Impoverished women in Maryland's rural Montgomery County found it increasingly difficult to obtain adequate obstetrical care. The growing threat of malpractice lawsuits had forced many obstetricians to cease providing service to low-income women because of a common misconception that these women were more likely to file suits. Physicians could not afford premiums for malpractice insurance while continuing to treat low-income women. By 1987, only one of four Montgomery County hospitals was willing to provide obstetrical care for Montgomery County Health Department patients, but even this hospital was threatening to cut off service entirely. The situation in Montgomery County was compounded by the fact that the area did not have either a public or a university-based teaching hospital to refer low-income patients; meanwhile the State of Maryland refused to accept responsibility for the crisis.
In 1988, the Montgomery County Health Department, the local medical society, and four private community hospitals created Project Deliver, an innovative public-private medical partnership so that all pregnant women would be able to receive proper care. To encourage obstetricians to return to treating low-income women, the County created a special obstetrician job class, permitting these physicians to be paid as employees of the County and therefore be eligible to receive malpractice insurance coverage through the government. In collaboration, the Medical Mutual Liability Insurance Company agreed to modify its policy for premium determination and allowed Montgomery County deliveries to exceed the number of deliveries allotted for a certain premium. By ensuring that physicians were no longer fearful of being subject to frivolous malpractice suits, the County dramatically improved the health care system for impoverished women.
Low-income women are eligible to receive prenatal care at five community health care clinics scattered throughout Montgomery County, which are staffed by full-time County physicians and nurse practitioners. The clinics also provide a wide array of community health programs including WIC, home visitations, dental care, health education, and social services since many of these women are coping with a larger set of problems, including substance abuse issues. For child labor and delivery, Health Department clinic patients are assigned to one of four community hospitals in the County. The hospital administrators created an equitable patient distribution plan based upon percentages of total deliveries performed so that the costs were evenly dispersed among the four centers. The private obstetricians serve as part-time Health Department employees during the period of labor and delivery and are paid directly for their services. The County's self-insurance program protects the physicians from personal liability.
The effect of the program is evident in the number of treated women who might not otherwise receive care. As of December 1989, the program served 1,313 women and more than 1,270 babies had been delivered. Two-thirds of the County's private obstetricians, approximately 80 physicians, had become part-time County employees. Most importantly, as of 1990, not a single malpractice lawsuit had been filed against participating obstetricians. Due to the program's success, County officials have attempted to extend the partnership to other areas of concern, including breast cancer screening, adolescent health problems, Hepatitis B vaccine, and AIDS treatment.