MILTON 1. ROEMER* and JEROMEL. SCHWARTZ? *University of California, Los Angeles. School of Public Health and tcalifornia

State Department

of Health.

Office of Planning

and Program




the first 35 days of 1976. doctors in Los Angeles County withheld their services, principally for non-emergency surgery. in reaction to escalating premiums for malpractice insurance. To assess the impacts of this action. studies were made along 3 lines (I) a survey of 1000 households lo determine the effects on access of people to medical care. (2) collection of data on utilization and finances of a sample of 17 general hospitals, and (3) determination of the county total death rates during and after the slowdown compared with equivalent weeks in the previous 5 years. It was found that only a small percentage of people were inconvenienced by the withdrawal of elective surgical services (since other types of care were evidently continued). In the hospitals. there was a decline in occupancy. loss of revenue, and many workers laid OK County mortality rates declined steadily during the slowdown, rising abruptly to a peak in the first week that elective surgery was resumed, and then levelling off to usual rates

For the first 35 days of 1976, from I January to 4 February, a substantial proportion, mounting gradually to about three-quarters, of the physicians in Los Angeles County, California withheld their services from all but emergency cases [ 11. The partial strike or “slowdown” was intended to put pressure on the State Legislature to take action which would halt or control the spiralling increase in malpractice insurance premiums being charged to doctors, mainly in the surgical specialties [2]. THE DOCTOR PROTEST The many causes for this “malpractice insurance crisis” in California-though occurring .in some degree throughout the United States-have been explored elsewhere [3]. Our objective in this report is to examine the effects of this “natural experiment”, in which thousands of doctors and millions of persons participated. Since the escalation of insurance rates hit the surgical specialists (including anaesthesiologists) hardest. and since service continued to be provided for life-threatening emergency cases. the slowdown resulted mainly in non-performance of elective surgery. (A telephone service was initiated to refer emergency patients to the nearest medical resource.) It was only on the 23rd day of action that primary care doctors. not customarily doing elective surgery anywa). joined in withholding their services [4]. The withdrawal of non-emergency services. as noted. did not occur all at once in all sections of this large county of over 7,OOO.OOO people. Decisions were made by doctors mainly through their medical staff organization in general hospitals. Participation in the slowdown protest was gradual. and by its end on 4 February 1976. of the 234 hospitals in the Hospital Council of Southern California (including also neighThis is an extended text of a presentation at the Annual Meeting of the American Public Health Association. Los Angeles. California. 18 October 1978. 213

boring Orange County), 115 or barely half reported feeling the effects in significant reduction of their occupancies and revenues [S]. It is reasonable to assume from the late entry of primary care doctors in the slowdown that the withholding of amhulatorJ> service was less than this. Staff doctors in the several large county government hospitals did not participate in the slowdown, nor did doctors in the Southern California Kaiser-Permanente Health Plan (with about 1,000,OOOmembers) or other prepaid HMOs in the county. By the end of the physician protest, some slightly ameliorative legislation was proposed in the State Legislature, but the major issues of high malpractice insurance rates remained unresolved [6]. By the end of January (the deadline after the 30-day “grace period” following expiration of insurance policies), the vast majority of doctors had renewed their malpractice coverage, even at the high rates. Physicians, however. started the development of their own insurance organization, which would hopefully lead to eventual reduction of malpractice protection costs c71.

What. then, were the effects of this withdrawal of certain physician services on conditions in Los Angeles County? Here was a “natural experiment”, which might heip to answer several questions of national significance in the health care field. Having a “before-and-after” design in one county, most extraneous variables were held constant. We can offer our methodologies and findings along three dimensions: (a) effects on the medical care of the population. (b) effects on the functioning of hospitals, and (c) effects on the health status of the people. Under the circumstances (with only a very small emergency research grant from the California State Department of Health). it was not feasible to probe these three questions in depth. but only to explore the apparent consequences on which some data were readily available. With the alarming daily newspaper accounts, one might have hypothesized “harmful effects” along all three lines.







