JEFFERSON CITY - Family practitioner Julie Wood considers herself one of the unfortunate casualties of a raging political debate in Missouri's Statehouse concerning medical malpractice insurance.
Wood had practiced medicine in Macon, located in rural northeast Missouri.
Wood said her practice was the only one left in Macon that delivered babies for a large Medicaid indigent population.
But Wood no longer works in Macon. She's left for Kansas City. And the family practitioner says the reason is the cost of her insurance.
"I saw my premium of $19,000 shoot up to $71,000 in less than three years," Wood said. "I didn't stick around to find out what would happen next."
So she moved to Kansas City in May to join a residency program where she could teach and be assured that some of her costs would be covered. Though the move has been positive, Wood, who also chairs the Missouri Academy of Family Physicians, said leaving her hometown was hurtful.
"It was very much my intention to stay there," she said. " While I didn't go into medicine to make money, I didn't go into it to borrow a lot either."
Depending on who's talking, Wood's departure either is an isolated situation or it is representative of a medical crisis of potentially historic consequences.
At issue is a debate as to whether rising medical malpractice insurance rates are driving out Missouri doctors like Wood who are needed to deliver babies, care for emergencies and provide other essential health-care services.
Across the country, insurance "sticker shock" has prompted frustrated health care providers to associate rising costs with individual malpractice awards.
Mobilized by the American Medical Association and other medical groups, doctors have arranged protests and information campaigns to plead their case that lawsuit awards -- rather than weak insurance company investment returns -- are behind the rising cost of medical malpractice insurance.
"Their very survival is at stake," proclaimed House Speaker Catherine Hanaway, R-St. Louis County, who said doctors are abandoning Missouri for states with cheaper medical malpractice insurance.
The Missouri State Medical Association and other medical groups argue that hefty lawsuit awards are to blame for their woes, and they propose lawsuit award caps now.
On the other side are lawyers' groups and some consumer advocates who contend that further restrictions on malpractice claims would be unfair to the public and do little to address the hemorraging insurance costs doctors now face.
A report released earlier this year by the state Insurance Department said doctors were hit with hefty premium increases of 100 percent or more within the last two years. These increases emerged after a relatively stable financial market during the '90s.
Missouri doctors, the report said, have been unable to absorb these rate increases because of declining reimbursements from managed care companies, Medicare and Medicaid.
The American Medical Association, one of the strongest political voices of the health care establishment, says conditions like Missouri's mean that consumers could face shortages of specialists, especially in rural areas and overtaxed urban hospitals.
The state's Insurance Department report confirms some of the association's warnings. According to the department, a number of malpractice insurance carriers have stopped taking new business from Missouri doctors. In addition, the department reports that the four largest malpractice insurance providers in the state have increased their rates ranging from 28 to 97 percent.
The Republican-controlled legislature's response was legislation that would impose caps on all liability lawsuit awards, medical or otherwise, for non-economic awards -- also known as "pain-and-suffering" damages.
The legislative measure also imposed a number of other restrictions designed to reduce liability lawsuit awards.
But that approach faced strong opposition from the Missouri Association of Trial Attorneys and it was vetoed by the governor.
Since then, Gov. Bob Holden has held three closed-door negotiating sessions with the various lawyer and medical groups, while barring legislators.
But the talks ceased after the Missouri State Medical Association (MSMA) and the state's Hospital Association sent memos to the governor's office breaking off the talks.
Neither side could agree on placing caps on pain and suffering awards, or on the practice of "venue shopping," which has allowed cases to be moved to St. Louis where critics charge juries give much higher damage awards than other areas of the state.
MSMA representatives have said that high-risk specialties like obstetrics aren't the only areas endangered if this situation is allowed to continue.
The group's spokesperson, Liz Fleenor, said members have reported at least 70 physicians who have left their practices over the last year. They anticipate more, she said.
Despite these reports, the state's Healing Arts Board -- which licenses and regulates doctors -- reports that the state has actually experienced a net increase of doctors within the last five years. The board currently licenses about 20,000 doctors to practice in the state.
And a recent study by the U.S. General Accounting Office (GAO) says that medical groups may have overstated the extent of the problems faced by the states.
Released in August, the GAO report, "Medical Malpractice: Implications of Rising Premiums on Access to Health Care," found that "multiple factors have contributed to recent increases in the medical malpractice rates," not just litigation. The report also disagreed with the American Medical Association, saying increased premiums haven't created the widespread health care crisis that the group claims.
The state Insurance Department's chief spokesman agreed with the GAO's assessment. Randy McConnell said the push for stronger caps on malpractice awards would have minimal effect on Missouri doctors'premiums and prove detrimental to future victims of malpractice.
"There's not much of an argument for fairness there," McConnell said.
Missouri already has a cap on non-economic malpractice damage awards, which was passed by the legislature in 1986. By law, the cap is adjusted annually for inflation. It now stands at $557,000.
The Insurance Department issued a report earlier this year recommending against limiting lawsuit awards as a solution for rising medical malpractice.
McConnell said the department has created a joint underwriting association, or JUA, to assist doctors experiencing difficulty finding and keeping malpractice insurance. JUAs are typically by created states to provide physicians with "an insurer of last resort." Eligibility would be limited to certain kinds of specialists and OB/GYNs, and the costs are usually more expensive than private insurance.
"Definitely not a substitute for tort reform," said the state's medical association Executive Vice President C.C. Swarens.
Swarens said the JUA is a "non-issue" for his members because it would affect less than 1 percent of physicians in the state and require that they pay twice the average premium.
McConnell said the department is still working on how to determine the rates.
Meanwhile, medical groups continue their push for lawsuit award limits. MSMA's Swarens said the only neurosurgeons' practice between Kansas City and Columbia is moving out of the state. He also said that members are reporting defections to Kansas, and several early retirements in St. Louis.
As the debate continues, the former northeast rural Missouri family physician Julie Wood said she's bracing herself for more stories from colleagues in Kansas City who've crossed the state line or left the Midwest because of rising insurance costs.