Consumer Choices and the American Health Care System To the Editor.\p=m-\DrReiser's1 article, "Consumer Competence and the Reform of American Health Care," is the best to date in your series on Caring for the Uninsured and Underinsured. Although I believe his confidence in our patients' potential as health care consumers is optimistic and I wonder about the need for "vouchers," the section on "Social and Professional Roles in Creating Consumer Competence" is timely to say the very least. For me, the concept of clinical practice guidelines, "mainly intended to provide practitioners with the best approach to [diagnosing and] treating particular illnesses,"2 is central to the resolution of our medical care crisis. It is surprising that guidelines such as these have never really been established by the medical profession; the result has been that there is too much divergence in medical practice from one town to the next, one hospital to another, and even from one office to another down the hall. The lack of such guidelines is also responsible for most of our waste in medical care delivery, most of the excess cost, most of our malpractice worries, most of the uncertainty felt by third-party carriers, and many other problems that our medical care system faces. The only way to deal with these inconsistencies is with well-established standards ("clinical practice guidelines") that our profession will agree to, teach, and support in practice. We need to unify our concept of cost-effective quality medical care. Central to the creation of clinical practice guidelines is what Koop et al3 refer to as "outcomes research." We need to study the efficacy of various diagnostic and therapeutic pro¬ tocols in a systematic fashion before we can decide which approach is best. The results need to be taught to trainees and practitioners alike. Finally, usage needs to be monitored in practice. All of this, however, is independent of (and prior to) payment (as it should be); although the efficiency of the system will, of necessity, result in drastically lowered medical care
costs.
There are two major advantages to this approach. First, it deals with the causes of the problem. (It is not another stop¬ gap payment scheme.) Second, and most important, it per¬ petuates the physician's ability to do what we do best (and want to do most)—provide quality medical care. Lawrence A. Davis, Calif
Danto, MD
1. Reiser SJ. Consumer competence and the reform of American health care. JAMA.
1992;267:1511-1515.
2. Institute of Medicine. Clinical Practice Guidelines. Washington, DC: National Academy Press Inc; 1990. 3. Koop CE, Laszewski RL, Wennberg JE. Health-care reform needs to go beyond
symptoms. Sacramento Bee. February 26,1992, p11. Reprinted by the Washington Post. February 19, 1992, p 819.
To the Editor.\p=m-\DrReiser1 makes some excellent observations and recommendations concerning current problems with the American health care system. But I fail to appreciate why he states that funding for health care, at least for the general population, "should come from workers, employers, and government," or why "an equal contribution by each is needed to spread the financial burden of health care." Government dollars, after all, are nothing but the dollars ofthe productive members of society (ie, workers), that have been extracted from them by taxation, less a handling fee. Similarly, employer-paid health insurance is merely a wage equivalent that factors into the economic reality of the labor market. Edited by Drummond Rennie, MD, Deputy Editor (West), and Bruce B. Dan, MD, Senior Editor.
I would like to see the tort law, insurance, and market incentive reforms that Reiser suggests. But I see no benefits in creating additional government involvement in the health care of the general population. Why should medicine be any more politicized than is the case already? Nor do I see any more reason for employers to participate in the purchase of health insurance than in the purchase of food, shelter, cloth¬ ing, or any other economic good that their employees may want or need. Where are the advantages of imposing this kind of barter in a modern economy, one of the key features of which is the use of money as a stable and universal medium of exchange? Reiser's analysis suggests two additional questions that the society at large and physicians in particular would do well to consider. The first is whether it is always and everywhere the case that government must do something to solve the problems of society. Is it not time to ask, instead, what gov¬ ernment should undo that has caused or contributed to these problems in the first place? And, seeing that we physicians can no longer continue to ignore the economic realities, per¬ haps we should be asking ourselves: would we rather deal with faceless bureaucrats, clerks, and uncomprehending prac¬ tice guidelines as a means of cost containment? Or would we rather deal with our patients as competent consumers who have incentives to economize and seek value for their health care dollars?
Timothy N. Gorski, MD Arlington, Tex 1. Reiser SJ. Consumer competence and the reform of American health care. JAMA.
1992;267:1511-1515.
