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ORIGINAL RESEARCH |
From the 1Department of Obstetrics and Gynecology, University of Washington; 2Center for Health Workforce Studies, Department of Family Medicine, University of Washington; 3College of Nursing, Seattle University; and4 Seattle Midwifery School, Seattle, Washington.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: All obstetrician–gynecologists, rural family physicians, certified nurse midwives, licensed midwives, and a simple random sample of urban family physicians were surveyed about demographic and practice characteristics, liability insurance characteristics, practice changes and limitations due to liability insurance issues, obstetric practices, and obstetric practice environment changes.
RESULTS: Fewer family physicians provide obstetric services than obstetrician–gynecologists, certified nurse midwives, and licensed midwives. Mean liability insurance premiums for obstetric providers increased by 61% for obstetrician–gynecologists, 75% for family physicians, 84% for certified nurse midwives, and 34% for licensed midwives from 2002 to 2004. Providers’ most common monetary responses to liability insurance issues were to reduce compensation and to raise cash through loans and liquidating assets. In the 2 years of markedly increased premiums, obstetrician–gynecologists reported increasing their cesarean rates, their obstetric consultation rates, and the number of deliveries. They reported decreasing high-risk obstetric procedures during that same period.
CONCLUSION: Liability insurance premiums rose dramatically from 2002 to 2004 for Washington’s obstetric providers, leading many to make difficult financial decisions. Many obstetric providers reported a variety of practice changes during that interval. Although this study’s results do not document an impending exodus of providers from obstetric practice, rural areas are most vulnerable because family physicians provide the majority of rural obstetric care and are less likely to practice obstetrics.
LEVEL OF EVIDENCE: III
There have been a few small surveys of selected groups of Washington’s obstetric providers to identify the consequences of the recent liability premium increases on provider practice patterns (personal communication, Jean Marshall, past president of the Washington Academy of Family Physicians, November 2, 2004). The American College of Obstetrics and Gynecology (ACOG) conducted a national survey of a sample of its members,2 including obstetrician–gynecologists practicing in Washington State, and reported results by ACOG-defined districts. In District 8, which includes Washington State, obstetrician–gynecologists were less likely than the national average to stop practicing obstetrics or to have decreased gynecologic surgical procedures. The Washington Academy of Family Medicine conducted brief surveys of their rural members in 2003 and 2004, and found that the proportion of family physicians practicing obstetrics decreased from 52% to 44% in an 18-month period (personal communication, Jean Marshall, past president of the Washington Academy of Family Physicians, November 2, 2004).
Washington State has 4 types of obstetric providers: obstetrician–gynecologists, family physicians, certified nurse midwives, and licensed midwives. Obstetrician–gynecologists are the majority maternity care providers in the state. Family physicians, while attending fewer births than obstetrician–gynecologists, are often the only obstetric providers in small rural areas. Certified nurse midwives, who are registered nurses with advanced training in midwifery, practice primarily in urban hospitals. Licensed midwives, who complete a three-year academic program in midwifery and pass a state licensing examination, primarily attend births outside the hospital setting. The purpose of this study was to provide a comprehensive view of the influence of the current liability environment on the practices of all obstetric provider groups.
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MATERIALS AND METHODS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The full questionnaire was mailed to nonresponders 2 additional times after the initial mailing. An abbreviated, 10-item questionnaire was mailed to nonrespondent obstetrician–gynecologists and rural family physicians after the first 3 mailings. The final response rates were 55.0% (obstetrician–gynecologists), 41.5% (urban family physicians), 54.7% (rural family physicians), 68.2% (certified nurse midwives), and 71.7% (licensed midwives). Because urban family physicians were sampled and all rural family physicians were included, we constructed weights for family physicians so that estimates accurately reflected the total population of Washington’s family physicians when rural and urban family physician responses were combined. Because additional responses were received for a limited number of items included on the abbreviated questionnaire, a second set of weights was necessary.
After excluding individuals who were not currently practicing, out of state, or in training programs, the data set included 1,182 practitioners: 337 obstetrician–gynecologists, 655 family physicians, 138 certified nurse midwives, and 52 licensed midwives. Because of the study’s interest in the practice patterns of providers who were actively delivering obstetric services, this article reports results only for obstetric providers unless otherwise indicated. Statistical significance was tested using 
2 tests and paired t tests as appropriate using SUDAAN 9.0.1 software (Research Triangle Institute, Research Triangle Park, NC).
