National Health Care Reform: The Aura of Inevitability Intensifies To the Editor.\p=m-\Inhis Editorial "National Health Care Reform," Dr Lundberg1 repeats the common misconception that specialists "do expensive things." He talks about the "incentive/ disincentive of paying much for procedures (whether or not they are needed or effective) and little for primary care." It made me angry to read in print once again the false conception of what specialists do and what specialists can offer. It is often the primary practitioner in defending his own economic turf who states that the minute you go to a specialist, he will "do something," meaning he will do some type of expensive procedure. In dermatology, we like to consider ourselves as "primary care doctors of the skin." We feel patients should have direct access to our services and knowledge, and it should not be a financial burden to send anyone to us or to have to have a patient be able to walk in themselves. We don't look for expensive procedures to do—we just try to diagnose the problem accurately and make the patient better. Health maintenance organizations (HMOs) buy the hy¬ pothesis that primary care physicians will always save mon¬ ey, and God forbid, self-referral to a dermatologist will ac¬ tually cost money. Quite the contrary! I propose that HMO patients with skin conditions should be required to see a dermatologist first! It will save money. It is also known that when presented with a list of 20 of the
dermatologie diagnoses, most primary care lucky to diagnose 60% of these correctly the physicians first time. Dermatologists are often in the 90% range. If that is doing something, to me it is doing the right thing—it is making the right diagnosis and using the right medicine the most
common are
first time. Please do not repeat the mistake that dermatologists should not be the first point of entry to the medical care system if a patient has a skin condition. Doesn't it save money to get the diagnosis right the first time and not try shotgun therapy after shotgun therapy searching for whatever might work? Why is primary access directly to the dermatologist by a patient such anathema? The definition of specialist does not mean "invasive pro¬ cedure-oriented practitioner looking for a way to use his new medical instrument." To me, the definition of specialist as it applies to dermatology means the person best trained to diagnose and cure a problem related to the skin. I would hope that our patients, in HMOs or otherwise, have access to us the first time, not at the end of a long chain of physicians trying to guess what is wrong by trying to guess what might fix it. Michael H. Coverman, MD Austin, Tex 1.
Lundberg GD. National health care reform: the 1992;267:2521-2524.
JAMA.
aura
of inevitability intensifies.
Deputy Editor (West),
profession.
The double burdens of malpractice and micromanagement rapidly becoming intolerable. The people driving these problems\p=m-\triallawyers and medical bureaucrats\p=m-\arehaving such a profoundly demoralizing effect on the medical community that many physicians I know are becoming disenchanted, considering early retirement or career changes, and discouraging their own children (as well as anyone else who asks) from going into the profession. This will dilute the quality of practitioners. Within a generation or two\p=m-\ if the current problems persist—few bright, aggressive people will be interested in medicine. One must ask oneself what this will mean for the quality of medical care in the United States, particularly for the 85% of the people cur¬ rently insured. Whatever solutions for rising costs are adopted must take into consideration tort reform and preservation of physician autonomy or there will be no system to be reformed. And it is urgent that these problems be addressed at once. are
Howard H. Kaufman, MD West Virginia University
Morgantown
1.
Lundberg GD. National health JAMA. 1992;267:2521-2524.
and Bruce B. Dan, MD,
care
reform: the
aura
of inevitability intensifies.
To the Editor.\p=m-\Iwas impressed with the power and simplicity of your graphic demonstration that the rapidly increasing portion of the US gross national product (GNP) that is spent on medical care has not proportionally advanced the mean life expectancy.1 The rapid rise in the percentage of
GNP spent for medical care since 1967 without increased life expectancy led you to doubt that US medicine provides a
proportional value for this
expense.