To determine the effects of the doctor slowdown on the availability of medical care to the Los Angeles County population. five questions were included on an interview survey of slightly over 1000 L.A. County households conducted in February 1976 [g]. This household survey was one of a regular series conducted by the UCLA Social Science Research Institute. and known as the “Los Angeles Metropolitan Area Survey” or LAMAS. The sampling techniques of LAMAS are based on a probability sample of area residents within Census tracts. If a household refuses to be interviewed, it is not replaced, to maintain the validity of the sample. Thus the initial sample size was 1495 households, of which 19.80,/, were nonrespondents and 10.2% were inaccessible (for some other reason). The 70% of the initial sample of households responding were asked: (1) Did you or any other household member need service from a medical doctor between 1 January and 4 February 1976? (2) If yes, how urgent (with scaled response)? (3) What did you do to obtain the service? (4) Since many doctors withheld services after January 1, was this any different from what you (or other household member) would usually have done? (5) How satisfactory (scaled response) was the service that was received? The questions solicited information on “other household members”, as well as the respondent, in order to maximize the number of health or sickness events on which the impact of the doctor slowdown could be analyzed. On this basis, 535 cases of medical need were identified in the 1039 households interviewed (52”/,)-some 70”/, of these involving the respondent and the balance involving other household members. This ratio was not surprising, since the usual respondent was the housewife, who would naturally recall her own ailments best, plus the wellknown higher rates of medical care use by adult females. Of the 535 cases of medical need reported in 1039 households, the degrees of urgency were distributed as follows: Extremely urgent Urgent Not urgent Unsure

Percent 15.5 39.9 43.9 0.8

With respect to the type of medical service obtained by the persons who perceived a health need, the answers (N = 534) were subject to varying interpretations, but the LAMAS analysts judged them to have the following distribution:

Routine visit or appointment Treatment of acute illness Emergency care (mainly trauma) Chronic disease treatment Unspecified medical visit Medication given

Percent 27.5 16.3 9.9 9.6 8.4 4.5

Maternal or child health visit Laboratory test Talk on telephone Post-operative care Surgery All other types of care Total

3.3 2. I 1.7 1.1 0.9 14.7


Regarding the outcome of the medical servtce received, the problems encountered were evidently very few. When asked if they encountered any prohlem. many of the open-ended responses were difficult for the Social Science Research Institute to interpret-suggesting by their vagueness (typically “don’t know” or “can’t say”) that the procurement of medical care was no more of a problem than it tcsutrii~ has been. (Obtaining medical care has been difhcult. in fact, in Los Angeles County for several yeurs-involving long waiting times or even denial of appointments.) Of the 126 responses that could be unequivocally interpreted. 74.6’” indicated that they encountered “no problem”. But perception of the care received as being “different from usual” was even less than one-quarter. When asked if the care received was any different than customary. in the light of the widely publicized doctor slowdown. the responses (N = 532) were: No difference Different from usual

Percent 88.3 Il.7

In their evaluation of the quality of the care received. satisfaction was high. as reflected by these (N = 525) responses: Very satisfactory Satisfactory Not satisfactory Very unsatisfactory

Percent 61.3 32.6 4.2 1.9

These rates of satisfaction were actually somewhat higher, and rates of dissatisfaction somewhat lower than responses to a somewhat comparable study in the same cbunty done about IO years before [Y]. When these responses are analyzed according to characteristics of the person. few differences are found. Probably most significant is a slight tendency for problems, associated with the doctor slowdown. to have been somewhat greater among persons of lesser education and lower income. Thus. in summary. the doctors’ withdrawal of services--consisting in large part of elective surgical procedures-appears to have caused relatively slight inconvenience to the people of Los Angeles County. EFFECTS


The doctor slowdown had more noticeable influence on the functioning of hospitals in Los Angeles County than on the general population. The slowdown affected: (a) surgical operations performed. (b) bed occupancy levels. (c) emergency department use. (d) hospital employment levels. and (e) hospital revenues. Data on these hospital effects were furnished by the Los A77yrlr.s Tin7e.s. which collected daily reports from