Obstetric providers were asked to estimate the number of births they attended in 2003, and more than 90% responded to this question. Weighting these responses to the total obstetric provider population resulted in a statewide estimate of 85,884 births in 2003. The actual number of live births in Washington in 2003 was 80,474,5 suggesting that our respondents were quite representative of the state’s obstetric providers.
For each obstetrician–gynecologist and family physician respondent who listed the number of births attended and his or her liability premium for 2003, we calculated an estimated cost of liability insurance per delivery. To do so, we first subtracted the median insurance premium of all nonobstetric providers from each obstetric provider’s total reported insurance premium, then divided the difference by the number of attended births reported by that provider. To estimate liability insurance costs per delivery for certified nurse midwives and licensed midwives, who almost uniformly practice obstetrics, the reported 2003 insurance premium of each provider was divided by his or her attended births. The 3 individual questionnaires are available online (www.greenjournal.org/cgi/content/full/107/6/1238/DC1, www.greenjournal.org/cgi/content/full/107/6/1238/DC2, www.greenjournal.org/cgi/content/full/107/6/1238/DC3).
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RESULTS |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Among those providing obstetric services, family physicians and licensed midwives were the youngest (median age 43 years); obstetrician–gynecologists and certified nurse midwives were much older: 47 and 50 years, respectively (Table 1). Certified nurse midwives and licensed midwives were almost entirely female, whereas closer to one half of the obstetrician–gynecologists and family physicians were female. Obstetrician–gynecologists commonly practiced in all 3 practice types: as solo practitioners, in single-specialty groups, and in multispecialty groups. Family physicians tended to practice in single-specialty and multispecialty groups, as did certified nurse midwives. Licensed midwives were most often in solo practice and single-specialty groups.
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A major focus of the survey was to examine Washington State’s liability insurance environment for obstetric providers and the changes in premiums between 2002 and 2004. The substantial proportion of obstetric providers who were unaware of their liability premium types and rates was surprising. Among certified nurse midwives, 42.9% did not know their type of liability coverage, followed by family physicians (24.1%), licensed midwives (18.6%), and obstetrician–gynecologists (13.2%). A few providers reported no liability insurance: 9.3% of licensed midwives, 2.7% of certified nurse midwives, and 1.0% of family physicians. No obstetrician–gynecologists reported going without liability insurance. Of the providers who knew their insurance type, most purchased claims-made insurance (Table 2). The majority of all 4 provider groups indicated that either they personally paid their liability insurance premiums or their practice group paid. Certified nurse midwives and family physicians reported the highest rates of hospital coverage of their liability premiums.
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More than one half of family physicians, certified nurse midwives, and licensed midwives (Table 2) indicated that they had some kind of practice restriction imposed by their liability insurer. The most frequent restrictions related to vaginal births after cesarean deliveries. For all but obstetrician–gynecologists, providing care to high-risk obstetric patients also was cited frequently as a restriction. Fewer than 20% of the physicians who said they had insurance-imposed limits said they were restricted from accepting midwifery referral or consults.
The obstetric providers’ mean liability insurance premiums increased for each provider group during the 2002–2004 interval (Fig. 1). The rate of increase was greatest for certified nurse midwives (84%), followed by family physicians (75%), obstetrician–gynecologists (61%), and licensed midwives (34%). There were smaller increases in liability insurance premiums for those not offering obstetric services (not shown). From 2002 to 2004, the mean liability insurance cost reported by obstetrician–gynecologists who did not provide obstetric care increased by 5%, and for family physicians not providing obstetric care, premiums increased by 66%.
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The estimates of liability insurance cost per delivery were limited to those obstetric providers who reported both number of deliveries and liability insurance premium cost in 2003. Because that proportion was relatively low (57.4% of obstetrician–gynecologists, 27.4% of family physicians, 23.9% of certified nurse midwives, and 62.7% of licensed midwives), these results should be interpreted with some caution. The estimated liability insurance cost per delivery was highest for the 2 provider groups who delivered the fewest neonates each year; $326 for family physicians and $272 for licensed midwives. The estimated cost of insurance for obstetrician–gynecologists was $199 per delivery and $98 for certified nurse midwives.
