So many factors in healthcare costs -- where to turn?
STUART H. ALTMAN is correct in identifying rising health costs as a critical problem, but I can't agree with his proposed solution ("A cure for spiraling healthcare costs," op-ed, Jan. 2). He wants to continue relying on employer-based private insurance while government pays part of the costs for the most expensive patients and insurers are required to use case-management methods to keep spending down. That isn't likely to work.
Unless we control the use of expensive technology, costs will continue to rise and nurse case managers won't be able to do much about it. Physicians make the big-ticket decisions, and they are responsible for allocating most of the healthcare dollar. Doesn't Professor Altman think physicians have to be a central part of any cost control plan?
Dr. ARNOLD S. RELMAN
Boston
The writer, a professor emeritus at Harvard Medical School, is former editor of the New England Journal of Medicine.
ALTMAN IS certainly correct that the government assumption of the cost of more-expensive patient care would remove those costs from insurance premiums . It is not clear that costs would thereby come down. They could just be transferred from premium payers to taxpayers.
Insurers already have every incentive to use the most effective case management methods to reduce their own spending. Why would there be an improvement if the government were making the payment? Managed care by health maintenance organizations has not been as effective as promised. Why do we believe that government funding would be more prudent or tight-fisted?
What the government can do to lower costs is to allow low-premium policies free of mandated coverage of treatments and procedures that insurance buyers do not want, leaving a menu of options for additional coverage they might choose to buy. This can best be achieved by allowing individuals and employers to purchase insurance on a national basis from insurers in any state, rather than from a regulated monopoly like the Massachusetts "Connector."
RICHARD E. RALSTON
Executive Director
Americans for Free Choice in Medicine
Newport Beach, Calif.
PROFESSOR ALTMAN'S diagnosis of healthcare's spiraling costs is right, but his proposed cure needs some tweaking. Given that only a fraction of patients account for most healthcare utilization and cost, it makes sense to coordinate the care of these patients before they reach a crisis point. But it is providers, not insurers, who are in the best position to manage this care and thus make a difference.
The challenge lies in identifying high-risk patients who are likely to need help next week, next month, or next year. This requires more than the information available to insurers, it requires regular clinical input from physicians and patients.
Providing interventions that work also can be challenging. Case management, telemedicine, home visits, end-of-life care, and mental health services can improve the quality of care and control costs, but these efforts must be coordinated by a team that understands the nuances of each patient. Indeed, it takes a village to care for the sickest patients, and separating case management into an insurer-based function, as Altman suggests, sets up a relationship destined to become adversarial.
Dr. GREGG S. MEYER
Boston
The writer is senior vice president for quality and patient safety at Massachusetts General Hospital.
YOUR NOD to Mitt Romney's role in our 2006 universal health law ("Romney's unfinished business," editorial, Dec. 26) makes cursory mention of both the vital import of his contribution and its historic context of presidential aspirations.
The governor first introduced his innovative proposal more than two years ago, in November 2004. While Senator Kennedy applauded it, the Massachusetts legislative leaders, for reasons best known to themselves, ignored it. It was six months before the Senate passed a bill and yet another six months until the House approved its separate version. A joint conference squabble consumed still another five months before we finally had a law in April , 18 years after our last serious effort.
That time, Governor Dukakis signed his universal bill and promptly headed back to his own presidential campaign. That law, however, was never implemented, succumbing to its inherent fiscal flaws as the ex-governor watched from the sidelines.
Then in 1994, Hillary Clinton, the 2008 Democratic presidential front runner, failed in her attempt at national universal health insurance, an effort infamously dubbed "Hillary Care."
Romney may never become president, but don't bet against his healthcare legacy to us and possibly the nation.
Dr. MARVIN S. WOOL
Boston
ABOUT YOUR profile of Deborah Klein Walker ("Her ambition is healthcare for all," Health/Science, Jan. 1): "Health is a right"? Did the Founding Fathers miss that one? I would say my health is my duty, your health is your duty. Your health is not my duty, be it by taxes or whatever. (A synonym for taxes is "duty.") Yes, she is indeed a liberal, all right, as you described. God save us.
MARSHALL McCLOSKEY
Belmont 
