Letters

From the May 1999 issue

(Page 2 of 5)

The solution is simple and was the model for medicine in this country until 1945, when it was corrupted by employer-funded insurance and later by Medicare. The solution is fee-for-service medicine (sounds like free markets, doesn’t it?). Under this model, the only role for insurance companies is to cover catastrophic illness or injury, with routine office visits, prescriptions, etc. paid for by the patient. At today’s prices that would be unaffordable, but with downward market pressures we would see significant deflation in the medical arena. Some things would suffer, like drug research and development, and we have to be prepared to accept that.

It is a fundamental non sequitur to "pressure providers to constrain spending." In what other area in life do we tell providers not to provide? The only one that comes to mind is the Agriculture Department’s policy of paying farmers not to grow. Is this the free market model Mr. Hazlett endorses? I don’t want lawyers, Congress, or Mr. Hazlett involved in medicine, and I’ll bet he won’t raise the issue the next time he’s in the emergency room with a broken arm facing an "overutilizing" provider.

Terry Wintory, D.O.
Aurora, CO
[e-mail]

As much as I usually admire Thomas Hazlett’s writings, he has managed to trivialize a very complicated and important issue by going after a classic "bad guy."

I don’t see what Hazlett’s problem is with Dr. Smith’s desire to make as much money as patients are willing to pay him. As far as I can tell, almost every serious investigator who has researched the origins of the high cost of medical care in the United States has concluded that after World War II employers, restricted by wartime wage and price controls, bid up the cost of third-party medical insurance benefits to prospective employees in an effort to recruit returning workers in a highly competitive environment.

This bidding war wrecked the market in low-cost health insurance, making employers the single largest purchasers of insurance (the feds only recently having surpassed them as a source of health care benefits) and divorcing the patient from tradeoffs between benefits and costs.

Naturally the feds couldn’t leave well enough alone and mandated that all larger employers who offered any health care benefits had to offer an HMO as an alternative to their employees, further warping the market. Now the feds can’t resist bashing the same concept they were touting just a decade ago.,/

For most ordinary middle-class people, the best option is to pay ordinary medical fees for ordinary visits as we go, insuring only against unexpected, high-cost illnesses and injuries. A wide range of tradeoffs between annual premiums and point-of-service co-payments is available, and employers can limit their costs by designing cafeteria-style benefits packages, allowing employees to choose the insurance plan and contribute more or less out of their own pockets to get their favorite choices.

There are many ethical and professional physicians who legitimately believe that the intrusion of powerful third parties into the practitioner-patient relationship has harmed the practice of medicine and been detrimental to the patients themselves. There are many excellent HMOs, and no one seriously believes they should be banned. The power struggle among government agencies, physicians’ groups, patients’ rights advocates, and employers is not relieving the situation.

Marshall Anderson, M.D., M.P.H.
Deer Park, TX
[e-mail]

I enjoy REASON but don’t find Mr. Hazlett’s thoughts in "HMO Phobia" very reasoned. Income baiting is expected in other publications, but Dr. Smith’s presumed golf habits seem out of place here. Instead of golf, I spend my afternoon off filling out forms for the latest Medicare perks–"free" batteries for blood sugar monitors, among other things. How much would that battery cost if time and paper shuffling were considered, and could my patient with the Mercedes afford a 59-cent battery?

Believe it or not, a patient and physician are concerned primarily with the patient’s outcome, rather than his money. Where is the logic in promoting an organization that "saves" perhaps 30 percent by denying recommended medical intervention while taking that 30 percent to reward its efforts? "Health care," as they like to call it, is overpriced because the monetary worth of the individual is inflated by our legal system beyond all reason. Mr. Hazlett starts in the middle of the story, where physicians without autonomy are held liable for perfect results while forbidden, by Medicare and some insurers, from obtaining even basic screening studies.

We are second-guessed at a distance, perhaps by an idiot with a cheat sheet, on clinical decisions that require a hands-on assessment. Being damned either way is having predictable results. Realizing that 23-plus years of training and your practice can be destroyed by one "malpractice" suit has encouraged some to maximize income and minimize years at risk–do procedures, make some money, and get out. It isn’t fun anymore.

A lot of money changes hands in health care. Receiving only a small portion of it, physicians assume most of the risks. We realize that costs would be hugely reduced without fear of litigation driving excessive studies and treatment. Go to the E.R. with a headache, and see how long it takes to get your CT brain scan.

The earnest concern voiced now about "patient rights" to sue HMOs seems intended to serve those attorneys not already flush from tobacco litigation and ambulance chasing.