Dear FRONTLINE,

Many who have commented on your excellent presentation site the "greed" of health plans. However, it is the consumer that drives the market. Every company that is, Human Resources Department that purchases insurance could choose an indemnity plan instead of an HMO. That they opt for an HMO says something about the priorities of the young families that constitute the majority of the work force in America today. These young families, not believing that they will become ill, choose the lower cost option. It is the minority that do become ill, or suffer an accident, and require care. The remainder of this population benefit from the low cost of insurance premiums. Insurance companies merely respond to this market characteristic, they do not create it.

One way of presenting a more balanced interpretation of the managed care versus fee-for-service traditional health care delivery system debate is to consider the following hypothetical:

Assume there are 20 orthopedic surgeons in a room asked to evaluate 100 patients for total hip replacement. This observer submits that of the 100 charts reviewed, there will be unanimous agreement that 25 require surgery failure of Physical Therapy, failure of Non-Steroidal, severe pain, low risk, etc.. Similarly, there will be unanimity concerning 25 that absolutely do not require surgery too high a surgical risk, no attempt to control symptoms with conservative treatment, etc.. The difficulty will be seen in the 50 in the middle, the "gray zone" of patients in which there is uncertainty. As one suggested in these comments, "above all do no harm." I submit that uncertainty, as manifested by the lack of agreement amongst these hypothetical 20 orthopedic surgeons leads to the conclusion that "when in doubt" it is sometimes safer to "wait and watch." Surgery, like toothpaste once out of the tube, is awfully hard to put back in.

The essence of the debate is this. In fee-for-service, the approach to uncertainty is "let's give it a try." In managed care, the approach to these 50 patients in the gray zone is, let's wait and watch. Managed care and fee-for-service both agree on the obvious need or lack of need in the obvious patient. Patients who need care get it, and patients that should not have care, do not get it, in both systems. Both systems are perverse, although outcomes have not been measurably different. The simple truth is, given equal outcomes, one cost less.

Dr. Reinertsen is correct, in my opinion. Medicine, as practiced in American today, requires a discipline of accountability. More is known about the quality of Dr. Soloman's practice today through data collection then of his colleagues in the past or of non-HMO practitioners today.

James Selevan
Mission Viejo, California

Dear FRONTLINE,

Were you able to ascertain how much the doctors in POD 11 were paid for their practices when they joined CareGroup? CareGroup is probably in a precarious position because they over-paid physicians for their practices. And after making substantial gains from selling their practices, physicians are now complaining about having to pay the bill now.

Norbert Guimond
Phoenix, Arizona

Dear FRONTLINE,

We must decide first whether or not Americans are entitled to an adequate standard of health care, otherwise we cannot even begin a rational debate on the best health policy. If essential medical care is a privilege for those who can afford it, then it's fine to leave patients to die if they have no money. If all Americans have the right to expect at least a minimally adequate qualtity of medical care, as is true in every other industrialized country in the world, then we should establish a universal health care system. And if we all have access to the same system of care, then we will all have an incentive to provide the resources that are needed but not to waste them.

As for the present problems, we doctors have only ourselves to blame. When insurance first became widely available, Blue Cross would pay whatever the doctor charged. So we inflated our bills to unimaginable levels. When I tried to suggest that my colleages were overcharging, I was laughed at.

We cut medical school positions to ensure we could all get the jobs we wanted, then complained when the physician shortage here attracted so many physicians from overseas.

When we were paid for every treatment and test, we shamelessly overtreated. Now, paid to deny care, we shamelessly undertreat. We complain about our patients' care, but the bottom line is that if we aren't paid about twice what a physician would make for the same work in most other counties, we will not take care of them.

We fought the evil of "socialized medicine" so effectively that our profession is now ruled by business executives some with MD after their names who are answerable only to their stockholders and demand "productivity" from us rather than quality care. We American physicians had a goose that laid golden eggs, and we strangled it with our shortsightedness and greed.

Dan Woodard, MD
dan@siri.org

Daniel Woodard
Merritt Island, FL

Dear FRONTLINE,

The incredibly huge cost nobody is looking at is the cost of maintaining the bean-counters themselves stands to reason, as they are the ones doing the analysis. But I ask what do these people contribute to the essential equation of health care? Nothing, they are a charge on the system. They are sitting in positions of middle and upper management collecting extravagant salaries and nagging my doctor over a $2 a month increase in his xray billing. Management is the extra layer, the element that can be reduced by computerization without hurting patient care. Let's do it!