To the Editor.\p=m-\DrReiser1 bases his advocacy for a system of health insurance vouchers on the notion of consumer autonomy. While we agree that consumer autonomy is paramount in health care financing reform, his proposal reflects a fundamental misunderstanding of the kind of autonomy for which consumers yearn. His voucher system aspires to promote autonomy in the selection of health plans with different bundles of benefits; what consumers really want is the freedom to choose their own health care provider and to participate in the management of their own health care, unencumbered by health insurance restrictions. Reiser's faith that vouchers would facilitate optimal choice of health insurance is misplaced. Consumers are knowledgeable about their own health values, but few can untangle health plans that confound even insurance specialists. Furthermore, it is untenable to expect health care professionals to effectively counsel consumers, as Reiser suggests. Physicians, in particular, have neither the time nor the training
Guidelines for Letters Letters will be published at the discretion of the editors as space permits and are subject to editing and abridgment. They should be typewritten double-spaced and submitted in duplicate. They should not exceed 500 words of text. References, if any, should be held to a minimum, preferably five or fewer. Letters discussing a recent JAMA article should be received within 1 month of the article's pub¬ lication. Letters must not duplicate other material published or sub¬ mitted for publication. A signed statement for copyright, authorship responsibility, and financial disclosure is essential for publication. Letters not meeting these guidelines are generally not acknowl¬ edged. We do not routinely return unpublished letters. Also see In¬ structions for Authors.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/13/2015
necessary to fulfill these tasks, and are unlikely to embrace the oversight necessary to monitor potential conflicts of in¬ terest. The inevitable result of a system encouraging individuals to choose health plans based on benefits would be segregation of the health insurance market. Because vouchers would have a fixed value, insurers would try to maximize profits by preferentially marketing to consumers with low expected medical expenses. To attract the young and healthy, they would offer amenities, but exclude coverage for costly ill¬ nesses. Meanwhile, persons with potentially high medical expenses, such as the elderly or those infected with the hu¬ man immunodeficiency virus, would be offered plans with strict dollar limits and copayments, or would have to sup¬ plement the vouchers to obtain more comprehensive cover¬ age. Reiser's proposal encourages people to seek plans cov¬ ering only those services they individually expect to require. The result would be a total undermining of intergenerational and community-wide sharing of the costs of health care. If true consumer autonomy is to be enhanced, we must rid medicine of excessive insurance bureaucracy. Universal par¬ ticipation in a single insurance plan would free consumers from the burden of evaluating byzantine health plans, allow them to seek care from any provider, and spread the economic risk of health care. Recent surveys indicate widespread pub¬ lic support for such an approach.1,2 Reiser's voucher system would perpetuate the confusing morass of health insurance, while providing only the illusion of free choice. James G. Kahn, MD, MPH Peter Lurie, MD Kevin Grumbach, MD University of California, San Francisco 1. Reiser SJ. Consumer competence and the reform of American health
1992;267:1511-1515. 2. Blendon RJ, Donelan K. Interpreting public opinion 1991(summer)10:166-169.
care.
JAMA.
surveys. Health
Aff.
MD, Altman DE, Leitman R, Moloney TW, Taylor H. Taking the public's pulse on health system reform. Health Aff.(summer)1992;11:125-133. 3. Smith
In Reply.\p=m-\Althoughthese responses to my article focus on different aspects of it, I am gratified that all of the commentators agree with my central point: that consumer knowledge and autonomy are significant goods that the medical profession and society should promote. While I agree with Dr Danto on the significance of practice guidelines constructed for physicians, we should develop equally informative guidelines for patients to lead them through the difficult task of understanding and making therapeutic choices. By comparison with guidelines produced for clinicians, those currently being created for patients are brief and do not contain adequate discussion of the relative merits of alternative treatments. This imbalance should be addressed. Dr Gorski in part misreads my article. I indicate that only worker and employer should contribute equal contributions to fund the worker's health care through vouchers. For the unemployed or part-time and full-time workers earning low wages, I recommend a government-funded contribution of varying amounts, depending on the circumstances of given individuals. This proposal spreads the cost of insurance to the segments of society best equipped to handle it. I do not see from where health care funding can come if not from these sectors, which brings me to the views of Drs Kahn, Lurie, and Grumbach. They misread the problem Americans have with health care in suggesting that we only be given a choice in selecting a physician, but not in choosing a health plan. This purchase decision, made through vouchers or other means, would pro¬ vide people with a critical education in what health care is about, draw the individual into considering the relation of
costs to benefits, and place health care squarely in the main¬ stream of American life. But they remain wedded to conventional views about health care in proposing the enrollment of everyone in a single insurance plan as a way to "free consumers from the burden" of evaluating and choosing a health plan. This is the sort of thinking that has gotten our system in trouble. It is based on the belief that health care choices are too difficult and bur¬ densome for individuals and should be delegated to experts. The result is a medically unlearned population that cannot collectively induce the health care system to meet their needs or to recognize its limits. As for the concern that insurers might undermine the system in an effort to maximize profit, legal and regulatory mechanisms can be put in place to pre¬ vent such predatory practices. Making choices in life about marriage, home, career, and other difficult matters is the best way to realize our unique¬ ness and to learn. The best health care system will be one that consumers into direct engagement with the health decisions that affect them.
