Nowhere does the old adage "statistics, damn statistics, and lies" ring more true more than in the health care malpractice crisis now plaguing Missouri.

The Missouri Association of Trial Attorneys, Governor Bob Holden's office, the Missouri Department of Insurance, and the Missouri State

Medical Association rattle off numbers with more gusto than a Moose Club Bingo caller. All of the numbers they call are likely accurate. It's just that some carry a whole lot more weight than others.

The trial lawyers define the health of the system by the number of practicing physicians and surgeons in Missouri. Since that number grew from 19,260 in 1997 to 19,966 in 2003, the idea that medical malpractice costs are re-ducing the ranks of Missouri doctors is, to them, pure "misinformation."

Randy McConnell, spokesman for the Missouri Department of Insurance (MDI), points to the small growth in the number of physicians during the last two rate-hiking years as still another sign of health. To be sure, there might be a problem, but no real crisis.

In the very tone of MDI press releases, however, one rightly reads a whiff of the political, to wit: "2003 malpractice claims reach record lows--cash flow yields windfall for insurers."

To the degree that there is a problem, the insurers, not the trial lawyers, are most at fault. The Department boasts that newly filed claims--a presumed indicator of future malpractice insurance costs--fell 16.1 percent, from 1,506 in 2002 to an all-time low of 1,263 against all health-care professionals and facilities. Claims filed against physicians also fell, in this case 13.9 percent from 726 to a record low of 625 in 2003. Claims paid on physician policies likewise declined from 226 to 161 in 2003, or by 28.8 percent, the second lowest on record.

Hospital administrators and physicians in Kansas City digest these numbers with a studied skepticism. To put their thoughts in perspective, imagine how an opposing coach might feel about the "time of possession" stats after watching Dante Hall return a kickoff. The time of possession numbers may be honestly recorded, but after the coach's team has spent nine minutes to kick a field goal and Dante Hall has spent nine seconds to score a touchdown, the coach loses faith in their value.

The numbers that demoralize local doctors and administrators are much more real and powerful. The fact is that western Missouri is hemorrhaging physicians, especially surgeons in critical specialty areas. Dr. Steve Reintjes of the Kansas City Neurosurgery Group observes that 14 years ago six different groups of neurosurgeons practiced on the Missouri side. Today only one does, his group. As he comments in Ingram's Healthcare Industry Outlook: "Neurosurgery from north and south is standing on the shoulders of our group." If his group moves to Kansas, western Missouri will suddenly find itself with little to no serious trauma care.

The numbers that inspire physicians to quit Missouri for Kansas are likewise real and relevant. Malpractice insurance rates have shot through the proverbial roof. Four years ago, as Reintjes notes, his group paid $27,000 a surgeon in liability insurance. Last November--despite the fact that in 54 collective years of practice, the surgeons in his group "have not paid out one dollar in judgment, not one dollar out in settlement"--the best quote his group saw was $130,000 per surgeon. Across the state, other neurosurgeons face equally staggering premiums.

To get a handle on the crisis in Missouri Dr. David Jimenez, MD, a professor in the Division of Neurosurgery at the University of Missouri-Columbia, and neurosurgeon Dr. John Krettek of St. Louis surveyed their colleagues throughout Missouri.

79 of the 89 practicing neurosurgeons in Missouri completed the survey. These surgeons reported an average increase in professional liability insurance premiums of 116 percent between the years 2001 and 2003. As a result of these rate hikes, 40 percent of the respondents were considering early retirement. 26 percent were considering relocation to another state, and two-thirds planned to reduce the type of service they provide in their communities. These numbers are real and relevant indeed. "Far worse," says Jiminez, "neurosurgeons living in eastern Kansas City (Missouri) have left the area."

Physicians of all stripes in Missouri are feeling the squeeze. In a speech on the Senate floor last summer, Senator Kit Bond cited some equally scary numbers. The average premium increase for all Missouri physicians in 2002 was 61.2%. This came on top of an increase in 2001 of 22.4%. As a result, said Bond, "Almost one in three physicians in my state of Missouri are considering leaving their practice altogether because they simply can no longer afford to practice because of exorbitant medical malpractice insurance rates."

The question remains, however, who or what is responsible for the surge in Missouri liability premiums. The Missouri trial lawyers and the Governor's office blame the insurance companies and the Republican-led legislature.

"At a time when insurance profits are at record levels," said Democratic Governor Bob Holden upon vetoing House Bill 1304 in late April, "it is beyond me why the legislature would fail to include meaningful insurance reform." He described such reform, and not the capping of liability payments, as "the most effective way" to reduce physician insurance rates.

