In search of a remedy

Stacy J. Willis

Friday, May 24, 2002 | 4:35 a.m.

WEEKEND EDITION: May 26, 2002

It started -- it always starts -- between a doctor and a patient.

An entire industry -- made up of physicians, patients, insurers, regulators and, inevitably, the legal system -- exists in the intimate space between any one doctor and one patient.

Typically, things go right. But if something goes wrong in the delivery of care -- or something is perceived to have gone wrong -- and the patient is hurt, what remedy does that patient have? He can allege malpractice, and take his case to an attorney, and file a lawsuit, and seek some financial compensation from the doctor.

Because of the potential for lawsuits, doctors carry malpractice insurance -- so that if they are charged with making a mistake, and found by the legal system to have made such a mistake, they won't be bankrupted by the outcome. They pay a premium every year to insure against potential claims.

Insurance companies underwrite to make money -- their business is based on projecting that the cost of claims will be less than revenue raised by premiums.

The state regulates the business between doctors and insurance companies, routinely checking to ensure that companies are solvent -- that is, that if they are taking premiums from the doctors, they have the money to pay for potential claims.

Attorneys who specialize in malpractice cases typically earn their living by collecting a contingency fee -- they take no upfront money from the patient and instead agree to take a cut of the award -- typically between 30 percent and 40 percent. In the event there is no award, the attorney doesn't get paid.

Somehow, Las Vegas finds itself in a situation in which medical malpractice insurers are leaving the market or are increasing their rates, doctors are threatening to leave town, patients are worried they won't have doctors and government officials are saddled with fixing the problem. Only the attorneys aren't complaining.

The local medical malpractice insurance dilemma surfaced in December when the state's largest insurer, St. Paul Cos. of Minnesota, announced it was pulling out of the market.

Rates offered by the remaining companies immediately began jumping up -- way up -- and doctors said they could no longer afford to practice in the valley.

When something goes awry in the medical malpractice insurance system, who is to blame? And who can fix it?

Patients

Las Vegan J. Kay, 74, will wear diapers for the rest of his life because of a medical procedure gone wrong. No one suggests that his case is typical -- even Kay says that most of the doctors he dealt with while being treated for a cancerous rectal polyp were "good people."

But when his body was permanently damaged, and his lifestyle subsequently limited, he wanted "some sort of justice."

"This doctor put me through misery," Kay said of his surgeon, Dr. Mohamed Eftaiha. "I have always taken good care of myself. And what's important to me at this stage of life is my health, which he took from me."

Eftaiha, who is one of three colo-rectal surgeons in Las Vegas, said he is not guilty of malpractice. Eftaiha said Kay rejected a plan to get a permanent colostomy bag and was aware of the risks of the "pull-through" surgery he opted for.

"It's a very sad story. He developed some problems," Eftaiha said.

"But my insurance company felt we had a great case because I didn't commit malpractice ... However, the jury didn't see it that way."

A District Court jury awarded Kay $1.5 million in October.

Eftaiha was insured for $1 million, so Kay and his attorney accepted that and decided not to pursue the doctor personally for the other $500,000.

Of the $1 million that Kay got, $400,000 went to his attorney.

"So I got $600,000," Kay said. "I'd rather have my quality of life ... I don't care about the money. I'm only interested in one thing -- I want his insurance rates to go through the ceiling to remind him of me every year."

And, in fact, Eftaiha's rates went from $15,000 last year to $100,000 this year, forcing him to borrow money to stay in business.

"I have no choice. I have a family," Eftaiha said. "I stopped funding my profit-sharing plan, I stopped giving them (office staff) insurance. I cannot leave because my son is in the 11th grade and is very bright, and I cannot take him out of his school.

"And where would I go? This will follow me anywhere," Eftaiha said. "But other doctors are leaving. That's what people don't understand: They are hurting their own health care -- making it unavailable."

Kay vows to steer clear of further medical procedures, but for most people that is not realistic. Many people rely on the availability of routine medical care and, in this society, take it for granted.

Las Vegan Kim Muagaotega found that out earlier this month when she, like countless other pregnant Clark County women, was denied prenatal care by her longtime obstetrician. Dr. Shelby Wilbourn had limited his practice because his malpractice insurance company, which had dramatically raised rates, offered him a discount for delivering fewer babies.

Although almost all physicians are experiencing rate increases, the most dramatic and practice-threatening are in a handful of high-risk specialties such as obstetrics and surgery.

