1. Catherine Kassens, MD Says:
   February 25th, 2008 at 4:16 pm

   Dr. Goodman, I read your editorial in the WSJ 2/23/2008. There are a few points which I, as a practicing physician, would like to make. (1) The federal government needs to separate money spent for custodial care from health care spending. Much of nursing home expense and in home services are not medical expenses. (2) Patients need incentives to change their unhealthy habits. We should not place the blame for rising costs from obesity on the medical care system. We must find ways to reduce the national average weight. (3) Medicare patients must be pulled into the cost saving effort. When many patients can get services and never write a check that comes out of what they see as their money they don’t care about reducing waste that they even complain about. HSA’s are a great step in that direction. All Medicare patients should have a version of one.

2. Jaime Manzano Says:
   February 27th, 2008 at 1:30 pm

   Much of the discussion on health care is a fight over whether individuals, employers, or the government should pay. Perhaps the question ought to be for what, and not just by whom. Your piece in the WSJ raises questions about the cost of the present system of care and its inefficiencies. But there is more.

   About 80 to 90 percent of doctors’ visits are for illnesses that are self-terminating. They are treated mostly using palliatives. A nurse practitioner, following common sense protocols of care, could handle them, including any necessary hand holding. Legally subordinating such trained professionals under physicians perpetuates a form of protectionism akin to indentured servitude, or medieval guild controls over the right to practice a craft. If costs of care are a national problem for lack of providers, freeing nurse practitioners from their bondage to physicians would improve access to care overnight. Costs for routine care would drop and physicians could then concentrate on practicing the higher forms of diagnosis and care for which their training prepared them. Freeing the consumer to choose even self-care, may also be warranted.

   But why stop there? A national accessible medical record would be helpful. It would cut administrative costs, and medical errors in record keeping. One might anticipate reducing costs by half. Most patients have experienced having to provide a medical history, a listing of medications, and their demographics (name, address, insurance, etc.) numerous times to obtain medical care. All that information, accessible electronically, and protected for purposes of privacy, might just around the corner, be it to qualify for Medicare, Medicaid, or other programs subsidized by government. It might even gain allegiance and implementation in the private sector for cost savings alone.

   Now, with such a medical record available to a medical provider, and accessible with the permission of a patient, a tectonic shift in the extension of care can and probably would, occur. An early indication of such a shift is the now virtually routine warning by pharmacists, armed with the listing of medications, that certain prescriptions, when taken together, are harmful and need special clearances from prescribers. Independent of such “contraindications” some insurance coverage already requires consideration of less costly generics when approving drug payments, all enforced by a computer program.

   Soon, and logically, a computer program would likely follow that would scan individual medical records (and DNA?) and alert consumers and/or their providers when authorized, if certain medical services recommend themselves. An easy example would be alerting the patient that his or her child would benefit from a visit to their provider for an immunization shot, or well-baby visit. A computer program might even advise a patient that a flu shot would be advisable. It doesn’t take much more programming to advise a patient that an annual medical check may be advisable. And if such a medical check up is advisable, it does not take much more to recommend certain laboratory tests before hand.

   The next step would be for the computer to authorize such tests, then scan the results and recommend that the patient see his provider with the findings. Now, when the patient sees his provider, he comes with his medical history, a full record of past medical interventions, a list of medications, a screening identifying potential problems, and the results of recent laboratory results. These diagnostic aids would then be supplemented by those only obtainable by the hands-on intervention of the physician, nurse practitioner, nurse, or the patient, e.g., the pulse, temperature, and blood pressure of the day, with these readings being routinely made part of the patients’ electronic medical record. Note: The number of visits to a provider’s office in this example would drop, wait time for lab results would be eliminated, and the speed of diagnosis and services would be accelerated.

   How would all of this affect the “quality” of care? It would improve. Problems with preventive immunizations, timely medical interventions, duplicative services, misdiagnosis, medical record errors, and over-hospitalizations would be reduced enormously.

   And here is the kicker. Public and private expenditures for health care would drop. Those insurance companies facilitating such programmatic interventions would beat their competition by increasing their share of the residual amount of funds made available for medical expenditures. They might expand services and enrollments while cutting costs, and increasing profits. In the public sector, funds saved could be used to cut taxes or fund new public sector programs. In the private sector, savings in health costs could be used for capital investments, increased wages, or dividends to investors. Productivity would increase as output increased. Even prices might be reduced while making products more competitive.

   Still on the horizon is the potential of data mining of accumulated health records and interventions. Epidemiology, efficacy of drugs, better protocols of care, etc., would be able to take giant steps in improving the health of mankind.

   And we all could live happier ever after.

3. Charles Landesman Says:
   February 29th, 2008 at 9:32 am

   Comments posted Feb. 24, 2008 from Charles Landesman’s blog The Realist:

   “According to a column in the Wall Street Journal (February 23-24, A9) by John C. Goodman, ‘Medicare’s unfunded liability is $74 trillion-five times that of Social Security. According to the Congressional Budget Office, health-care spending is on a course that could crowd out all other government programs.’”

   …

   “The more the government undertakes to support medical services for the general population, the greater is the budget deficit, the greater the burden on future generations, the greater the temptation to generate inflation (a great way to pay debts), and the worse the general financial condition of the United States.”

   …

   “What is to be done? Perhaps with an extreme problem, one should aim for a radical solution…Arrange for inexpensive catastrophe insurance to be available for purchase by everyone; and then let everyone pay for their non-catastrophic expenses…Private philanthropy will flow to help those who are really too poor to pay for routine care even if their priorities were in that direction.”

   Charles Landesman is a retired philosophy professor who taught at Hunter College and the Graduate School of the City University of New York.

4. Daniel B. Gute, M.D. Says:
   March 24th, 2008 at 3:22 pm

   My only question re Markets and Medicare is in the fourth paragraph the number $74 trillion unfunded liability for Medicare is stated, according to the trustees. That seems out of line to me. I would like to know more specifically the source of that figure.

   Sincerely, Daniel B. Gute, M.D.

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