brings care
Stanley J. Reiser, MD The University of Texas Health Science Center at Houston
Rapid Classification of Positive Blood Cultures To the Editor.\p=m-\Theauthors of a recent study1 evaluating the interpretation of positive blood cultures are to be commended for publicizing the unglamorous but important truth that infectious disease specialists commonly categorize positive blood cultures as reflecting true bacteremia as opposed to contamination, based on a few simple clinical and laboratory parameters. Whether it was really necessary to perform complex statistical analyses on an extensive data set to reach the study's conclusions is arguable, since the same conclusions probably could have been arrived at equally well through brief conversations with the participating infectious diseases
specialists. The important point is that infectious disease specialists do indeed use time to culture positivity, number of cultures positive, organism type, and the pretest clinical likelihood of bacteremia to assess the validity of a positive blood culture. Infection at a different site caused by the same organism is also an important consideration; this factor was unfortunately excluded from the study's algorithm for methodologic reasons. As the authors point out, in the absence of an objective gold standard, true bacteremia is defined by a clinical judg¬ ment that is based
on these parameters. These simple principles are neither new nor secret; they have been passed down to generations of infectious disease trainees by their mentors and taught enthusiastically by spe¬ cialists and fellows in infectious disease to referring physi¬ cians and medical students whenever patients with positive blood cultures are seen in consultation. These principles are fundamental to competent medical care and should be con¬ sidered part of the "core curriculum" for all clinicians in
training. Physicians who currently do not remember or apply these simple intuitive principles will be unlikely to remember or apply a quantitative algorithm derived therefrom. Better ways are needed to disseminate and promote the use of these basic principles themselves. The study in question addresses this need by restating these principles. James R.
Johnson,
MD
University of Minnesota Minneapolis 1. Bates DW, Lee TH. Rapid classification of positive blood cultures: validation of a multivariate algorithm. JAMA. 1992;267:1962-1966.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/13/2015
prospective
costs.
There are two major advantages to this approach. First, it deals with the causes of the problem. (It is not another stop¬ gap payment scheme.) Second, and most important, it per¬ petuates the physician's ability to do what we do best (and want to do most)—provide quality medical care. Lawrence A. Davis, Calif
Danto, MD
1. Reiser SJ. Consumer competence and the reform of American health care. JAMA.
1992;267:1511-1515.
2. Institute of Medicine. Clinical Practice Guidelines. Washington, DC: National Academy Press Inc; 1990. 3. Koop CE, Laszewski RL, Wennberg JE. Health-care reform needs to go beyond
symptoms. Sacramento Bee. February 26,1992, p11. Reprinted by the Washington Post. February 19, 1992, p 819.
To the Editor.\p=m-\DrReiser1 makes some excellent observations and recommendations concerning current problems with the American health care system. But I fail to appreciate why he states that funding for health care, at least for the general population, "should come from workers, employers, and government," or why "an equal contribution by each is needed to spread the financial burden of health care." Government dollars, after all, are nothing but the dollars ofthe productive members of society (ie, workers), that have been extracted from them by taxation, less a handling fee. Similarly, employer-paid health insurance is merely a wage equivalent that factors into the economic reality of the labor market. Edited by Drummond Rennie, MD, Deputy Editor (West), and Bruce B. Dan, MD, Senior Editor.