effects on the population

a stratified sample of I7 major hospitals (containing about one-third of the voluntary hospital beds) in five principal districts of the county* [IO]. Most dramatic was the reduction of surgical operations in the hospital sample. The newspaper survey began on the fifth day of the slowdown so that it covers 31 of the 35 days. Over this period. there were 7157 operations performed in the 17 study-hospitals, which was a reduction of 58.7”,, from the comparable 31-day period in 1975. [I I] Along with this. there were 42.951 pa&ient-days of care provided-a reduction of 25.59, from 1975. (This lesser reduction of bed occupant\ than of surgical procedures. suggests that hospitals may have responded to the reduction in surgical admissions by keeping those patients admitted for longer average stays. or perhaps by admitting more non-surgical cases to fill beds.) The use of hospital emergency departments showed remarkably little change until 24 January, toward the end of the slowdown. Before that date, Emergency Room utilization was actually slightly lower in the study hospitals than during the comparable period in 1975 (which may have been due to a higher incidence of respiratory infection or other illness in 1975). It will be recalled that only on 23 January did the primary care doctors of the county join in the slowdown. and only then did the E.R. use in major voluntary hospitals rise above that of the comparable period the year before. In the county government hospitals for the poor and the UCLA Hospital (not included in the LA. Tirws hospital sample. which was limited to voluntar) institutions) however. there was a rise reported in E.R. usef throughout the entire slowdown period. With the reduced hospital bed occupancies. hospital income declined. The I15 hospitals (which reported some impact) out of 234 in the Hospital Council of Southern California estimated that, as of 4 February. they had sustained a decline in revenue of about 625.000.000. The reduced occupancy also meant that nearly 30,000 hospital employees were laid off from work. partially or totally. suffering a loss of over $8.400.000 in wages [12]. The slowdown dramatized the dependence of hospital financial status on the admission of patients for elective surgery. EFFECT


of Los Angeles



mortality rates in the county for each week of the slowdown in 1976. and for comparable weeks in the previous 5 years. This methodology is widely used, of course, in epidemiological studies, to adjust for the random fluctflations in death rates normally occurring for short time-periods (such as one week) in any single year. This work was done partially by Dr J. James, a doctoral student at the UCLA School of Public Health [13]. Since deaths that might be due to surgery often occur 2 or 3 weeks after the operation (not to mention lags in death recording, explained below), mortality figures were obtained for the 5-week period of the slowdown as well as for the subsequent seven weeks. As a basis for comparison, mortality rates were calculated for the same 12 weeks of the year during the previous 5 years. These two sets of data, presenting the 1976 mortality rates along with the mean of the rates for 1971-75, are shown in Table I. Graphic curves showing the 12-week trends for each of the previous 5 years separately, along with the means and the 1976 mortality rates, are shown in Figure 1. Before interpreting the data in this tabte and chart. it should be explained that the Los Angeles County Health Department records weekly deaths according to the time of reporting and processing. rather than the actual date of death; hence, there is a lag of 7-14 days in these figures from the actual time at which the death occurred. The rates for each year were calculated by the Los Angeles County Department of Health on the basis of intercensal estimates of the county population as of 1 July of that year. On this basis, the mortality rates-in deaths per 100,000 population-that are presented in Table 1 are accompanied with comments on the circumstances in 1976. It may be noted from Figure 1 that there were many irregularities in the trend of weekly death rates for the 12-week period in each of the 5 years previous to 1976. None of the trend curves, however-with the partial exception of that for 1971-is parallel to that of 1976, in which, beginning from week 3 (recording deaths in the first week of the slowdown) there is a virtually steady decline to week 7 (recording deaths in the final week of the slowdown). Then in week 8. when elective surgery was resumed “as usual”, there is a leap upward of the death rate from 14 to 26 per


Table I. Weekly death rates (deaths per 100,000 populaUltimately one would like to know the effect of the doctor slowdown-essentially a sharp decline in elective surgery-on the health of the population in Los Angeles County. Direct measurements of health status changes during this period were not available, but with the collaboration of the Los Angeles County Department of Health. data could be gathered on

* Thea sample of hospital; was chosen by the professlonal research staff of the Los A~~e/es Tirnrs. after consultatIon with the Hospital Council of Southern California. HospIrals were selecred to represent those major institutlons ahlch the Council knen to be operating the largest our-patient departments: hence the hospital sample constituted onI> ?.J”,, of the iixtitutions in the area. but contalnrd about one-third of the beds. + Directors of these hospitals stated this emphatically. hut did not report rates of increase.

tion) reported during doctor slowdown (weeks I-5) and subsequent period (weeks 6-12) in 1976, and during equivalent weeks averaged over years 1971-1975, Los Angeles County, California Week --

1 2 3 4 5 6 7 8 9 10 11 12




15.2 21.8 21.4 20.6 19.2 18.4 ‘0.0 19.4 22.4 19.0 17.6 17.4

21 21 20 17 17 13 14 26 20 18 19 19

Lag in death recording Lag in death recording Onset of doctor slowdown Slowdown Slowdown Slowdown Slowdown Return to normal surgery Return to normal surger) Return to normal surgery Return to normal surgery Return lo normal surgery










Weeks af

the Fig.