"I was in shock," Maugaotega said. "The people in his office took me in the back and said, 'We are not going to be able to take you for this pregnancy because of our insurance.' "

"This is my doctor ... I'm six weeks pregnant. I called 27 doctors and I couldn't find one that was taking patients," she said.

"What am I supposed to do?"

The public wants care -- but it wants mistake-free care. Somewhere between expectations of perfection and the reality of human errors lies -- for Las Vegas -- a sizable problem.

Physicians

Wilbourn's friends say he should run for office because he talks about the issue so frequently; instead, the doctor is thinking of buying a video-poker bar -- "a profitable business."

But he was trained over the course of a dozen years to deliver babies and provide gynecological care.

His aunt was a nurse. He was a hospital orderly, an ambulance driver and an emergency medical technician.

"I knew that doctors made a better living than most people -- but the reason I went into is I just liked taking care of people," Wilbourn said.

He borrowed $186,000 for his education at Tulane University. On top of that, he borrowed $150,000 to start his Las Vegas practice. He hasn't paid off either loan yet.

Today, at 41, Wilbourn earns between $150,000 and $200,000 a year.

"I see 40 patients a day, and I do 20 to 25 deliveries every month. I've been doing it for 12 years, and I pay an office staff of five -- three of them have been with me since 1990.

"What business do you know with this kind of track record that wouldn't be a successful business?"

But Wilbourn says he is struggling to make ends meet.

Part of the doctors' problem, he says, is that they get limited reimbursement from patients' insurance companies. Doctors sign contracts with those companies, agreeing to accept certain rates for each procedure. For example, under one contract, Wilbourn gets $33 for every Pap smear he does, he said.

Once doctors are locked into low-reimbursement contracts, the only way they can increase income is by increasing volume.

"You don't reject the low-reimbursement rates because you worry that you will lose the contract and lose all of your patients they insure," he said."So then docs just say 'OK, I'll just see more patients to make ends meet.'

"Do you know how many $33 Pap smears I have to do to pay $70,000 worth of insurance?

"So then you get patients saying, 'My doctor doesn't sit and talk to me.' And also, you are rushed more and are more apt to make an error."

"We are a business that cannot pass down our increasing costs to the consumer," Wilbourn said. "We are squeezed in the middle."

According to the Medical Liability Monitor, Nevada's obstetricians' rate quotes for the upcoming year average between $70,000 and $94,000; some local physicians report quotes above $120,000.

By comparison, Florida obstetricians pay as much as $208,000 and Texans pay up to $160,000. But in California, they pay between $46,000 and $57,000, and in Kansas, they pay between $21,000 and $33,000.

Obstetricians are not the only specialists whose rates have gone up -- rates are increasing across the board by varying amounts depending on the medical specialty.

Wilbourn paid $33,000 this year for his malpractice insurance. For next year, he has been quoted $70,000.

"So I have to come up with $35,000 more unless I go to the bank and borrow more money," he said. "And I've never been sued in 12 years."

When his insurer, APA, offered a discount to limit the number of deliveries per year to 125, he felt he had no choice.

Larry Matheis, Nevada State Medical Association executive director, said that puts doctors in a situation that goes against everything they've been trained to do.

The public also forgets that physicians routinely handle intense pressure without making errors, he added.

"A lot of these physicians must make immediate judgments in life and death situations," Matheis said. "Some are literally up to their elbows in blood, and very rarely do they fail, even under that kind of strain. Think of a neurosurgeon trying to handle a traumatic head injury -- it's an astounding pressure that we put on doctors."

Dr. John Nowins, Clark County OB/GYN Society president, says Las Vegas' medical climate forebodes disaster.

"I am very concerned about patient access to care," Nowins said. "The doctors are between a rock and a hard place: The rock is the insurance companies, and the hard place is the attorneys. Both are making a living off of us.

"This is a gold mine for lawyers," Nowins said.

Legal system

Nationally, the median jury award for medical negligence in childbirth cases was $2,050,000 in 2000, representing the highest such award for all types of medical malpractice, according to Jury Verdict Research.

The median awards for other types of malpractice cases were $750,000 for diagnosis, $688,000 for medication, $400,000 for nonsurgical treatment and $355,000 for surgical negligence.

"The whole system needs an overhaul, and it should start with caps (limits on jury awards for pain and suffering)," Nowins said.

