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Juan M. Bertran, MD, SPOT president, meets with Sen. Jorge De Castro-Font, a high-ranking member of the Puerto Rico legislature, to discuss the proposed tort reform legislation.
Courtesy of Charlene MacDonald

AAOS Now

Published 8/1/2008
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Charlene MacDonald

Puerto Rico surgeons tackle liability reform

Comprehensive campaign makes significant progress

In response to a growing crisis created by Puerto Rico’s flawed medical liability system, the Puerto Rico Orthopaedic Society (Sociedad Puertorriqueña de Ortopedia y Traumatología or SPOT) has conducted an aggressive advocacy campaign for comprehensive policy reforms. With an active membership and support from the American Association of Orthopaedic Surgeons (AAOS), SPOT advanced liability reform legislation in 2008 farther than ever before. The legislation passed in the Assembly and was narrowly defeated in the Senate. SPOT and AAOS view this as an important, incremental victory and a solid building block toward success in the next legislative session.

“Considering that this type of legislative effort is usually a multiyear initiative, we are content that a major objective was achieved with the approval of legislation in the House of Representatives and the setting of a basis for comprehensive health reform,” said Juan M. Bertran, MD, president of SPOT. “We are encouraged and confident that eventually we will succeed.”

Medicine in crisis
Several factors helped to trigger a medical liability crisis in Puerto Rico. The number of medical liability suits against healthcare providers has increased by 50 per­cent, prompting scores of physicians to relocate outside the island, retire early, or refuse to accept high-risk patients. Because most general hospitals in Puerto Rico do not have an orthopaedic surgeon on-call or willing to treat emergency department patients, patient access to specialty care is increasingly threatened.

In addition, the only provider of medical liability insurance on the island, Simid Health Care Group, offers maximum coverage of only $100,000 per incident or $300,000 over the life of the policy. As jury awards increased into millions of dollars, physicians found the risk factor too high to justify continuing to practice medicine. With just one orthopaedic surgeon for every 42,000 inhabitants, access to care is limited.

Launching a campaign
The campaign to enact liability reform by capping noneconomic damage awards began in 2004. Orthopaedic surgeons across the island staged a brief, but high-profile, walk out, demanding reforms from lawmakers and raising awareness of the crisis among patients. Unfortunately, the strategy backfired as the opposition accused physicians of stranding patients in the name of financial self-interest.

As a result of this experience, SPOT reconsidered its strategy in 2007 and launched a more nuanced, multipronged campaign developed in conjunction with the prominent government relations firm, SDA Global, which has offices in Washington, D.C., and San Juan, the capital of Puerto Rico. Success­ful fundraising among members and a Health Policy Action Fund Grant from the AAOS enabled SPOT to fund a comprehensive campaign, including public affairs, direct lobbying, grassroots and grasstops efforts, and coalition building.

The society launched a massive media campaign through radio, television, and newspapers. Puerto Rican orthopaedic leaders focused on the connection between medical liability policies and patient access to care. The consistent, compelling message reached patients and policy makers alike, raised awareness, and created a political environment conducive to reform. Orthopaedic surgeons made appearances at shopping centers and other high traffic locations to obtain signatures supporting a petition for reform.

Going “Grasstops”
An increasing trend in issue advocacy is the development of “grasstops” efforts, a strategy characterized by attempts to reach key political, business, and community leaders who have influence at various levels of government. SPOT’s campaign approached this in two ways: by holding public meetings on liability reform throughout the island and by targeting party officials from Puerto Rico’s three major political parties to incorporate reforms into their party platforms. The public meetings involved patients as well as prominent city leaders who could deliver the message to their contacts in the legislature.

Although orthopaedic surgeons took the lead on the liability campaign, they also recognized the need to present a united front and involve the larger physician community, representing a broad spectrum of specialties. The coalition that SPOT developed, known as “Pacientes Van Primero” (“Patients First”), lent credibility to the message, attracted additional attention from the media, and increased pressure on elected officials.

Liability reform in the legislature
Traditional lobbying served as the final and most direct link to the legislature during the 2008 session. SDA Global facilitated meetings with key legislators, and orthopaedic leaders emphasized the connection between the current healthcare crisis in Puerto Rico and the pressing need for liability reform.

Although many SPOT members had not been involved in previous reform efforts, solid arguments and persistence of those involved convinced four prominent legislators to introduce a bill that would cap noneconomic damages at $250,000 and that included other provisions to protect physicians from excessive malpractice claims. For the first time, SPOT had a comprehensive, bipartisan bill with solid prospects for passage.

SPOT continued to apply pressure throughout the session, meeting with key committee members and testifying at public hearings. Passage in the Puerto Rico Assembly marked a significant victory, demonstrating the bill’s viability and pressing the Senate to take further action. The bill finally reached the floor for a vote on June 25, 2008. Its defeat was a blow to the physician community, which had demonstrated remarkable stamina and an unprecedented commitment to advocacy.

“We have already started our 2009 lobbying efforts on several fronts, including meetings with representatives from all political parties, the hospital association, the American Medical Association, and others. Our internal communications with our colleagues and published detailed accounts of our experience are drawing attention from the usually silent majority,” said Dr. Bertran.

As the fight for liability reform continues at the state level, the AAOS will continue to support the ongoing advocacy efforts of its members in Puerto Rico and across the country.

Charlene MacDonald is manager, state legislative affairs, in the AAOS office of government relations. She can be reached at macdonald@aaos.org