So much healthcare, so many costs

(PAUL LACHINE ILLUSTRATION)

THE DEC. 1 op-ed "How to control healthcare costs" by James Roosevelt Jr. and Charles D. Baker and the campaign platforms of various presidential candidates outline important steps to evaluate healthcare delivery costs, and ways to control these expenditures. However, they overlook a key element in cost containment: preventing the development of conditions that require treatment.

Imagine if the need for cancer therapy were reduced by eliminating smoking as a cause of cancer, or if the need for management of diabetes, cardiovascular disease, and cancer were reduced by prevention of obesity, or if treatment and long-term care of auto accident victims were reduced by eliminating alcohol as a cause of car crashes. Why not devote substantial resources and effort to prevention?

One option would be to establish forceful incentive programs directed at patients. Actions such as cessation of tobacco or of alcohol abuse, weight reduction, and adherence to a legitimate exercise program would be rewarded with reduced health insurance premiums or other incentives. Continuation of unhealthy life choices would be penalized by premiums, increased copayments, or other costs.

These are not new ideas, just ideas that need resurrection. Prevention will cost less than treatment. Why should society pay for the controllable, unhealthy choices of many citizens?

Dr. ROBERT A. PETERFREUND
Boston

The writer, an associate professor at Harvard Medical School, is an anesthetist at Massachusetts General Hospital.

I APPLAUD Roosevelt and Baker's push for greater transparency in healthcare plans' financial reporting. And I agree that efforts to control healthcare costs will require the cooperation of various stakeholders, including physicians. One stakeholder not mentioned, however, is the consumer of health care, otherwise known as the patient. The patient is as important a driver of healthcare costs as any other stakeholder, and when a physician does not agree to a patient's request for a medical test or drug, the physician does so at his or her own peril.

Each healthcare plan has its own set of restrictions for prescription drugs and medical tests, and while there are commonalities, there are enough differences among the plans that it is impossible for many physicians - even when using an electronic medical record - to work in partnership with their patients and the plans to control costs.

While there are legal and business reasons for each plan to act on its own, until the healthcare plans develop a more rational and uniform approach, the tug of war among health plans, physicians, and patients will continue, and efforts to control skyrocketing costs and health insurance premiums will fail.

Dr. DONALD ACCETTA
Taunton

ROOSEVELT AND Baker knowledgeably approach the problem, but fail to tackle the fundamental issue: The US healthcare system is organized to produce the wrong products. Payers, including Medicare, most HMOs, and self-funded employers, provide insurance against the risks of healthcare costs, but with few if any tools to control the volume or nature of services provided. Effective control of healthcare costs is a mirage without changing the organization and delivery of, and payment for, medical care (1) by eliminating the volume-inducing incentives of the fee-for-service physician and hospital outpatient payment systems, (2) by transferring reasonable insurance risk to physicians to meet prescribed budgetary targets, and (3) by including pay-for-performance positive incentives for physicians to meet established goals for budget, quality of care, and patient satisfaction.

Staff-model HMOs and Medicare's diagnosis-related group hospital payment arrangements, two effective cost-containment initiatives, show that transforming insurance risk to providers is fundamental to making the system efficient and effective. Ignoring this only delays resolution of our nation's healthcare crisis.

Dr. MITCHELL T. RABKIN
Boston
JOHN S. COOK
Williamstown

Rabkin, a professor of medicine at Harvard Medical School, is CEO emeritus of Beth Israel Hospital; Cook is an independent consultant.