I would like to see the tort law, insurance, and market incentive reforms that Reiser suggests. But I see no benefits in creating additional government involvement in the health care of the general population. Why should medicine be any more politicized than is the case already? Nor do I see any more reason for employers to participate in the purchase of health insurance than in the purchase of food, shelter, cloth¬ ing, or any other economic good that their employees may want or need. Where are the advantages of imposing this kind of barter in a modern economy, one of the key features of which is the use of money as a stable and universal medium of exchange? Reiser's analysis suggests two additional questions that the society at large and physicians in particular would do well to consider. The first is whether it is always and everywhere the case that government must do something to solve the problems of society. Is it not time to ask, instead, what gov¬ ernment should undo that has caused or contributed to these problems in the first place? And, seeing that we physicians can no longer continue to ignore the economic realities, per¬ haps we should be asking ourselves: would we rather deal with faceless bureaucrats, clerks, and uncomprehending prac¬ tice guidelines as a means of cost containment? Or would we rather deal with our patients as competent consumers who have incentives to economize and seek value for their health care dollars?
Timothy N. Gorski, MD Arlington, Tex 1. Reiser SJ. Consumer competence and the reform of American health care. JAMA.
1992;267:1511-1515.
To the Editor.\p=m-\DrReiser1 bases his advocacy for a system of health insurance vouchers on the notion of consumer autonomy. While we agree that consumer autonomy is paramount in health care financing reform, his proposal reflects a fundamental misunderstanding of the kind of autonomy for which consumers yearn. His voucher system aspires to promote autonomy in the selection of health plans with different bundles of benefits; what consumers really want is the freedom to choose their own health care provider and to participate in the management of their own health care, unencumbered by health insurance restrictions. Reiser's faith that vouchers would facilitate optimal choice of health insurance is misplaced. Consumers are knowledgeable about their own health values, but few can untangle health plans that confound even insurance specialists. Furthermore, it is untenable to expect health care professionals to effectively counsel consumers, as Reiser suggests. Physicians, in particular, have neither the time nor the training
Guidelines for Letters Letters will be published at the discretion of the editors as space permits and are subject to editing and abridgment. They should be typewritten double-spaced and submitted in duplicate. They should not exceed 500 words of text. References, if any, should be held to a minimum, preferably five or fewer. Letters discussing a recent JAMA article should be received within 1 month of the article's pub¬ lication. Letters must not duplicate other material published or sub¬ mitted for publication. A signed statement for copyright, authorship responsibility, and financial disclosure is essential for publication. Letters not meeting these guidelines are generally not acknowl¬ edged. We do not routinely return unpublished letters. Also see In¬ structions for Authors.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/13/2015
necessary to fulfill these tasks, and are unlikely to embrace the oversight necessary to monitor potential conflicts of in¬ terest. The inevitable result of a system encouraging individuals to choose health plans based on benefits would be segregation of the health insurance market. Because vouchers would have a fixed value, insurers would try to maximize profits by preferentially marketing to consumers with low expected medical expenses. To attract the young and healthy, they would offer amenities, but exclude coverage for costly ill¬ nesses. Meanwhile, persons with potentially high medical expenses, such as the elderly or those infected with the hu¬ man immunodeficiency virus, would be offered plans with strict dollar limits and copayments, or would have to sup¬ plement the vouchers to obtain more comprehensive cover¬ age. Reiser's proposal encourages people to seek plans cov¬ ering only those services they individually expect to require. The result would be a total undermining of intergenerational and community-wide sharing of the costs of health care. If true consumer autonomy is to be enhanced, we must rid medicine of excessive insurance bureaucracy. Universal par¬ ticipation in a single insurance plan would free consumers from the burden of evaluating byzantine health plans, allow them to seek care from any provider, and spread the economic risk of health care. Recent surveys indicate widespread pub¬ lic support for such an approach.1,2 Reiser's voucher system would perpetuate the confusing morass of health insurance, while providing only the illusion of free choice. James G. Kahn, MD, MPH Peter Lurie, MD Kevin Grumbach, MD University of California, San Francisco 1. Reiser SJ. Consumer competence and the reform of American health
1992;267:1511-1515. 2. Blendon RJ, Donelan K. Interpreting public opinion 1991(summer)10:166-169.
care.
