Letters to the Editor - July 10, 2006

SGR stealthily undermines care -- what will physicians do about it? - Urgent care fellowships as valid as other specialist training - Quote, as it appeared in AMNews, did not accurately reflect my position

SGR stealthily undermines care -- what will physicians do about it?

There's an old folk myth that says a frog thrown in boiling water will quickly jump out. But a frog in a pan of cold water that is gradually heated will doze happily and cook to death, without ever waking up.

Medicare beneficiaries are not frogs -- but the frog-boiling analogy resonates.

There are certainly valid reasons for the federal government's concern about the cost of the Medicare program: our increasing life expectancy, the impact from baby boomers and ever more expensive diagnostic procedures and therapies. Adding to the pressure on Washington is the taxpayer expectation that after a lifetime of paying into the system, the Medicare program will provide virtually unlimited, American-style (read: no waiting), excellent health care.

The government faces these choices: increase taxes, decrease benefits or increase efficiency.

Increasing efficiency is a great idea, but pay-for-performance is not going to do it. The necessary adoption of appropriate information technology that could help requires a huge investment in both time and money -- investments that not many individual doctors are able to make.

Since the government is unwilling to raise taxes, that leaves decreasing benefits as the remaining option.

And that is how we came to have the sustainable growth rate, the formula that bases payment for physician services on the number of cars produced, ears of corn harvested, pizzas sold and so on.

So how does the SGR boil the frog?

With the decreased, and decreasing, Medicare reimbursement rates, medical students are avoiding the specialties that are heavily dependent on the low reimbursement Medicare E&M services -- general internal medicine and family practice. Already in some areas of America, patients are waiting for a 10-minute-or-less appointment for follow-up on their diabetes, hypertension, heart disease or other chronic illness.

So what should we do about the SGR and our relationship with Medicare?

For the past several years, physicians have been begging for reimbursement increases that are consistent with the increase in the cost of living. We have been phenomenally unsuccessful. The government cites the almost universal acceptance of Medicare assignment as clear evidence that the sky is not falling; that there is no access-to-care crisis. Meanwhile, we have been pacified with increases that are significantly less than the increase in our expenses -- and less than what other components of health care receive.

So the question that I ask our colleagues, including today's medical students, is: What should we do? What should we ask our professional organizations to do, and how should we suggest that it be accomplished?

How can we protect access to good, perhaps even excellent, health care for the expanding Medicare population?

How can we save the frog?

--Melvyn Sterling, MD, Orange, Calif.

Editor's note: Dr. Sterling is a California delegate to the AMA House of Delegates and a member of the AMA Council on Science and Public Health.

Urgent care fellowships as valid as other specialist training

Regarding "Urgent care medicine eyes specialty status" (Article, June 12): You interviewed a physician -- chair of an emergency and urgent care group practice -- who noted, in the words of the article, "that most family and emergency medicine physicians are adequately trained to handle urgent care medicine." I can't help but wonder what someone like that physician would have said back in 1969 when the AAFP developed its certifying board. I'm sure that most GPs back then thought the same thing: "I don't think it's necessary."

Using that physician's line of reasoning, why should we bother with ER residencies? Just expand the number of family physician positions?

As a physician actively practicing urgent care medicine, I applaud the establishment of an urgent care fellowship. We're not just a bunch of "docs-in-the-box." What I do is every bit as valid as long-term management of chronic problems.

--John White, MD, Jackson, Tenn.

Quote, as it appeared in AMNews, did not accurately reflect my position

Regarding "Looking for a financial adviser? Beware these red flags" (Column, June 12):

I am quoted in your article as saying, "Even though it's someone you trust, and even if your account is doing well, [it's important] not to ignore red flags, because ultimately the responsibility comes down to the investor."

The construction of the quote makes it appear that I was saying it is the investor's ultimate responsibility to ensure misconduct does not occur with respect to his or her investment accounts.

That is not something I would contend because it is not something I believe. If that was true, the legal system would offer no opportunity for an aggrieved investor to obtain meaningful relief against a financial adviser who engages in misconduct.

The truth is that investors who have suffered losses due to broker misconduct can recoup wrongfully-caused losses through arbitration or, in some cases, litigation.

I agree that investors certainly should be aware of potential red flags in order to protect themselves against losses, and I believe articles such as yours help educate investors. Unfortunately, an article that leaves the wrong impression of who bears ultimate responsibility for a broker's misconduct risks losing much of the good it otherwise achieved.

An investor's failure to recognize these warning signals does not mean he or she is "ultimately responsible" for any resulting losses.

Such responsibility belongs with the financial advisers and brokerage firms who engage in wrongdoing with respect to their customers' investment accounts.

--Laurence M. Landsman, Chicago

Editor's note: Landsman is a partner with the Chicago law firm of Block & Landsman.