Obstetrician–gynecologists were the only obstetric providers who reported a change in liability insurance limits for both single claims and all claims between 2002 and 2004. The proportion of obstetrician–gynecologists purchasing more than $1 million single claim limit declined from 49.7% in 2002 to 26.0% in 2004. During the same time period, family physicians purchasing more than $1 million single claim coverage changed from 36.4% to 35.1%, certified nurse midwives from 13.2% to 15.0%. No licensed midwives purchased more than $1 million single claim coverage. Similarly, the percentage of obstetrician–gynecologists purchasing more than $5 million aggregate insurance coverage declined from 28.3% in 2002 to 15.9% in 2004, the only group with major change. The proportion of family physicians purchasing more than $5 million aggregate insurance coverage was 20.3% in 2002 and 20.2% in 2004; certified nurse midwives changed from 9.6% to 13.8%. Again, no licensed midwives had aggregate coverage greater than $5 million in any years.
An unexpected finding was the influence of tail coverage for claims-made insurance on practice patterns. Claims-made insurance covers claims made during years of purchased coverage only. Tail coverage extends liability insurance to incidents that occurred during the time of coverage but were filed after the policy had terminated. Most providers view tail coverage as a necessary protection of personal assets. Almost half of obstetrician–gynecologists said tail coverage affected practice behavior (Table 2). Most respondents explained how tail coverage affected their behavior in an open-ended question (92/102—90.1%). The most common responses for obstetrician–gynecologists were 1) inability to leave practice in Washington State or to terminate obstetric services (42.4%), 2) limitation of selection or change of liability insurance carrier (13.0%), and 3) limitations in the options to change the type of obstetric practice (ie, private practice, health maintenance organization, military, or academic) (15.2%). Among family physicians, 26.7% said tail coverage affected their practice behavior, and 19.0% of those providing explanation (32/168) cited being constrained on a decision to leave the state or quit obstetric practice. Tail coverage was an issue of less concern for both certified nurse midwives and licensed midwives.
In 2001, Washington Casualty Insurance Company, a major insurer of obstetric providers, withdrew from the Washington State market, leaving their clients without coverage. Other smaller insurers have also withdrawn from Washington’s medical liability insurance market over the past few years. The survey questionnaire for physicians asked specifically if they lost coverage from Washington Casualty Insurance Company, and the midwives’ questionnaire asked more generally if they lost any insurer since 2001. Sizeable minorities of each provider type (14.8% of obstetrician–gynecologists, 22.1% of family physicians, 26.8% of certified nurse midwives, and 28.3% of licensed midwives) indicated that their carrier had either left the state or canceled their policy. More obstetrician–gynecologists who had lost their carrier (57.9%) reported difficulty obtaining liability coverage from another carrier than did other provider types (35.6% of family physicians, 50.0% of certified nurse midwives, and 9.1% of licensed midwives; overall 2 P < .001). The most commonly cited difficulties encountered were an increase in cost of insurance and limitation on the liability insurance amount available to purchase.
Respondents were asked about monetary and practice changes they or their practices had made in response to professional liability insurance affordability or availability issues in the prior 2 years. They were also asked about personal obstetric practice changes in the prior 2 years, without specifically linking the latter question to liability insurance issues.
Raising cash and compensation reductions were the most common monetary changes cited by obstetric providers attributable to liability insurance pressures. A substantial number of respondents raised cash, either by securing a loan or liquidating assets (15.9% of obstetrician–gynecologists, 4.6% of family physicians, 12.2% of certified nurse midwives, and 26.8% of licensed midwives; overall 2 P < .001). An even larger percentage of providers, most commonly obstetrician–gynecologists, reported reducing their compensation (47.8% of obstetrician–gynecologists, 32.3% of family physicians, 9.7% of certified nurse midwives, and 15.4% of licensed midwives; P < .001).