I~,~ population, By contrast, for the previous 5-year average there was a decline in death rates from the seventh to the eighth week. The justification for using the average for the 5 years 1971-75, as a basis of comparison with 1976, would seem to be borne out by the effect of this averaging in tevelling out the non-consistent &iftuations of previous years. Except for week 1 (explained by special factors discussed below), the trend of the period of weeks 2-12 is relatively ““evened out”, showing a maximum range of 5 per l#O,OW, and a mean deviation of only 1.35 around an average of 19.7 deaths per lOO,OOO per week. The exceptionally Iow death rate in the average of week 1 af the previous five years (15.2 per ~~,~) can be plausibly explained by the customary reduction in hospital admissions for elective surgery over the Christmas holiday period, Indeed, the much higher death rate for the first week of 1976 is further evidence of our interpretation, insofar as in December I975--in expectation of the widely announced p’lans for a doctor slowdown on 1 January I976 (when mai-








elective surgery was performed. in spite of Christmas. Furthermore. the decline in the 1971-75 average death rates for weeks It and 12 (17.6 and 17.4 pet lOO,OOO) may well be due to seasonaf Factors-,-with the onset of Spring-such benefits being counteracted in L976 by the backlog of elective surgery still being done in those weeks foliowing the doctor slowdown. Thus. except for the first 2 weeks, which are in fact predominantly a record ofdeaths occurring before the onset of the doctor slowdown, all the death rates recorded during the stowdown--that is. considering the reporting lag. weeks 3-7-were lower than for the average of the equivalent weeks of the previous five years. Moreover. even examining each of the previous years separately (as shown in Fig. I). the 19% death rate is lower than that for all five of the years in weeks 4, 6, and 7, and for four out of five of the years in week 5. Likewise in week 8 (reporting deaths during the week that elective surgery was resumed), the lY76 death rate is not only substantially fti&r than the average. but also higher than the rates in four of the five previous years. To ruie out other possible general causes For this

practice insurance policies expired)_the customary lull did not occur, and an exc~pti~~~aliy high rate 013 sequence

OFtotal death

rates in Los Angeles County,

Doctor slowdown: effects on the population of Los Angeles County we calculated infant mortafity rates, widely accepted as a highly sensitive index of general social and epidemiofogicaf conditions influencing health. Since maternity services were continued normally during the slowdown (and elective surgery is known to be very infrequent during the first year of fife), one would not expect any significant di~erentiaf in these rates. compared with previous years. During the first seven weeks of 1976, in fact. no consistent trend was found. For three of these weeks. a higher rate of infants died in their first year of fife in 1976 than m the average for the years 1971-75. but for the other four of these weeks. the infant mortality rates in 1976 were sfightfy greater than in the previous 5 years. It would seem reasonable to infer that the withholding of elective surgery during the doctor slowdown in 1976 was associated with a significant reduction in the county’s overall mortality experience, compared with the previous 5 years. For the first week that normal surgical practice was resumed, there was a substantial jump in the mortality rate. During the subsequent four weeks. the comparisons showed no consistent trend.




From measurement of three types of possible influence of a slowdown in the services of Los Angeles County doctors-mainly a sharp reduction in the performance of elective surgery-during the first five weeks of 1976, the following conclusions appear warranted. (1) The reduction in access to medical care for the county population was refativefy small. as perceived by the families themselves, although slightly greater for families of lower socio-economic status. Only after primary care doctors joined in the slowdown (during its fourth week) was there an increase in the rate of use of voluntary hospital emergency departments.* (2) A substantial decline occurred in the rate of elective surgical operations in 115 of the county’s 234 hospitals. This led to a reduction in occupancy levels, a decline in hospital income, and economic hardships for many hospital workers who were laid off. (3) The overall mortality rates in the county declined steadily for the five weeks of the doctor sfowdown (allowing for delayed recording), compared with the mean of equivalent weeks during the previous 5 years (as well as compared with most of the equivalent weeks in each of these years separately). This decline could not readily be attributed to causes other than the withholding of elective surgery. As soon as elective surgery was resumed, the county death rate rose sharply. Infant mortality rates-a sensitive index of overall epidemiofogi~f influences-showed no significant differentials between 1976 and the previ’ous 5-year period. One can speculate. of course. on whether higher death rates may occur at a future time. due to posrporrr,?tenr of elective surgery during *It should be realized that about 1520”, of the LOS Angeles Count! population were enrolled in prepaid health plans. which did not withdraw services. Count? and Liniversit> hospital physicians also continued to provide services.


