Dear FRONTLINE,

This a very shocking report! I live in Minnesota and I would like to know if my state has the same situation. Please tell me if it's the same in every state?

minneapolis, mn

Producer David Murdock responds: The areas of this country generally considered to be furthest along in shifting risk to physicians are 1. the West Coast, particularly California, 2. Minnesota, and 3. Massachussetts.

Dear FRONTLINE,

Congratulations on an excellent and thoughtful show. Do you have any statisitics on what has happened to incomes of physician specialists, eg rehabilitation and other experts for eldercare, in the Boston area in the last three years since this new trend has taken hold? My impression is that these highly skilled professionals are also being dislocated and experiencing severe difficulty being paid for their services. I would appreciate your comments and any statistics you might have.

Thank you.

las cruces, nm

Producer David Murdock responds: Current statistics can be hard to come by in this fragmented world. This is especially true when it comes to personal income. There is no doubt that rehab centers have taken a big hit from the federal government since the Balanced Budget Act went into effect and that this has lead to many closings. Many physicians in Boston described this to us as one of their most vexing problems. How do you deal with someone who doesn't belong in the hospital but can't make it at home when there are fewer and fewer good rehab places to send them? It becomes a choice between spending more on them to keep them in the hospital or sending them home before they are ready to go, hoping they will be able to cope.

Dear FRONTLINE,

I work in a Managed Care field and was very interested in the program(s) that produced the reports that Dr. Solomon reviewed with Pod 11. I think that level of data would help any managed care field. Can I get more information about the software? I have never seen such extensive analysis of that type of data.

Casey Newton
albany, ga

Producer David Murdock responds: The organization that compiles that information is called the Providers Service Network. Information about them can be accessed through the CareGroup website.

Dear FRONTLINE,

I found this show very informative and disturbing. These are issues I have trouble discussing with the doctor--don't want to upset him, right?

I heard "10 questions to ask your doctor" somewhere in the show, but can't find it on the site. Where might I find this information? Many thanks.

punta gorda, florida

Producer David Murdock responds: It is very difficult to raise financial questions with our doctors. Such questions have always been considered to be rude and challenging. Nonetheless, all of the doctors we spoke with in researching the show professed the importance of the patients understanding the financial incentives at work in their care. Here are some basic questions you might raise with your physician. 1. Are you "at risk" financially for my care? 2. Do you get paid a bonus based on performance measures? 3. Are you penalized financially if your costs are too high? 4. Does your practice follow a drug formulary? (A drug formulary is a chart developed by a practice or a health plan that encourages physicians to prescribe less expensive drugs). 5. Is your practice owned by a larger conglomerate? 6. What specialists are you able to refer me to? (Often the answer will involve certain medical centers or clinics with whom the physician has a contractual relationship). 7. Are you restricted in any way from referring me to someone I want to go visit? (If they are and your specialist is important to you, you may want to consider choosing a primary care physician who is not restricted from referring you to your specialist of choice). 8. Does the cost of the care you give effect your colleagues income? 9. What emergency rooms can I go to without question? 10. What rehab/skilled nursing/hospice centers do you refer to?

Dear FRONTLINE,

Your show was terriffic but very disturbing. My health care plan is Blue Cross which is not an HMO. I am also a patient of Dr. Solomon. My understanding from my benefits office is that although Dr. Solomon is my primary care physician, I do not need his permission to see a specialist nor is he penalized if I do so. If I am hospitalized, I have to pay 20% up to a maximum of several thousand dollars. Again, as far as I know Dr. Solomon is not penalized findancially. So my question is, does the information presented in the Frontline program only apply to people who are in HMOs or are people like myself also effected?

newton, ma

Producer David Murdock responds: Every plan is different. Not all patients are under plans that put their physician at financial risk for care. Under some plans you are free to go wherever you want. The best way to find out your personal situation is by asking Dr. Solomon himself - clearly he is up-front with his patients about the financial constraints he feels. You can also ask your HMO.

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

Producer David Murdock responds: Several viewers have raised this point. It is a fine example of how quickly the accepted wisdom of day can be turned upside down in the medical marketplace ñ driving administrators, doctors, and patients to distraction. Five years ago the hospital systems like CareGroup and the much larger competitor known as Partners were in a huge rush to buy up primary care practices in order to funnel patients into their hospital beds. This kind of frenzied buying was taking place in many areas of the country. No system wanted to be left behind in the rush to grab doctors. Today, this medical arms race is looked on as one of the most unfortunate miscalculations in the health care business. These purchases did play a part in putting these systems in the hole they find themselves in today. Mr. Guimond and other viewers are correct to suspect that this is one of the reasons the systems now are expecting the doctors to help control costs and make the institution more financially stable.

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?

Sincerely, Daryl Gilmore
charlotte, nc

Producer David Murdock responds: The fact of the matter is that absolutely no one knows where this is leading. Most everyone agrees that we are headed for another crisis period similar to the one that led to the era of managed care to begin with. Many think that more and more of the cost will be shifted directly to the patient. Dr. Reinerten discusses this possibility in his interview.