A lower proportion of providers reported medical practice changes directly related to professional liability insurance affordability or availability issues. For example, 20.1% of family physicians, but only 6.3% of obstetrician–gynecologists, said they decreased major gynecologic surgery; 6.9% of family physicians and 2.4% of obstetrician–gynecologists stopped performing major gynecologic surgery (these response options were not asked of certified nurse midwives and licensed midwives). Few providers reported that liability insurance issues had led them to add medical services in the prior 2 years (9.7% of obstetrician–gynecologists, 5.2% of family physicians, 11.5% of certified nurse midwives, and 7.1% of licensed midwives) (not shown).
Figure 2 shows the obstetric practice changes not linked to liability insurance issues that providers reported over the prior 2 years. The most common changes were increases in the number of deliveries, increases in the cesarean delivery rate, increases in obstetrician–gynecologist consults, and decreases in high-risk obstetric care. These changes varied greatly by provider group.
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Table 3 presents responses to 5 questions related to access to obstetric services. The vast majority of all provider groups reported accepting new obstetric patients. About one half of respondents reported that their community was recruiting new obstetric providers; a smaller percentage of the respondents’ own practices were recruiting new obstetric providers. All provider groups reported increases in on-call hours due to changes in obstetric provider supply. This was most marked for the physician groups. Similarly, between one quarter and two thirds of all provider groups reported fewer providers were available for obstetric consultation, with licensed midwives reporting the highest rate of difficulty. Only obstetrician–gynecologists and family physicians planned to reduce or stop offering obstetric services in the next year.
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DISCUSSION |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This survey, although representing responses from only 1 state’s obstetric providers, represents 1 of the largest surveys conducted regarding practitioners’ attitudes and actions related to professional liability in recent years. Several main findings deserve comment. First, the cost of liability insurance has increased significantly for all groups of obstetric providers during the years covered by this survey, 2002 to 2004. This increase was most apparent in estimating the per delivery cost of liability insurance. The groups that provided small numbers of births, family physicians and licensed midwives, incurred the greatest per-delivery insurance cost.
The financial stress of these cost increases on individual practitioners is apparent. Nearly one half of all obstetrician–gynecologists reported having taken compensation reductions, possibly because they found it difficult to increase revenue to offset increased liability costs. A notable proportion of providers (15.9% of obstetrician–gynecologists, 12.2% of certified nurse midwives, and 26.8% of licensed midwives) reported having to liquidate assets or secure a loan to pay practice expenses. This is consistent with, although less dramatic than, a recent report by Amon and Winn8 from Missouri, who found that 20% of obstetrician–gynecologists needed to take out a loan and 10% needed to liquidate assets to pay practice expenses.
Providers also reported significant change in their clinical practices, including limiting or eliminating major gynecologic procedures, and among obstetric providers, decreasing care for high-risk patients and increasing use of obstetric consultation. Similar changes were also reported in the 2003 ACOG Professional Liability Study, although there were significant regional differences in these practices.2 Increasing cesarean delivery rates were also reported during this period. Whether this change was related to defensive medical practice, renewed concerns about the safety of vaginal birth after cesarean delivery, or hospital policy (eg, no vaginal birth after cesarean deliveries without an in-hospital anesthesiologist throughout labor) cannot be determined from this survey. The practice of defensive medicine in response to liability pressures on physicians has been difficult to document conclusively. Some authors have found evidence of such practices,9,10 most often with reference to obstetric practice, but others have failed to document an association.11,12 Mello and Brennan13 hypothesized recently that defensive medicine is likely to be less common due to the economic pressures of managed care. However, managed care pressures on obstetric practice are subject to heavy regional influences. The Washington State market is currently not heavily influenced by traditional managed care financial constraints.
Two findings related to liability insurance coverage were surprising. First was the high percentage of respondents who did not know which type of liability insurance they carried. This was most commonly seen among certified nurse midwives, whose liability insurance was more often paid by a hospital. Given that providers with claims-made insurance may incur considerable future expense when purchasing "tail" coverage after leaving their practice or changing insurance carriers, ensuring that all providers understand their coverage type is crucial. Second, obstetrician–gynecologists decreased their single claim and aggregate claim limits between 2002 and 2004, a period when award amounts increased. Review of the comments from survey respondents suggests that this resulted from 2 factors: increasing cost and decreasing availability of higher-limit policies. Limited insurance coverage could force settlement of malpractice cases out of fear of a jury verdict exceeding policy limits. Exceeding policy limits would put the defendant physician personally at risk for the excess verdict. On the other hand, a settlement made to avoid exceeding policy limits could limit the availability or could raise the future cost of insurance to the particular provider or their practice group. Obstetric providers may feel as if they are in a no-win situation, and choose to limit their coverage as the lesser of 2 evils.