Susan Williams
Lakewood, Colorado

Dear FRONTLINE,

With the rising costs of healthcare what can consumers do to
get the kind of care needed? I am
in an HMO and there are recent reports that the Nalle Clinic will have to start paying its doctors less and this could result in many of the physicans leaving. If this king of action is ocurring now what is going to happen 10 20 years
from now?

Sincrely,
Daryl Gilmore

Daryl Gilmore
Charlotte, NC

Dear FRONTLINE,

I think that doctors should assist the patient in making choices including financial aspects of care as opposed to doctors having a financial incentive "for keeping costs down". It seems interesting to me that if this is to be run as a business, from the patient's business perspective, it's actually a bad financial control model for the patient since the doctor has a conflict of interest. The patient is in a contract with the doctor to receive the best advice the doctor's medical skill can provide. If the patient managed their life as a business, they wouldn't allow such a business relationship where a contractor had a conflict of interest.

A very good program. I wished there could be more information on what insurance alternatives can/could be offered that would allow patients more control to make choices that insurance companies and doctors both can live with. Do such alternative exist? Or if they did would the premiums be tolerable? I think US policy should be based on providing patients with choices where patients have up full knowledge of the services and the services limitations. People will make the right choices for themselves and if the "right" level of services isn't available, then the government should act to faciliate some basic level of services. And if society decides it is acceptable that there is a need for a minimum level of care resulting in institutions "losing" money, then it is not really losing money but rather a national premium for a minimum care. Bottom line let patients drive the level of service and not the insurance company. Patients seem to be powerless to get the services they want.

Marty Ferris
Washington, DC

Dear FRONTLINE,

The Frontline show did not mention sources of the economic pressures, e.g., drug companies' overpricing of medications, or insurance companies' overpricing of group benefits which raises the cost to employers. Health care personnel have already taken cuts in pay & benefits,not just doctors, who suffer the least because they earn more. Why doesn't the gov't regulate these companies, as they did during WWII, so that they limit their profits? An economic problem can be solved by economic means, not by sacrificing people.

Julia Spears
Brenham, Tx

Dear FRONTLINE,

If you make a deal with the devil you have to be willing to pay the price. Dr. Salomon was eager to enter into a capitated HMO scheme when he thought it would be profitable to him, but now that it's not, he's upset, complaining and whining that things aren't fair. How much money did he receive front when he sold his practice? It's part of the same "bargain". If doctors weren't willing to participate in these schemes in the first place, they wouldn't exist, but he bought in for the cash, now he's got to pay the price, or do his patients? Dr. Salomon has obviously been a doctor for sometime. He was probably a beneficiary of the financial heyday of when American doctors made 10 or 20 times the average U.S. wage. Was he complaining then? It was those excesses that helped bring on this horrible, reactive environment of dramatic cost cutting. Part of the problem is Dr. Salomon's feeling of finacial entitlement. If his top priority is maintaining his six figure income, perhaps he should move into medical investment banking and out of healthcare. Once upon a time U.S. doctors went into medicine to do "good". Somehow many people in America get by on less than a six figure income. Dr. Salomon's dilema, is really the fact the he can't give top quality healthcare AND make the amount of money to which he feels entitled.

cynthia cycon

Dear FRONTLINE,

You did not fully discuss the economics that is drove the clinicians and hospitals to accept the risk of treating patients under capitated contracts. Health care poses a delimma because it is considered both a market good and an essential human right to many people. Yes, the cost of the quality of health care that people have grown to expect has risen. However, the individual consumers are not the ones making decisions about how to pay for the health care they feel they deserve. Large employers are the ones that have the market power over purchasing health plans. Because of the nature of health care, it cannot and should not be considered a market good that can be freely and fairly traded in today's market. We do need to regulate health care. Otherwise, we are allowing employers and insurance companies to gamble with people's lives.