the slowdown. Whether that surgery was or will be justified or not is a separate and crucial question. As Bunker and Wennberg have stated, “The evidence is strong that some operations are performed with a frequency in excess of documentable cost-benefit usefulness”. And they ask rhetorically, “Do more total operations lead to an increase in overaff population mortality?” [ 143. The findings of this study should not be construed to lend support to the thesis of Ivan Iffich or others that medical care as a whole does more harm than good [15]. it must be realized that during most of the doctor slowdown, emergency surgical services and general primary care were provided as necessary. These findings do, however, fend support to the mounting evidence that people might benefit if less elective surgery were performed in the United States. We know that all surgical interventions carry some degree of surgical risk. That risk is obviously more acceptable if the patient faces a clear hazard from failure to perform the surgery. Moses and Mosteffer have shown, however, the large nationwide variations in that risk-reflected in post-operative death ratesthat cannot be explained by the patient’s condition, but point rather to the performance of surgeons and of hospitals [16]. Several studies suggest, moreover, that much elective surgery performed in the United States is of questionable justification [f7-19). It would appear. therefore, that greater restraint in the performance of elective surgical operations might well improve U.S. fife expectancy. Acknowledgements-For their advice on statistical aspects of this paper. we are indebted to Professor Potter Chang and Mr Steve Kuritz of the UCLA School of Public Health.


1. Kistler R. Impact of slowdown by doctors growing. L.os Angeles Times. 7 January 1976. 2. Stammer L. No solution yet on malpractice. Brown concedes. Los Angeies Times, 14 January 1976.

3. Schwartz D. H. Societal responsibility for malpractice. Hlth Society Fall, 469-488, 1976. 4. Nelson H. Number of doctors joining protest soars. Los Angeles Times, 23 January 1976. 5. Kistler R. and Nelson H. 3.5day doctor slowdown ends. Los Angeles Times, 5 February 1976. 6. Ibid. 7. Stammer L. Post raps malpractice plan backed by doctors. Los Angeles Times, 10 February 1976. 8. UCLA Social Science Research Institute. Los Angeles Metropolitan Area Survey. February 1976. 9. Roemer M. I, et al. Health Insurance Effects: Services, Expenditures. and Attitudes under Three-Types of Plan, pp. 50-58. School of Public Health, University of

Michigan, 1972.

10. 17 major hospitals of Times sample group. LOS Angeles Times. 4 February 1976. 11. Kistler R. L.A. health care system slowly getting into gear. Los Angeles Times, 6 February 1976. 12. Gamble S. W. Coping with a strike bx doctors. Hospirals 5% 62. 1976. 13. James J. The Morrality Impact qfthe Medicoi Mal~racrice Sbwdawn

in Los Angeios County: January


Unpublished doctoral dissertation. U.C.L.A. School of Public Health. June 1976.



14. Bunker J. P. and Wennberg J. E. Operation rates. mortality statistics and the quality of life. ‘V. Engi. J. .Mrd. 289. 1249. 1973. 15. Illich I. .Medical Vernesix Pantheon Press. New York. 1976. 16. Moses L. E. and Mosteller F. Institutional differences in postoperative death rates. J. hr. Med. .-b-s. 203. 492. 1968.

17. Unneeded surgeries put at 2 million a year. M’c~s/~in~~rori Post. 18 July 1972. 18. Bunker J. P. Surgical manpower: comparisons of operations and surgeons in the United States and England. .V. E,iyl. J. .Urd. 282. I?!. 1970. 19. U.S. House of Representatives. Subcommittee on Oversight and Investigations. Cosr md Qutr/ir~- o/ Hraltli Crrrr. Cnnrcrs.sczr~ Strrqeri,. Government Printing Office. Washington. 1976

Doctor slowdown: effects on the population of Los Angeles County.

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