As expected, the liability premium to provide obstetric services was highest for obstetrician–gynecologists. However, when expressed as a per-delivery rate, family physicians and licensed midwives paid the highest liability insurance rate of provider groups in 2003: more than $300 per delivery for family physicians and nearly $300 per delivery for licensed midwives or approximately 15% of the total compensation for global obstetric care. The cost of liability insurance for family physicians could be providing the impetus for the documented exodus of many family physicians from obstetric services over the past few years. Unpublished surveys by the Washington Academy of Family Physicians in spring 2003 and fall 2004 found a decline in the proportion of rural family physicians practicing obstetrics from 52% to 44% (personal communication, Jean Marshall, past president of the Washington Academy of Family Physicians, November 2, 2004). Because many rural areas’ obstetric services are exclusively provided by family physicians, their exit from providing obstetric services could have severe effects on access to obstetric services in rural Washington. It remains to be seen whether continued cost increases stimulate a similar exodus in licensed midwives providing obstetric services. The exit of licensed midwives would primarily limit the access to care for women seeking alternative delivery settings, primarily home birth.
The population’s access to obstetric services is difficult to measure from provider surveys because of incomplete response rates. This study used proxy measures for examining access, such as on-call workload, availability of obstetric consultants, and vacancies for obstetric providers. These proxy measures suggest a system currently underserved with obstetric practitioners. Nearly one half of the physician providers are working more on-call hours; the communities of one half of the respondents are recruiting new providers, and substantial proportions of all practitioner types have difficulty obtaining consultation. However, few practices are refusing new patients, and only small percentages of the providers surveyed were planning to reduce obstetric practice activity in the next year. This latter finding is consistent with the recent ACOG survey of its members, which found that obstetrician–gynecologists in the ACOG district that includes Washington State were less likely than physicians in other areas of the United States to stop obstetric practice in response to liability concerns.2
An unexpected influence on obstetric practice was related to the cost of the tail coverage portion of a claims-made policy. The very high cost of such coverage, often triple or more the annual premium, can make it financially painful to discontinue obstetric services or to change practice locations. Some respondents commented that they would have either stopped obstetric practice or left the state if they were not constrained by the need to purchase tail coverage. Thus, some access problems might be deferred, at least temporarily, by this high cost of tail coverage. Some providers qualify for 1-time reduced or free tail coverage if they maintain coverage with a specific insurance company for a specified number of years. This has the potential to influence access to obstetric services by giving providers an incentive to quit their obstetric practices when this threshold is reached. There are no available data on the number of obstetric providers who leave practice each year, nor whether this number is increasing or decreasing as a result of liability concerns.
The extent to which the results of this study can be generalized to the entire population of obstetrician–gynecologists, family physicians, certified nurse midwives and licensed midwives is limited. The survey response rates are relatively low but not uncharacteristically so for physician surveys. This low response rate raises concerns about nonresponse bias. It is encouraging that the weighted number of reported deliveries for 2003 is within 7% of the number of live births reported by Washington’s vital records system in 2003. This suggests that the survey respondents are representative of Washington’s obstetric providers. The incomplete response to the survey also precludes our ability to identify the distribution of obstetric providers across the state.
The response rate to some questions, such as liability insurance premium rates, was low. Respondents who provided rate information may have been more likely than those who did not to pay their own malpractice insurance bills or to be in small practices, and thus be more aware of their rates. If larger practices or organizations negotiate lower liability insurance premiums, this study’s results may be biased toward higher premiums.
Last, by selecting providers for the study who were actively practicing in the state, the survey cannot assess how many providers left the state, quit practicing, or left the profession because of liability insurance issues. Pursuing that question would have required a different survey design, and required more resources to track providers in other states and those no longer on licensing or professional association rosters.