But some states that have caps have had their constitutionality challenged. Oregon's Supreme Court, for example, struck down a limit on noneconomic damage awards in 1999

If Nevada enacted caps,the law would likely be challenged and be reviewed by the state Supreme Court, Nowins said.

"Then it would take three to five years to get that through the Supreme Court before it becomes law. But if it gives doctors at least a little light at the end of the tunnel, maybe we can stay and weather the storm, " Nowins said.

"The whole thing is so screwed up."

Between 1996 and 2001, 62 medical malpractice cases were tried in Clark County District Court, according to the Nevada Trial Lawyers Association.

Twenty-four had jury verdicts in favor of the plaintiff. Statistics were not available on what percentage of the remainder were settled or had verdicts in favor of the defendant. Total damages awarded by juries over the five-year period were $42.05 million, the association said.

In the last three years, insurance companies paid $86.9 million in Nevada medical malpractice claims; $73 million were not in verdicts but in settlements -- more than 600, according to the Division of Insurance.

"A few verdicts have a tremendous influence on the ability to settle. It dictates the benchmark for settlements," said Joel Whitcraft, senior vice president of Medical Protective Co., which insures Nevada doctors. "Verdicts have gone down, but settlements have gone up, and so we see an upward trend in losses."

Doctors and insurance companies say Las Vegas has a more litigious climate because it has a "jackpot" mentality; some say there are more attorneys locally than in areas with similar populations -- although statistics from the American Bar Association do not bear that out.

Nevada, with a population of about 2 million in 2000, has 4,640 active attorneys, according to the American Bar Association. Utah (2000 population 2.2 million) has 5,362 attorneys, New Mexico (2000 population 1.9 million) has 4,748 attorneys and West Virginia (2000 population 1.8 million) has 4,072 attorneys. California (2000 population 33.8 million) has 132,452 attorneys.

But statistics show that Nevada ranks among the top states when it comes to its percentage of jury awards (in all tort claims, not just malpractice) that exceed $1 million.

According to Jury Verdict Research, 18 percent of Nevada jury awards between 1994 and 2000 were more than $1 million. Only three states -- Mississippi, New York and Pennsylvania -- had higher percentages.

Additionally, Nevada's tort jury verdicts have been higher than the national median in recent years, Jury Verdict Research said.

Nevada's median damage award between 1994 and 2000 was $71,510. The national median was $45,000. Eight states had higher medians -- among them, California at $72,000. Compensatory awards include those for emotional distress, physical pain and medical expenses and wage loss.

The region's "more litigious climate" has doctors and insurance companies calling for legal reform.

And here the issue becomes somewhat esoteric: How can you put a price on someone's pain and suffering, and how can you limit that?

The Nevada Trial Lawyers Association says malpractice lawsuits are a necessity, a constitutional right, a check on the medical system.

"In general, caps unfairly restrict people's rights to pursue damages," said attorney Bill Bradley, the association's past president.

Patricia Bowling, a Las Vegas attorney who recently represented a plaintiff in a medical malpractice case against Sunrise Hospital and Medical Center, said, "What I really want legislators to understand is: The cause of medical malpractice lawsuits is medical malpractice."

Her client, who never regained consciousness after outpatient shoulder surgery, was awarded $5.4 million by a jury; the case is being appealed.

"One thing I don't think the Legislature understands is that these cases are expensive to litigate," Bowling said. Attorneys don't just take any case -- but only those where there is substantial evidence to push the case forward, she said.

Bradley said doctors should be more accountable for their errors, and that if they focused more on disclosing errors, they could identify trends and establish better risk-management policies.

The American Medical Association has successfully lobbied against disclosure of medical errors in recent years, saying the public doesn't have the knowledge to understand the technical nature of medical science.

Hospitals and insurance companies have access to the National Practitioner Data Bank, a government database in Fairfax, Va. According to the National Academy of Science Institute of Medicine, more than 44,000 deaths are caused each year by medical errors in the United States.

Attorney Gerald Gillock said, "The presumption is the medical profession has the best ability to monitor themselves -- but they don't.

"There is a conspiracy of silence among doctors. They refuse to take responsibility for policing their colleagues."

But doctors say they have high standards of self-policing. They routinely meet in hospital settings, for example, to rehash procedures in which an error was made and determine whether a physician was negligent.

Larry Matheis, executive director of the Nevada State Medical Association, said there are many self-policing policies in place.