When asked what shape such reform might take, Randy McConnell of the Missouri Department of Insurance described a "flex rating system." As the system would work, any proposed annual increases or decreases in liability premiums of more than 15% would have to be submitted 60 days in advance and subjected to a public hearing with the Director of the Department of Insur-ance reserving the right to reject or amend the proposed increase. The governor included this plan in his very recent proposal to the legislature. According to the Missouri State Medical Association, however, of the 32 insurance companies licensed to write professional liability insurance for Missouri physicians, only three are willing or able to write new business.

As Bond noted on the Senate floor, three companies that accounted for a third of Missouri's business as late 2001 have left the Missouri market all together. McConnell described this as a "perfect storm" of companies closing shop.

Given the insurer's fear of the Missouri market, this reporter asked McConnell how the additional costs and scrutiny of the proposed flex rating reform would encourage more insurers to invest in Missouri. He responded that a flex rating system does seem to be working in California.

Given the size and wealth of California, however, insurance companies cannot easily quit that market. They can and are quitting Missouri. Besides, a California doctor who wants to leave, say, San Diego, finds himself in Mexico when he crosses the nearby border. The Missouri doctor finds himself in Kansas, and many already have. To prosper, the western side of Missouri has to compete with the more historically business-friendly Kansas, a state in which trial lawyers have little sway.

In his appeal for national malpractice reform last summer Senator Pat Roberts joined Kit Bond on the Senate floor. The figures Roberts cited for Kansas stun the dispassionate observer. As Roberts noted, a Kansas family physician who delivers babies paid $13,790 in premiums in 1991. In 2001, that same physician paid $12,575, an 8.8 percent decrease.

"Similar reductions exist for virtually every specialty," added Roberts. Despite the fact some 15 percent more physicians practice in Kansas today than 12 years ago, physicians paid $75.3 million in aggregate premiums in 1991 and $60 million in 2002. In an apolitical debate, or in a non-election year, all Missouri parties would turn to Kansas and ask what is that state doing right that Missouri is not.

Randy McConnell of the Missouri Department of Insurance suggests that Kansas's Health Care Stabilization Fund makes the difference. In fact, however, the fund merely provides basic coverage for providers denied coverage in the voluntary insurance market. In that the fund is drawn from a surcharge on liability insurance, it actually increases the premium that Kansas providers pay. Indeed, if the fund were such a miracle fix, one would expect Missouri to adopt it and put the issue to rest.

When asked why Kansan physicians pay so much less in liability insurance, the spokesman for the Kansas Depart-ment of Insurance, Scott Holeman, does not even mention the Health Care Stabilization Fund. "We have some tort reform that Missouri doesn't have," volunteers Holeman reflexively, "particularly the 250,000 cap."

Pat Roberts reiterated this point on the Senate floor. "Kansas doesn't have the same problems that Missouri doctors and patients are facing," said Roberts. He argued that in the 1980's, Kansas enacted "sweeping medical liability reform legislation," which put a hard cap of $250,000 on non-economic damages. In Missouri, that cap is $557,000 and can go even higher under certain circumstances.

Back to those damn statistics, the Governor's office and the trial lawyers are fond of citing a June 2003 report by the highly respected Weiss Ratings. "Caps on non-economic damages have failed to prevent sharp increases in medical malpractice insurance premiums," concluded the study, "even though insurers enjoyed a slowdown in their payouts." Weiss, in fact, reported that physicians in states with caps endured a 48.2 percent increase in median annual premiums while premiums in states without caps rose at a slower pace of 35.9

The Weiss ratings, however, still do not account for the Kansas-Missouri differential. Roberts did. As he commented, the Weiss report tracked nineteen states with caps, but only five of those states, like Kansas, have $250,000 caps on non-economic damages. The rest are sufficiently high that they fail to reduce the cap's impact on payouts and premiums. Kansas' cap on non-economic damages, said Roberts unequivocally, "has had an impact on premiums. It has created an unparalleled period of premium stability for Kansas physicians and hospitals."

McConnell argues that the legislature's proposed $400,000 cap in Missouri "had absolutely no prospect of lowering the rates at all." He may be right. With Kansas sitting next door and setting the example, Missouri may have to come in with lower caps still to have an impact. This is not about to happen. As this article goes to press, Holden has come back to the legislature with a proposed $450,000 cap on non-economic damages. If a $400,000 cap has "no prospect" of lowering rates, one is forced to wonder how a higher cap might accomplish the same.

The politics of this debate are self-evident and best discussed elsewhere, but they are also self-destructive, literally." I'd caution travelers on I-70 to drive carefully," said Roberts, "because there is no trauma care basically between the Kansas State Line and Columbia."

This crisis also makes the positioning of Kansas City and the state of Missouri as a center for the life sciences almost comical. As hard it has been for Kansas City to be a jazz capital without musicians, it will be doubly hard for the city to be a life science center without physicians.

And no one ever died for want of an alto sax.