Mello et al15 recently published on the issue of physician satisfaction in high liability risk practices. They found 5 important areas related to physicians’ career satisfaction: income, interpersonal relationships, autonomy, practice environment and broader market environment. As in Mello et al’s work, this study found evidence of disruption in many of these areas for obstetric providers, both physicians and midwives, in Washington State. Income was reduced for a high percentage of respondents, and some secured personal loans to meet practice expenses. Provider autonomy appeared to be threatened, as evidenced by respondents’ perceived need to decrease high-risk services and increase obstetric consultation. In addition, many practitioners reported limits placed on their practice as a prerequisite for liability insurance. Practice environment was affected, with many providers working in practices or communities with reduced availability of consultation, more on-call hours, increased number of deliveries, or without a full complement of obstetric providers. Finally, rising liability premiums have had an effect on the general market environment, forcing individual providers to make difficult decisions regarding limits of coverage and protection of personal assets.
Although this study did not examine satisfaction directly, it documents that Washington’s providers experience many factors associated with dissatisfaction. Although dissatisfied physicians are presumably more likely to leave clinical practice or relocate, Mello et al14 hypothesize that access is a late victim of physician dissatisfaction and that quality of care is affected before actual provider shortages occur in a community. The prospect of dissatisfaction leading to quality impairments, which could in turn lead to more malpractice claims, is a frightening positive feedback loop, hazardous to both patients and providers of obstetric services. Consistent with this hypothesis, this study did not clearly demonstrate decreased access for patients but did suggest defensive medical practices that could be associated with lower quality of care. Future studies are needed to more directly examine Mello et al’s hypothesis that professional liability issues may negatively affect the quality of patient care, because this would work at cross-purposes to the tort system’s goal of deterring medical mistakes.
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Footnotes |
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Financial support was provided by U.S. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis, Grant #1 U79 HP 00007-0.
Corresponding author: Laura-Mae Baldwin, MD, MPH, University of Washington, Department of Family Medicine, Box 354982, Seattle, WA 98195-4982; e-mail: lmb{at}u.washington.edu.
doi:10.1097/01.AOG.0000218721.83011.7a
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REFERENCES |
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ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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2. Strunk A, Esser L. Overview of the 2003 ACOG Survey of Professional Liability. ACOG Clin Rev 2004;9:1,13–6.
3. WWAMI Rural Health Research Center. Available at: http://www.fammed.washington.edu/wwamirhrc/. Retrieved July 8, 2005.
4. Morrill R, Cromartie J, Hart LG. Metropolitan, urban, and rural commuting areas: toward a better depiction of the US settlement system. Urban Geogr 1999;20:727–48.
5. Centers for Disease Control. National Center for Health Statistics. Birth data. Available at: http://www.cdc.gov/nchs/births.htm. Retrieved July 8, 2005.
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7. Firth PA, Chu J, Bell MA, Bailey GA, Soderstrom RM. Changing practice habits of King County obstetricians. Obstet Gynecol 1988;72:419–22.
8. Amon E, Winn HN. Review of the professional medical liability insurance crisis: lessons from Missouri. Am J Obstet Gynecol 2004;190:1534–8.[Medline]
9. Dubay L, Kaestner R, Waidmann T. The impact of malpractice fears on cesarean section rates. J Health Econ 1999;18:491–522.[Medline]
10. Localio AR, Lawthers AG, Bengtson JM, Hebert LE, Weaver SL, Brennan TA, et al. Relationship between malpractice claims and cesarean delivery. JAMA 1993;269:366–73.[Abstract]
11. Office of Technology Assessment. Defensive medicine. Washington (DC): 103D Congress; 1994.
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13. Mello M, Brennan T. Deterrence of medical errors: theory and evidence for malpractice reform. Tex Law Rev 2002;80:1595–637.
14. Mello MM, Studdert DM, DesRoches CM, Peugh J, Zapert K, Brennan TA, et al. Caring for patients in a malpractice crisis: physician satisfaction and quality of care. Health Aff (Millwood) 2004;23:42–53.
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.001 for the paired t test comparison of 2002 and 2004 mean liability insurance premiums among providers with data for both years. 
n reflects the number of providers who responded for all 3 years. Numbers of unweighted responses for family physicians are shown. 
Premium amounts are calculated using weighted responses.
Overall