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May14, 2008

Vol. 108, No. 13

Honesty on health care

In response to:

Like most of the critical issues involving our country, opinions about health care are very polarized. I have heard Professor Uwe Reinhardt (feature, Dec. 12) speak many times throughout my years as a physician executive working for an integrated delivery system in Sacramento, which is, by the way, one of the most managed-care areas in the country. Professor Reinhardt has always addressed the problems with health care directly, albeit with humor. His underlying theme is basically, “Everybody wants it, and nobody wants to pay.”

The escalating costs in health care reflect technology, cost-shifting, and gross inefficiencies. There is no easy fix, but in order to control costs, there needs to be a budget. To implement a budget in health care, your options are very limited. There is 1) capitation, which is the hallmark of managed care; 2) fee-for-service and rationing, which occurs in Britain and Canada; and 3) a slowly reducing fee-for-service compensation, also called zero-based budget, which has been utilized in several medical groups in California. Comparing the three choices carefully, capitation is far and away the best option.

Managed care was an initial attempt to implement capitation and control costs. Unfortunately, it suffered the fate of many good ideas when buffeted by greed, politics, and special interests. Professor Reinhardt always has presented an honest view of the economics of American health care. In truth, it is not a pretty picture. As Massachusetts is rapidly discovering, insuring everyone is not a viable solution.

Dr. Howard Zeft ’58 (Letters, April 2) should check the options available. Managed care is not bad when viewed as a model. As Professor Reinhardt has aptly demonstrated, “Don’t kill the model when it is the implementation that is at fault.”

Gary A. Fields '61, M.D.
Medical Director, Sutter Medical Foundation
Sacramento, Calif.

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