"Every hospital has quality control committees specifically looking for incidents that show problems or trends of problems," Matheis said.

If a particular physician comes to their attention, Matheis said, the hospital will have him reviewed by a peer committee to determine whether there was a problem with his performance.

If they determine that there is a problem, "then they can limit his ability to practice on staff, and submit that information to the National Practitioner Database, and other hospitals check that," Matheis said.

Additionally, the state Board of Medical Examiners is charged with ensuring that licensed physicians are competent, and it investigates incompetency charges.

The board -- six doctors and three laypeople -- investigates between 600 and 800 complaints annually against physicians.

About 20 end up with formal hearings that might result in disciplinary action, according to Larry Lessly, executive director.

A malpractice claim "doesn't necessarily initiate an investigation by the board," he said.

"You don't take such cases at face value. Many of these cases are frivolous," Lessly said. Instead, the panel decides upon reviewing cases whether further investigation is required.

Insurance companies

Eight insurers are active in Nevada's medical malpractice market, but representatives say they consider it -- especially in Las Vegas -- to be risky because it is unpredictable.

"Our business is all about predictability," Medical Protective Co.'s Joel Whitcraft said.

When setting rates, insurers look at a number of factors in a given region, including claim frequency, amount paid per claim and legal expenses per claim.

"We have various rules used to differentiate insureds," Whitcraft said.

"First, a doctor has to pass the underwriting guidelines. Someone who is found negligent -- not just named -- in a malpractice suit probably wouldn't meet our guidelines ... But to some degree, everyone eats the risk for the bad doctor -- we spread the risk."

"Other things that influence our rates are the legal environment -- legal expenses certainly are a factor. Eighty percent of our premiums is earmarked for loss -- we operate on a 6 percent profit here," Whitcraft said. The remaining 14 percent covers commission, brokerage and taxes.

In the last three years, Nevada's aggregate amount of malpractice claims has gone up more than 30 percent.

According to the Division of Insurance, in 1999 insurance companies paid $19.2 million in verdicts and settlements in malpractice claims against Nevada physicians. In 2000 that grew to $33.8 million; in 2001, $33.9 million.

In 1999 170 claims were paid in the state; in 2000, 237; and in 2001, 220.

St. Paul, which had 60 percent of market share by 2001, saw its loss ratio -- the ratio of premium dollars to expenses and losses -- in Clark County shoot up from less than 60 percent in 1995 to almost 200 percent in 1996. That means for every dollar of premium it collected, it paid out $2 in expenses and losses. Its loss ratio stayed above 150 percent through 2001.

But the claims volatility came at a time when St. Paul, like most insurance companies, was enjoying investing in the bull market. St. Paul opted to keep rates low so that it could keep market share and invest the premiums in the stock market.

But in the end, it lost that gamble when the economy turned sour and insurers were strapped with enormous claims stemming from the Sept. 11 terrorist attacks.

"St. Paul suffered the largest loss in its 149-year history in 2001, driven by unprecedented losses from one event -- the Sept. 11 terrorist attack," its website says.

Because it was the market leader in Nevada, other companies based their rates on St. Paul's, which turned out to be artificially low.

"In 1999, St. Paul recognized an upward trend in (claims in) Clark County, and in 2000 (company officials) made the same observation, but they didn't make any changes in rates then," Whitcraft said. "We predicated our rates on St. Paul's, and now we are facing the fact that our rates are inadequate."

Paul Thistle, a UNLV business professor, said the insurance companies' behavior was typical for a bull market.

"Companies have been very aggressive about pricing, and they tried to make it up with investment income," Thistle said. "But because of losses and lower investment income, they have had to raise their rates. That's the nature of the business."

But Bradley said that insurance companies' financial management is a large part Nevada's medical malpractice problem.

"The insurance companies don't mind running at a loss when the economy is fine -- they say, 'Make your money on the investment portfolio,' " Bradley said. "And up through 2000 there was clearly that mentality: It's OK to lose money in premiums so long as your investments were paying off.

"A responsible insurer incrementally increases rates. St. Paul did not do that. St. Paul stayed flat hoping to get market share," Bradley said.

"We keep asking, 'What caused this?' and we have to go back to a downturn in the economy, not our malpractice system."

Government

So where were the regulators in all of this? In theory, it is the government's job to ensure that the business among doctors, patients and insurers is fair.