While life expectancy has little relation to health care expense, the median age of the US population may be the engine that is driving the explosion in percentage of the GNP used for health care costs (Figure).2,3 Both of these measures began their rapid and unrelenting increases about 1970, and predict a difficult and expensive future. This dramatic aging of the US population is both the result of our most impressive medical successes and the cause of our medical economic
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. a
To the Editor.\p=m-\The recent Editorial dealing with the scope of proposals for health care reform in the United States demonstrated the pressures for such reform.1 But it did not explore either the adverse reactions of the people in or conEdited by Drummond Rennie, MD, Senior Editor.
the medical profession or the implications for the future of health care of some of the current changes and those being proposed, if they lead to a decrease in the number and quality of individuals interested in the
templating entering
minimum, preferably five
References, if any, should be held to fewer. Letters discussing a recent
or
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 Florida International University Medical Library User on 06/02/2015
dermatologie diagnoses, most primary care lucky to diagnose 60% of these correctly the physicians first time. Dermatologists are often in the 90% range. If that is doing something, to me it is doing the right thing—it is making the right diagnosis and using the right medicine the most
common are
first time. Please do not repeat the mistake that dermatologists should not be the first point of entry to the medical care system if a patient has a skin condition. Doesn't it save money to get the diagnosis right the first time and not try shotgun therapy after shotgun therapy searching for whatever might work? Why is primary access directly to the dermatologist by a patient such anathema? The definition of specialist does not mean "invasive pro¬ cedure-oriented practitioner looking for a way to use his new medical instrument." To me, the definition of specialist as it applies to dermatology means the person best trained to diagnose and cure a problem related to the skin. I would hope that our patients, in HMOs or otherwise, have access to us the first time, not at the end of a long chain of physicians trying to guess what is wrong by trying to guess what might fix it. Michael H. Coverman, MD Austin, Tex 1.
Lundberg GD. National health care reform: the 1992;267:2521-2524.
JAMA.
aura
of inevitability intensifies.
Deputy Editor (West),
profession.
The double burdens of malpractice and micromanagement rapidly becoming intolerable. The people driving these problems\p=m-\triallawyers and medical bureaucrats\p=m-\arehaving such a profoundly demoralizing effect on the medical community that many physicians I know are becoming disenchanted, considering early retirement or career changes, and discouraging their own children (as well as anyone else who asks) from going into the profession. This will dilute the quality of practitioners. Within a generation or two\p=m-\ if the current problems persist—few bright, aggressive people will be interested in medicine. One must ask oneself what this will mean for the quality of medical care in the United States, particularly for the 85% of the people cur¬ rently insured. Whatever solutions for rising costs are adopted must take into consideration tort reform and preservation of physician autonomy or there will be no system to be reformed. And it is urgent that these problems be addressed at once. are
Howard H. Kaufman, MD West Virginia University
Morgantown
1.
Lundberg GD. National health JAMA. 1992;267:2521-2524.
and Bruce B. Dan, MD,
care
reform: the
aura
of inevitability intensifies.
To the Editor.\p=m-\Iwas impressed with the power and simplicity of your graphic demonstration that the rapidly increasing portion of the US gross national product (GNP) that is spent on medical care has not proportionally advanced the mean life expectancy.1 The rapid rise in the percentage of
GNP spent for medical care since 1967 without increased life expectancy led you to doubt that US medicine provides a
proportional value for this
expense.
While life expectancy has little relation to health care expense, the median age of the US population may be the engine that is driving the explosion in percentage of the GNP used for health care costs (Figure).2,3 Both of these measures began their rapid and unrelenting increases about 1970, and predict a difficult and expensive future. This dramatic aging of the US population is both the result of our most impressive medical successes and the cause of our medical economic
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. a
To the Editor.\p=m-\The recent Editorial dealing with the scope of proposals for health care reform in the United States demonstrated the pressures for such reform.1 But it did not explore either the adverse reactions of the people in or conEdited by Drummond Rennie, MD, Senior Editor.
the medical profession or the implications for the future of health care of some of the current changes and those being proposed, if they lead to a decrease in the number and quality of individuals interested in the
templating entering
minimum, preferably five
References, if any, should be held to fewer. Letters discussing a recent
or
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 Florida International University Medical Library User on 06/02/2015
