Healthy Prescriptions

The series of articles on health care in the March issue was outstanding. The political process is mostly talking about payment issues and ignoring the real issues of delivery of care. It's the same old story. Politicians want to talk about money and income transfers. The real issue is how the special-interest provider groups have been able to increase their incomes at the cost of the receivers of care. Changes in federal tax policy and regulatory reforms at the state level are at the heart of the needed changes in public policy on health care.

Ross C. Korves
Deputy Chief Economist
American Farm Bureau Federation
Park Ridge, IL

The articles in the March issue were most informative. "Political Prescriptions" provides an excellent summary of the current Washington climate for health-care reform and the proposals being debated. As the tone of the article suggests, the pressing health-care crisis cannot wait for major solutions at the national level. Knowing that progress will be slow in Washington, we in Virginia are moving ahead in the areas of insurance reform by strengthening the primary infrastructure and critically looking at the appropriate use of our high-technology and cost-intensive resources.

"Market Medicine" raises the issue of appropriate manpower usage in the provision of health care. Faced with the cost of subsidizing expensive specialized physician training and fees, as well as the existence of many medically underserved areas, Virginia is looking at ways to better utilize alternative providers. Also, we need to go further when we talk about health-care quality. We need to address the appropriateness of procedures as they relate to the outcome of a diagnosis and treatment of a patient. After all, health care that does not significantly improve a patient's condition, such as additional tests, is unnecessary and adds to costs.

"Home Delivery" provides some good information that can be used as we continue to debate the appropriate place of nurse-midwives and birthing centers in Virginia's health-care system.

"Cold Reality" provides some excellent information about patient waiting times by specialty in the Canadian system. The article's look at Canadian forms of rationing is particularly instructive. I find it interesting to compare Oregon's public debate over health-care service priorities to the decisions made by hospital administrators and health officials through budgets in the Canadian provinces and hospitals.

Of course, we were pleased to see that Roanoke's Bradley Clinic had such a wonderful spotlight in "Doctors Without Bills." We are currently in the midst of assessing the primary-care needs of the uninsured throughout the state and encouraging more public/private community solutions in which communities identify local health-care problems, assume responsibility for the problems, and solve them locally. We have other successful examples in Virginia, but the Bradley Clinic, which annually provides approximately 7,000 physician visits and 10,000 free prescriptions on an operating budget of about $250,000 in donations, is truly a star in our system.

Gov. L. Douglas Wilder
Richmond, VA

Will Free Work?

As the director of one of the oldest and largest free clinics in the country, I appreciate the value of these agencies to the communities fortunate enough to have one. The Bradley Free Clinic ("Doctors Without Bills," Mar.) is a fine organization and has done an admirable job of enlisting the support of the medical community in Roanoke to assure continuity and success. Nevertheless, we should recognize that the free-clinic model has specific limits as well as values.

Free clinics may play an important role in the health-care delivery system of any community who can mobilize such efforts. The most obvious role is to serve those who do not have access to other care. However, when the free-clinic role is defined as a specific part of any national health-care plan, I believe we have extended our reliance on this model beyond the bounds of reason. This belief is not intended to devalue volunteerism or charity care; rather it focuses on the nature of free clinics. These agencies are designed to respond to community crises. They are able to mobilize resources to respond to emerging and changing health-care needs.

Free clinics flourish in the vacuum of unmet need. They are driven by the organizational value of the provision of quality service. Support bureaucracies, important in other systems to determine eligibility for care or for securing first- or third-party reimbursement, are anathema to their efficient operation. Free clinics should serve as the community conscience, advocating for inclusion into our health-care system those who are unable to gain access to health care, while assuring that their short-term needs are met.

Finally, I believe that it speaks poorly of the United States, a country that spends such a high percentage of our gross national product on health care, if we rely upon the charity of others to provide a system to assure basic services to our population. Free clinics are the fail-safe for those missed in the sweep of the system. Allow them to continue that role, one in which they have demonstrated ample effectiveness over time, and let us get on with the business of adopting a system to provide health care to all our citizenry.

W. Martin Hiller
Executive Director
The Free Clinic of Greater Cleveland
Cleveland, OH

One big impediment to charitable work is the potential medical-malpractice liability. Medical professionals are asked to provide pro bono services, but doctors are just as exposed to suit for these services as they are from their paying clients. In fact, they may be even more exposed because the patients that they see for free are probably in worse shape, and therefore in more medical danger, than their paying clients.