Nevada law requires medical malpractice insurance companies to submit to the Insurance Division annual reports detailing premiums, how many policies they write, net investment income, losses paid, loss reserves and net underwriting gains and losses.

The division's actuaries read the reports to decide whether each company's rates are appropriate. It has the authority to reject rates that are "excessive, inadequate or unfairly discriminatory," or any rate "which if continued will have the effect of destroying competition or creating a monopoly," state law says.

In determining the reasonableness of rates, the commissioner should consider the number of insurers engaged in the class of business, the existence of differentials in rates, whether long-run profitability for insurers is unreasonably high in relation to riskiness, consumer knowledge of the particular market and whether price competition is caused by the market or is artificial, the law says.

"It's a very difficult situation," said Janice Moskowitz, one of two Insurance Division actuaries charged with analyzing malpractice insurance company reports. "No matter what we do, we are criticized. We cannot control the market."

After reviewing St. Paul's 1999-2000 rate filing, Moskowitz said, "I think (its) rate level was too low, but we didn't know that at the time. If we had known that (it was) too low, we could have done something.

"In several cases we have asked a company to raise its rates because they are too low. But nobody was complaining about St. Paul, and they are A-plus rated company, and we really didn't know," Moskowitz, who has been at the division for two years, said.

"It's a difficult line to walk. And I also think the market is overreacting," she said.

Regulators often have trouble predicting medical malpractice markets, Thistle said. And there is a trend away from heavy regulating, he added.

"The Insurance Division just doesn't have the personnel. That's not unique to Nevada," Thistle said. "The reason regulators exist is to look for solvency. The Insurance Division isn't going to want to see every claim that comes in to a company.

"In principle, regulators can get companies to charge higher rates, but that's a very tricky bit of business and the movement has been away from that sort of thing for a long time," Thistle said.

"If you look a the longer history of the insurance industry, there are a lot of people who argue that the role of regulators is to do what amounts to price-fixing in the industry," Thistle said. "That's not very popular now."

"But the thing you have to keep going back to is the history of claims. That is the fundamental underlying thing. If there is a sudden increase in claims, that seems unpredictable. But if it is a rising trend, stable growth, you have to have some foresight in preparing for that," Thistle said.

"It's something that is difficult to head off at the pass. That's the problem. There is probably blame to go around," Thistle said.

Possible answers

As a community that wants regular, reliable health care, and one that wants to be financially compensated for accidents and negligence, Las Vegas is left in the lurch.

Should the state levy a tax on health care transactions to pay for a verdict or a premium pool? The state can't just set insurance companies' rates at a "reasonable" profit because, Moskowitz says, Nevada has a small number of doctors (roughly 4,000) and many insurers are apt to abandon the market. Additionally, most medical malpractice insurers only sell medical malpractice insurance -- so the Insurance Division has no bargaining power with the companies' other lines of business in the state.

The state could set up its own insurance plan, as Gov. Kenny Guinn decided to try to do earlier this month, but doctors have said that plan is barely better than others.

In an ideal world, doctors could implement additional programs to guard against medical malpractice. They could be more forthcoming about medical errors so that the public isn't left in the dark about physician performance. They could be more diligent about disciplining bad doctors.

The public could recognize its growing tendency to demand money whenever anything goes wrong, could question that belief and could be more aware of the trade-off between knee-jerk lawsuits and the availability of health care.

Attorneys, too, could self-regulate the bilkers among their ranks. Rather than randomly calling nursing homes looking for someone who has been injured, as doctors allege they do, attorneys could work to develop a more responsible complaint climate.

And, in theory, insurance companies could operate with the community's interest in mind -- at least somewhat.

But if the parties cannot work it out, as it appears they have failed to do -- the government could increase regulations on insurance companies or on the public as it goes to trial or on attorneys as they collect fees or on doctors as they commit malpractice.

A state legislative subcommittee that is studying medical malpractice has begun hearings on the crisis in Nevada and is expected to make recommendations later this year.

As the committee, chaired by Assembly Majority Leader Barbara Buckley, D-Las Vegas, a practicing attorney, investigates the situation, it is reviewing a previous attempt to address a similar medical malpractice insurance crisis. In 1985, the Legislature created the Medical Legal Screening Panel (now the Medical Dental Legal Screening Panel) to limit the number of frivolous lawsuits, and thus limit the number of claims and thus limit premiums.

By most accounts, it is mildly functional.

