As doctors voiced anger at an Annapolis rally yesterday over escalating insurance costs, legislative leaders said they remain far from a consensus on how to address the problem before Maryland physicians' bills come due next month.

Gov. Robert L. Ehrlich Jr. (R) and the General Assembly's top two Democrats have stepped up negotiations in recent days and plan to meet again today in hopes of bridging differences on key issues: how to pay for a proposed state reinsurance fund and what limits might be placed on malpractice lawsuits, which doctors blame for escalating premiums.

"The two real sticking points are still unresolved," House Speaker Michael E. Busch (D-Anne Arundel) said. "I hope everyone would rise to the occasion to address the issue."

Ehrlich and lawmakers have been talking since summer about the possibility of a special session to deal with medical malpractice insurance. But the search for common ground has become more urgent with the approach of Dec. 1, the day that insurance payments are due to the state's largest malpractice carrier.

T. Michael Preston, executive director of the Maryland State Medical Society, said he does not believe a special session is "out of the question," but added: "It's getting harder to see as time moves on. Here it is almost Thanksgiving, and it hasn't happened yet."

Medical Mutual Liability Insurance Society of Maryland, which provides coverage to more than three-fourths of the state's doctors in private practice, plans to raise rates by 33 percent next year, after a 28 percent increase this year.

At yesterday's rally, organized by a group called Save Our Doctors, Protect Our Patients, doctors decked out in white lab coats argued that, without state intervention, they could be forced to quit practicing.

Carol Ritter of Baltimore County said she had participated in a rally 10 months ago in which she told the audience of having given up her obstetrics practice because of rising insurance costs. Since then, calls to the legislature for help have gone unheeded, she said.

"When are you guys going to get to work?" Ritter asked. "What's it going to take to convince you?"

Senate President Thomas V. Mike Miller Jr. (D-Calvert), Busch and Ehrlich have all expressed interest in creating a state fund that would allow insurance companies to freeze next year's rates by having the state pay a portion of malpractice jury awards and settlements.

Miller and Busch advocate paying for the fund by imposing a 2 percent premium tax on health maintenance organizations. Ehrlich opposes that approach, which legislative analysts say could generate more than $80 million a year. Ehrlich said he is looking at several alternatives, including covering payouts through the state's general fund. That approach could require budget cuts in other areas.

More contentious is a list of legal reforms being pushed by Ehrlich that would effectively curb jury awards and settlements to plaintiffs in malpractice cases. Miller, a lawyer, said he considers some of those measures "patient abuse." Busch has tried to position himself in the middle on legal reforms, none of which is expected to affect doctors' premiums for several years.

"The House would support as much as the governor and president can come to agreement on," said Busch, whose chamber passed a bill last spring that included some of the reforms Ehrlich seeks.

Ehrlich said there have been "intense negotiations" in recent days over his proposal to cap at $650,000 damages available for "pain and suffering" in all malpractice cases, including those in which the victim dies. Under current law, damages for pain and suffering are capped at that level but the amount can rise to more than $1.6 million if there are multiple claimants in a wrongful death case.

Several lobbyists involved in the issue have said in recent days that Miller's acceptance of a reduction in that cap could be key to brokering a compromise. Miller declined to offer his position.

Other proposals by the governor seek to curb payouts for lost wages and medical expenses. Miller has referred to several of the proposals as "right-wing."

Ehrlich acknowledged this week that he knew Miller would have "major problems" with some of the provisions, including a cap on contingency fees for lawyers. But Ehrlich defended his initiatives as sound policy.

Meanwhile, a Senate task force is still developing measures to protect patients and to reform the insurance industry. Sen. Brian E. Frosh (D-Montgomery) said the group will not meet again until Dec. 1 and suggested that a special session before then is unlikely.

"Part of this process is patient safety and allowing the hospitals to get rid of the bad doctors that are causing the problem," Miller said.

Surgeon Karl Riggle of Washington County, founder of Save Our Doctors, Protect Our Patients, addresses a rally at the State House in Annapolis to urge action on malpractice insurance rates. At the rally, Megan Bonham, 4, sits near her father, Brian, a doctor in Smithsburg, Md.