One cure for this would be the charitable-immunity defense, but this doctrine was eliminated in Texas by the state Supreme Court years ago. I imagine that it only takes the sight of one community-minded doctor getting sued for his generous efforts to make others ask, "What's the point?"

Jim Parker
Austin, TX

A Helping Hand

Midwives want to practice with physician backup ("Home Delivery," Mar.). I would be delighted to back up midwives if I could be guaranteed that I will not be sued for malpractice. I will take whatever situation they hand me and do the best job I can consulting on it and remedying the situation for them if they will pay my malpractice insurance and any award that the patients might be able to extract from me.

Also, if they want to be allowed to practice in my hospital they will have to get some sort of special dispensation from regulators so that my hospital will not be disapproved, and they will have to free me from surveying their work, auditing their cases, or commenting on their management in any way.

John H. Koning, M.D.
Corona, CA

Canadian Club

If the Canadian system "rationed" health care, as Michael Walker argues ("Cold Reality," Mar.), we would expect to see significantly fewer hospital admissions than in the United States. Instead, the rates are roughly comparable. The popular anecdotal specter of the "waiting list" should be juxtaposed with the statistically verifiable higher death rates among the poor and uninsured in this country who, unable to afford health care, sometimes lack even the luxury of a waiting list until their illness has progressed beyond the point of no return.

As to rising health-care costs, the statement that "Canada doesn't control the cost of individual medical procedures" ducks the fact that costs such as physician's fees are controlled by negotiations on the provincial level.

The bottom line is that both systems appear to work, but ours costs more. This may be largely due to the fact that the U.S. system of private insurers and large hospital billing offices is three times more costly to administer, drawing valuable resources away from health care. Find a way to control those costs, by whatever means, and a solution may be well at hand.

John Walker
Coaldale, CO

Michael Walker replies: John Walker's letter indicates why it is that many people who think the market is the appropriate way to produce and distribute everything from bubble gum to automobiles nevertheless think "health care is different." Health care is an exceedingly complex product and deficiencies in its production are difficult to ascertain. That is why people in U.S. audiences will politely listen to Canadian experts offering monopoly medicine as the cure for U.S. ills. The same audiences would laugh off the stage an expert opining that an automobile monopoly would solve the auto sector's problems. Everybody can tell that a Trabant is an inferior product.

Mr. Walker says that if there is rationing in Canada, there should be lower hospital admissions. This simply isn't the case. A recent personal example will illustrate. In January I was diagnosed as having a kidney stone lodged in my ureter. My heavy travel schedule and the associated risks caused my urologist to recommend that I have the stone removed. Lithotripsy is a painless way to do this. Unfortunately, the waiting lists for this procedure were much longer—three weeks—than I could wait. I had the stone removed by the direct and more painful technique that was the only solution before lithotripsy was invented and the only means effectively available to me in British Columbia at that time.

In this case, a hospital admission and surgery are actually recorded in our statistics because there is a waiting list for the lithotripter. In other cases, procedures that are done in private clinics in the United States would be done in hospitals in Canada, because such clinics do not exist here.

On death rates and poverty and the notion that nationalized health care will make a difference, the following comment appeared in a recent issue of the B.C. Medical Journal: "…twice as many infant deaths occurred in the most-poor areas as in the least-poor areas….Among adults, those in the most-poor areas had the shortest life expectancy, with males in the most-poor areas living six years less than those in the least-poor areas." This study refers to the two largest cities in British Columbia. Monopoly, nationalized health care will not solve the problems of the poor.

Physicians' fees for services are controlled. Until recently, the total billings of physicians were not. Numbers of patients seen per day adjusted so as to partially offset the impact of the fee controls. Since the fee is meant to buy a physician's time, a combination of reduced time and lower fees produces an unknown change in the cost per unit of service actually provided.

On the costs of administering the competitive, private U.S. health-care systems, I think Mr. Walker is really on to something, but he doesn't go nearly far enough. Think, for example, of all the money that could be saved if the wasteful duplication involved in the automobile market were eliminated. Think of all the invoices and other paperwork, not to mention showrooms, service people, and other duplicated facilities, that could be eliminated. Think of all the advertising workers and media space and time that could be freed up. And, when we're finished with autos, let's turn to breakfast cereals and from there to life insurance, and what about all those gasoline stations wasting all the space on our best street corners selling, on a competitive basis, essentially identical products? Before we are done we can save half of the GDP, which would not only provide everybody with health care, but also ensure, finally, that nobody in the United States would have an income less than the average. (I know, but now is no time to get technical!)