 (41.7%) of 247, endoscopic procedures; 187 (40.9%) of 457, office-based surgical procedures; and 105 (34.5%) of 304, mental health services. Elimination of services was highest for general surgeons (78.4%), surgical specialists (73.6%), and obstetricians/gynecologists (70.2%). Premiums for PLI rose a mean of 93.5%. Difficulty finding or paying for PLI was listed as an important factor by those reducing or eliminating services and by those planning to leave the community within the next 2 years. The current crisis in medical PLI in Florida has a major impact on the availability and delivery of health care services to rural areas. Given the number of states that are experiencing similar insurance market upheavals, adverse effects on access to care are likely occurring nationwide.