Letters to the Editor - July 19, 2004

Practice guidelines a good antidote to forces of self-interest in medicine - Okla. tort reforms not quite so rosy - Public financing central to solving problem of the uninsured - Tax credits must be paired with requirement to purchase coverage

Practice guidelines a good antidote to forces of self-interest in medicine

Regarding "Better ways to address self-referral than impugning integrity of physicians" (Letters, July 5):

I agree with the published letter regarding self-referral that suggests practice guidelines as a means to control the natural human desire to promote one's own interests.

Physicians would do well to admit that no one and no group can promise to ignore their own interests for the benefit of society. Our society is based on economic principles of every person pursuing his or her own interests, and the social benefit that comes from this. The professional altruism of doctors is usually extended to the patient before them, but as most patients see little of the costs of medical care, this is no protection against overuse of expensive technology.

Let's come clean. The medical profession can't change basic economics or human behavior. At the macro level, what is well-funded gets done. What is not, rots.

The public needs to find effective ways to align their own interests with the interests of the decision-makers in health care if good value is to be restored. Those of us with an interest in medicine as a service and a profession need to help it happen, lest we slide further into the abyss of rising costs sans value.

--Bruce E. Robinson MD, MPH, Sarasota, Fla.

Okla. tort reforms not quite so rosy

Regarding "N.J., Ohio, Oklahoma pass tort reform" (Article, June 14): I am shocked by your positive take on what is obviously one of Oklahoma medicine's greatest defeats ever in the Legislature.

You said we were the "biggest winners" with a $300,000 cap on noneconomic damages. But it's a soft cap and removes the old real cap we won for the ER and OB doctors. This soft cap does not apply in wrongful death cases, if the settlement offer isn't considered large enough. Also, the jurors may decide to remove the cap if they so desire. In short, there is no cap in Oklahoma now.

At least, now we can legally say we are sorry in Oklahoma now. I'm sorry we have this bill.

--Layne Subera, DO, Skiatook, Okla.

Public financing central to solving problem of the uninsured

Regarding "Tax credits are best approach for uninsured" (Editorial, June 14): I must disagree. If we are to be compensating for caring for the uninsured, organized medicine must abandon its love affair with tax credits and private commercial insurance. There is a reason insurers don't currently compete to offer coverage to individuals and small businesses. The insurers know that a small percentage of people (the sick) are responsible for a large percentage of the cost.

The easiest way to make money in the insurance business is to cover large groups of healthy people, and find and exclude the high risks, the sick. This is called underwriting, or risk management. It denies coverage to the very people who need it most. Consider our experience with the portability provisions of HIPAA: Certainly a laid-off employee can continue to participate in his or her former employer's health plan, but often only with a big premium hike. Regulations won't solve the problem either. If government mandates premiums that are too low to cover the cost of care, companies may simply withdraw from the market (think Medicare+Choice, or malpractice insurance.)

The only way we can cover the uninsured -- the working poor and the sick -- is to provide public financing in some way, whether government re-insurance a la Kerry, pay-or-play, or the opportunity to buy into Medicare.

--Caroline Poplin, MD, Bethesda, Md.

Tax credits must be paired with requirement to purchase coverage

Regarding "Tax credits are best approach for uninsured" (Editorial, June 14): Your editorial highlighted the clear potential to provide subsidies in order to reduce the number of uninsured. However, the editorial did not discuss the key follow-on issue, the mandatory use of such credits.

The key issue is that the purchase of health insurance cannot be left to a voluntary decision. Because 20% of the population generates 80% of the costs, all of the 80% must join the insurance pool in order to reduce the costs for the 20%.

Therefore, we have no choice but to discuss and eventually pass an individual health insurance mandate. Through this mechanism, the 15% of the population who is uninsured will be simply forced to buy health insurance, just as we are forced to buy into Social Security.

By complementing such a mandate with the subsidies provided by refundable tax credits or tax deductions, depending on the income, we should be able to cover the remaining 15% of the population who persist in remaining uninsured, within weeks of passing such a simple law.

--Kenneth S. Abramowitz, New York

Editor's note: Abramowitz is a health care analyst and general partner at New Global Network, a health care venture capital firm.