Maria Ramos
Houston, Texas

Dear FRONTLINE,

In a time when there are billions being made daily and spent foolishly, as per example, gambling we can't find the funds to maintain an efficient and dignified medical health system. We waste more money than it would take to fund such a system. Somehow this issue was lost after Mrs. Clinton was ravaged by her detractors and now it's untouchable. It's time to revisit it.

Robert Herbert
Neptune, NJ

Dear FRONTLINE,

I am a physician who has been trained in both acute care Internal Medicine and rehabilitation care Physical Medicine and Rehabilitation. I have pondered this dilemma for many years. I have seen other country's systems that have universal access to what is usually universally poor care unless other alternative routes are taken for instance, tipping is not uncommon in these situations.

I have concluded that the day someone tells me what to do, how to do it and when to do it and does not take responsibility for doing so then that is the day I quit medicine. I view myself as someone who makes the recommendations for optimal and reasonable care. I often tell my patients that I am not in charge of what their health plan pays for-that contract is between the customer/patient and the carrier.

I have also come to conclude that the only viable and ethically realistic solution is the following:
1 Allow all individuals to have their own Medical Savings Account.
2 Allow all individuals to deduct the premiums of the health care plan of that individual's choice
3 Allow physicians to deduct the charity care they provide
4 Truth in pricing-i.e.physicians would have to clearly state what the charges were for procedures, etc.

Roy Blackburn M.D.
Elizabethtown, KY

Dear FRONTLINE,

I am a kidney transplant patient, and what I saw on "Dr. Solomon's Dilemma" pissed me off. The show should have been titled "Dr. Solomon has a Dilemma because Insurance companies value record profits over patients health care." I am worried that in the future I will become too costly to care for and then what will I do?

joseph drake
newnan, georgia

Dear FRONTLINE,

When I was pregnant with my first child over 6 years agoI did not belong to an HMO. Rather, my insurance covered 80%, I had a $250 deductible, and an out-of-pocket maximum of about $2000. I did not want to be part of an HMO because my various doctors were all a part of different plans. I was totally pleased with all aspects of my care. Having the baby, and the subsequent medical costs of the baby pregnancy, delivery and baby were all normalamounted to a total cost to me of over $2000.
By the time I was pregnant with my second child we had moved to another state, and I was now a part of an HMO. Again I had a totally normal pregnancy and delivery, and the baby was fine. This pregnancy cost me only $50! Plus the extra $100 I paid for a private hospital room.
It seems that something has to give in this equation. I believe that my monthly premiums were coomparable, but the out of pocket cost to me was so much lower with the HMO. While as a consumer I was happy to pay only $50 and not $2000 out-of-pocket, this system seems doomed for failure. How could I receive the same care for so much less? Obviously the doctors and the hospitals are bearing the bulk of my cost savings.
Is this situation in general true, that I pay less as a patient, and the doctor and the hospital are under pressure to keep their costs down?

Jane Davey

Dear FRONTLINE,

It never ceases to amaze me how the responsibility for the current health care system is laid at the feet of us physicians. We are constantly being accused of putting money before patient care.

We did not invent managed care. It was foist upon us by enormous insurance companies. Because of anti-trust laws, we are forced to negotiate against these behemoths as individuals. Like anyone else, we have bills to pay, and we have to be able to make a living.

The truth is, there is either too little money in the system, or we are offering too much. There is no other place on earth where there is an MRI machine on every corner, where patients can have whatever service they want, and get it almost immediately. As the saying goes, you can't have everything.

In England and Canada, which have nationalized medicine, care is strictly rationed and they are still always in the red - how much more so are we going to be with total free access to just about anything.

Michael Pinn
Dallas, Texas

Dear FRONTLINE,

I am a physician struggling with capitated health care on a daily basis. In the report featuring Dr. Solomon you failed to focus on a driving force behind the decline of our system. The patients have chosen to accept less expensive insurance plans that will not pay for the high quality care they expect. How can a patient complain about her doctor's concern about the cost of her care if she or her employer has chosen to pay for the least expensive health plan? Also why was there no mention of the responsibility of the government and its voters for the continued reduction in medicare reimbursement? Someone has to pay for the excellent care we are able to provide. Patients must realize that if they continue to demand lower premiums from their insurance companies, they will get lower quality care.

David Vigder, MD
Chicago, Illinois