The panel has three doctor and three lawyer volunteers assigned by the Nevada State Medical Association and the Nevada Trial Lawyers Association. It reviews and votes on the merits of every medical malpractice lawsuit before it goes forward. The panel meets in private -- no one, not even the plaintiff or attorneys involved is allowed into deliberations.

Its decision -- "has merit," "no merit" or "unable to decide" -- is forwarded to the Board of Medical Examiners.

If the panel decides that a case does not have merit, the case can still go to court. However, its determination is admissible as evidence.

Additionally, in findings of "no malpractice" where the plaintiff pursues the case and loses, he must pay the other side's fees.

"It's the most Draconian loser-pays law in any state," Bradley said.

In "unable to decide" judgments, there are no financial ramifications for either side if the case goes to court.

The number of claims filed each year continues to grow with the population, Insurance Commissioner Alice Molasky-Arman said.

Typically, Molasky-Arman said, it takes nearly two years to get through the screening panel.

"One problem is the voluntary nature of the panel. Physicians and attorneys re-schedule meetings for some ridiculous reasons," she said. Additionally, she said, some medical malpractice cases are very complicated and involve "boxes of paperwork" that are "virtually impossible to consider in one evening."

"(The panel) is not successful in discouraging how many go on from the panel, even if they are deemed nonmeritorious," Matheis said. "The problem for doctors is 65 percent of cases with 'no malpractice' findings by the panel go on forward, and that means the panel has little credibility within the physician community."

Matheis recommended that the state pay for a staff of physicians and attorneys to sit on the panel, rather than relying on volunteers.

But in addition to beefing up the panel, lawmakers are considering a number of other remedies.

Perhaps the most common answer to the crisis is the call for tort reform.

Physicians and insurance companies are lobbying heavily for limits on noneconomic damages in the next legislative session.

Cheye Calvo, program manager of employment and insurance for the National Conference of State Legislatures, spent a recent morning briefing subcommittee members on "tort reforms" that other states have enacted.

Some states have shorter statutes of limitation to weed out frivolous lawsuits; others have capped attorneys fees, Calvo said.

Dr. Donald Palmisano, American Medical Association treasurer, told the subcommittee that it should consider $250,000 caps on pain and suffering awards, as California did.

California is widely regarded as a state in which tort reform legislation stabilized the malpractice insurance market.

In 1975 California doctors' rates rose 300 percent, and its Legislature passed the Medical Injury Compensation Reform Act,.

Enacting similar legislation is favored by Nevada physicians as a way handle the crisis.

The reform act has four main provisions: It placed a sliding scale limit on attorney contingency fees; it required juries to be informed of compensation already received by plaintiffs for the same injury; it guaranteed payment of future damages in periodic payments to ensure funds would be available for a victim's future medical treatments; and it allowed unlimited recovery for economic losses, but limits pain and suffering awards to $250,000.

Consumer Advocate Jay Dee Michael of Californians Allied for Patient Protection says the legislation allowed the state to "achieve stability and predictability" in its insurance system.

Injured patients are receiving 17 percent more compensation for their injuries, and claims are settling 30 percent faster than in states without such reforms, Michael added.

Buckley said she wants to consider insurance and legal reforms.

"Certainly, we at least need to look at the resources the Division of Insurance has," she said.

Molasky-Arman said the division needs more people to adequately monitor insurance companies and the Medical Dental Legal Screening Panel.

"But we need to look closer at the way we allow insurance companies to do business in this state," Buckley said.

The subcommittee requested that each active insurance company send a representative to its last meeting, but only two showed up: Whitcraft and a representative of the Doctors Co. of Wisconsin.

Buckley said she is "less than pleased" with the lack of accountability that insurance companies have shown and will subpoena executives if they fail to show at the next meeting July 29.

Sen. Ray Rawson, R-Las Vegas, chairman of the Legislative Interim Health Care Committee and a dentist, said insurance reforms should be considered only after stabilizing the health care market with legal reforms.

"No solution can be complete without addressing insurance issues and regulation, but it is meaningless without the other items (tort reform)," Rawson told the Nevada Medical Liability Physicians Task Force, a group of medical professionals.

"California limits of $250,000 may not be realistic today, but there have to be limits if we ever hope to adequately insure," he said.

"This is a time for all physicians to try to stay at the table and through logic, reason and the power of right and fair issues, find an acceptable compromise," he told doctors.

"This is not a time to threaten or walk away."