Dear FRONTLINE,

When I was pregnant with my first child (over 6 years ago)I 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 normal)amounted 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?

chatham, nj

Producer David Murdock responds: This is an excellent point that echoes what many doctors are saying. We spoke to many who believe that patients have been spoiled by their managed care plans into believing that co-pays of ten to twenty dollars should cover any test, drug, or procedure they make use of. What drives doctors crazy is that they feel like they are put in the position of educating patients about the actual cost of care when they (the doctors) should be keeping their hands clean and concentrating solely on medical care. Many, like Jim Reinertsen believe that more cost will be shifted to the consumer and therefore it will be up to the patient to decide whether certain expensive drugs or tests of procedures are worth their money.

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

Producer David Murdock responds: The role of the employer is one of the great misunderstood elements in the American health care system. The cost and quality of the care we receive is influenced greatly by what employers ñ and the government as the nationís largest employer ñ are willing to ante up. Thank you for raising this important point. Many people have written in to note aspects of the American health care system we did not address in the hour. That is one of the most difficult challenges facing producers doing stories on health care or any other complicated story ñ how do you tell something in a compelling way, and how much information can viewers absorb in 50 minutes of television? In the end we always have to make choices about what we can include and how much complexity a story can bear. Our hope is that this show was both informative and interesting. In no way do we believe that we have answered or even raised all the important questions surrounding this most vexing area of our public and private lives. We are grateful, therefore, to the many intelligent and articulate suggestions for further thought that viewers have been inspired to contribute to the website. They are a valuable addition to our show.

Dear FRONTLINE,

This was an interesting program, but it is like a doctor looking at symptoms rather than causes. The question on my mind at many times during the program was: how can this be fixed ? To answer this question, you need to go deeper into the health care network, and talk about insurers and the politics involved. Of course, that might not make for television that is that exciting.

Also, if some people are actually benefiting financially or in other ways from the decline in patient care, who are they and how can they get away with it ? In this respect, the demise of the Pennsylvania AHERF group might be worth looking into.

Regards,
Frank Dellaert

Producer/Correspondent Hedrick Smith responds: We appreciate your interest in Dr. Solomon's Dilemma and your questions about the health insurance industry. In this Frontline program, we looked at doctors closely. In the next program that we're doing called "Critical Condition" we'll look at the different needs of health plans, and the problems of chronic care, the uninsured, quality of care. It will be a three hour broadcast on PBS on October 18th. I hope you watch and tell us what you think about that program. It will have its own website. Thanks for your interest.

Dear FRONTLINE,

Great show!! Would you consider doing a follow-up show re: how people are managing in this complicated world and finding solutions for themselves and their families health problems? Also, devoting one show to web sites that deal with health topics? Thank you again for this very interesting piece.

Corinne Jones
riverside, ca

Producer/Correspondent Hedrick Smith responds: Keep your eye out for "Critical Condition with Hedrick Smith," which is coming on PBS on October 18th. It will deal with several other aspects of our health system including examples of how people are dealing successfully with health problems and who is working on improving quality care -- the kinds of things you are interested in. Thanks for your message.

Dear FRONTLINE,

While your program demonstrated the conflict between doctor role and service vs monetary incentives/disincentives to the doctor to improve the financial position of the institutions and managed care insurance programs, it failed seriously by not putting this in the larger context of the for-profit corporate managed care environment and modus operandi that prevails today in health care, whether or not the employer/or institution is nominally for profit or not-for profit.

EG

Producer/Correspondent Hedrick Smith responds: The issue of for profit and non profit health plans will be dealt with in a follow-up broadcast on PBS called "Critical Condition with Hedrick Smith." That 3-hour special on health care and many of its facets is scheduled for broadcast on October 18th. I hope you find it helpful on some of the very good questions you have raised.

Dear FRONTLINE,

(1) What are the salary scales of the top administrators and executives?

(2) What percentage of the premium dollar goes for profit and administration to run and control the system, manage doctors and nurse behavior (vs that for health care) and how has this increased and consumed money resources since managed care began?

(3) All of these programs are the product of for-profit corporate capitalist enterprise, naturally driven by motive to maximize return to investors, which may or may not yield maximum care and service to the patient-consumer. This was not even hinted in the program. Are Hedrick Smith or the producers afraid of the insurance industry?

(4) There was not mention or hint of patient-consumer-doctor/nurse resistance centered in Boston, exemplified by the Ad Hoc Committee initiative in the Massachusetts legislature to oppose these developments?

Daniel Fine
new kensington, pa

Producer/Correspondent Hedrick Smith responds: Thanks for your good questions, many of which will be dealt with in a future 3-hour broadcast on managed care companies, people who are uninsured, people with chronic care problems, and issues of quality of care. That program will be coming this fall on PBS. It's called "Critical Condition With Hedrick Smith" and it is scheduled to be broadcast the evening of October 18th. Health care is a huge subject, so we have to take it one bite at a time. Let us know what you think of the next program, too.