For a little more than a year, Mark Macumher, M.D., has been conducting a health policy experiment--operating his medical practice without liability insurance.

"The most surprising and rewarding thing is the response I get from the patients," said Dr. Macumber, a family physician practicing

It's been a year full of surprises for Dr. Macumber since he opened his family medicine practice in September 2003 in Berwyn with no medical liability coverage (FAMILY PRACTICE NEWS, Nov 1, 2003, p. 1). Today, he is breaking even and has opened a second location in Chicago.

When he started, he knew he couldn't afford the $40,000 liability premium he would have to pay; he also wanted to draw attention to the skyrocketing malpractice rates many physicians must pay. That's still the case, he said, but his experience has also driven the issue of access to health care to the top of his priority list, he said.

"It started out about medical malpractice, but it's really about access," he said.

Since most patients' insurance companies require physicians to carry liability insurance, he doesn't bill insurance companies and, instead, offers his services for a reduced fee--$40 for an average office visit. Patients who have insurance can still submit claims to be reimbursed by their insurance company.

About 25%-33% of his patients have health insurance, but most are uninsured. Some patients come to see him because they support what he's doing; others have said they want continuity and are sick of changing doctors every year. For still others, it's cheaper to see him at $40 a visit than it is to pay the copayments or coinsurance associated with their health plans.

Some patients come to him because they want the confidentiality he provides by not filing information with insurance companies.

And for Dr. Macumber, cutting out insurance companies means more time, more money, and less aggravation. "I'm so relieved I don't have to deal with that at all," he said.

Not accepting insurance also means that he can charge whatever he wants, including giving someone a break on a bill, or even bartering for care. He can also choose to charge for telephone calls, though he hasn't done that yet. He already charges patients about $10 to flu out paperwork.

Dr. Macumber's practice has been a safety net for those patients who don't qualify for Medicaid and don't have insurance, said Ellen Brull, M.D., president of the Illinois Family Physicians Association.

Although Dr. Macumber initially received a lot of publicity for practicing without insurance, the other aspect of his practice is that he is providing a medical home for the uninsured, she remarked.

But Dr. Brull said she would still rather work to fix the system than see more physicians follow Dr. Macumber's experiment. "The whole system is so flawed, it needs to be revamped," she said.

Although Dr. Macumber's practice is rapidly growing and becoming financially viable, he still doesn't recommend that other physicians follow in his footsteps.

"I'm not going without malpractice insurance because I want to go without malpractice insurance," he said. Once liability insurance is affordable, he plans to get it.

Dr. Macumber said he got to really see how destructive the medical liability compensation system had gotten when he decided to practice without it. But he sees traditional tort reform strategies, such as damage caps, as a gut response from physicians who feel angry and cornered.

"Tort reform is nice, but the system itself is flawed on so many levels," he said.

The medical liability system is a barrier to improving quality and a barrier to reporting and learning from our mistakes, he said. Dr. Macumber said that he believes that the answer is a set of comprehensive reforms that address the current system's economic, practice, and ethical problems.

"What he's doing is very interesting and it's obviously risky, but it is something that challenges the status quo," said Patrick Tranmer, M.D., professor of clinical family medicine at the University of Illinois at Chicago (UIC), who works with Dr. Macumber at the university.

Dr. Macumber, who holds a clinical faculty appointment in the family medicine department at UIC, has spoken to students and residents about his practice setup--though he is careful not to recommend it.

So far none of the residents has expressed an interest in practicing without insurance, Dr. Tranmer said, but it's good for them to hear about a practice that is doing things differently, including how Dr. Macumber runs his office with fewer employees and charges lower rates.