JAMA.
surveys. Health
Aff.
MD, Altman DE, Leitman R, Moloney TW, Taylor H. Taking the public's pulse on health system reform. Health Aff.(summer)1992;11:125-133. 3. Smith
In Reply.\p=m-\Althoughthese responses to my article focus on different aspects of it, I am gratified that all of the commentators agree with my central point: that consumer knowledge and autonomy are significant goods that the medical profession and society should promote. While I agree with Dr Danto on the significance of practice guidelines constructed for physicians, we should develop equally informative guidelines for patients to lead them through the difficult task of understanding and making therapeutic choices. By comparison with guidelines produced for clinicians, those currently being created for patients are brief and do not contain adequate discussion of the relative merits of alternative treatments. This imbalance should be addressed. Dr Gorski in part misreads my article. I indicate that only worker and employer should contribute equal contributions to fund the worker's health care through vouchers. For the unemployed or part-time and full-time workers earning low wages, I recommend a government-funded contribution of varying amounts, depending on the circumstances of given individuals. This proposal spreads the cost of insurance to the segments of society best equipped to handle it. I do not see from where health care funding can come if not from these sectors, which brings me to the views of Drs Kahn, Lurie, and Grumbach. They misread the problem Americans have with health care in suggesting that we only be given a choice in selecting a physician, but not in choosing a health plan. This purchase decision, made through vouchers or other means, would pro¬ vide people with a critical education in what health care is about, draw the individual into considering the relation of
costs to benefits, and place health care squarely in the main¬ stream of American life. But they remain wedded to conventional views about health care in proposing the enrollment of everyone in a single insurance plan as a way to "free consumers from the burden" of evaluating and choosing a health plan. This is the sort of thinking that has gotten our system in trouble. It is based on the belief that health care choices are too difficult and bur¬ densome for individuals and should be delegated to experts. The result is a medically unlearned population that cannot collectively induce the health care system to meet their needs or to recognize its limits. As for the concern that insurers might undermine the system in an effort to maximize profit, legal and regulatory mechanisms can be put in place to pre¬ vent such predatory practices. Making choices in life about marriage, home, career, and other difficult matters is the best way to realize our unique¬ ness and to learn. The best health care system will be one that consumers into direct engagement with the health decisions that affect them.
brings care
Stanley J. Reiser, MD The University of Texas Health Science Center at Houston
Rapid Classification of Positive Blood Cultures To the Editor.\p=m-\Theauthors of a recent study1 evaluating the interpretation of positive blood cultures are to be commended for publicizing the unglamorous but important truth that infectious disease specialists commonly categorize positive blood cultures as reflecting true bacteremia as opposed to contamination, based on a few simple clinical and laboratory parameters. Whether it was really necessary to perform complex statistical analyses on an extensive data set to reach the study's conclusions is arguable, since the same conclusions probably could have been arrived at equally well through brief conversations with the participating infectious diseases
specialists. The important point is that infectious disease specialists do indeed use time to culture positivity, number of cultures positive, organism type, and the pretest clinical likelihood of bacteremia to assess the validity of a positive blood culture. Infection at a different site caused by the same organism is also an important consideration; this factor was unfortunately excluded from the study's algorithm for methodologic reasons. As the authors point out, in the absence of an objective gold standard, true bacteremia is defined by a clinical judg¬ ment that is based
on these parameters. These simple principles are neither new nor secret; they have been passed down to generations of infectious disease trainees by their mentors and taught enthusiastically by spe¬ cialists and fellows in infectious disease to referring physi¬ cians and medical students whenever patients with positive blood cultures are seen in consultation. These principles are fundamental to competent medical care and should be con¬ sidered part of the "core curriculum" for all clinicians in
training. Physicians who currently do not remember or apply these simple intuitive principles will be unlikely to remember or apply a quantitative algorithm derived therefrom. Better ways are needed to disseminate and promote the use of these basic principles themselves. The study in question addresses this need by restating these principles. James R.
Johnson,
MD
University of Minnesota Minneapolis 1. Bates DW, Lee TH. Rapid classification of positive blood cultures: validation of a multivariate algorithm. JAMA. 1992;267:1962-1966.
Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/13/2015
prospective
