Correspondence

Slowing the Growth of Health Care Costs

N Engl J Med 2008; 359:434-435July 24, 2008

Article

To the Editor:

The limitation of the article by Mongan et al. (April 3 issue)1 on options for slowing the growth of health care costs is the acceptance only of reforms that will not irritate powerful, entrenched corporate and labor interests. Our system is costing us perhaps twice as much as it should. We need to target the fattest cats and slim them down. Hospitals currently seek consolidation rather than efficiencies, charge a fortune for routine services, and pay higher wages rather than taking strikes. Insurance companies add so little at so high a charge. Pharmaceutical companies advertise, develop frivolously repetitive drugs, and charge without restraint. Medical specialists in some areas operate and serve dying patients with little restraint.

The interventions suggested in the article are popguns against a profit-bound army. Restraint in our mixed system needs to come from government, not voluntary acts by corporations.2 Schlesinger3 has identified a cycle of government activism at 30 years, the last peak being 40 years ago. It is possible, then, that suggestions that are more challenging to entrenched interests should be entertained.

Budd N. Shenkin, M.D., M.A.P.A.
Bayside Medical Group, Oakland, CA 94609
bshenkin@gmail.com

3 References

1. 1

   Mongan JJ, Ferris TG, Lee TH. Options for slowing the growth of health care costs. N Engl J Med 2008;358:1509-1514
   Full Text | Web of Science | Medline

2. 2

   Reich RB. Supercapitalism: the transformation of business, democracy, and everyday life. New York: Borzoi Books, 2007.
   

3. 3

   Schlesinger AM Jr. The cycles in American history. New York: Houghton Mifflin, 1986.
   

To the Editor:

Mongan et al. list 12 options for reducing health care spending. I would like to point out two options that they seem to have overlooked. The first option is to increase the ratio of primary care physicians to specialists. Numerous studies have shown that as the ratio increases, costs decline.1 The second option is to eliminate the ever-growing administrative restrictions in managed care that markedly reduce the efficiency of primary care practices — especially including prior authorization for referrals, medications, and imaging procedures. These needless restrictions waste the time of physicians and their staffs, considerably increase overhead, and lower morale. Primary care physicians have every desire to practice cost-effective, evidence-based medicine and are well trained to do so. A high degree of self-regulation must be restored in order to promote and maintain professionalism. Otherwise, the first option listed above cannot be achieved.

Michael K. Rees, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215
mrees@caregroup.harvard.edu

1 References

1. 1

   Kravet SJ, Shore AD, Miller R, Green GB, Kolodner K, Wright SM. Health care utilization and the proportion of primary care physicians. Am J Med 2008;121:142-148
   CrossRef | Web of Science | Medline

To the Editor:

Mongan et al. discuss many options for slowing the growth of health care costs. However, the authors do not bring up the taboo subject that we physicians are a significant cause of high health care costs. The greatest cost-saving option, in my opinion, is changing the outlook and ordering habits of physicians. We need to be reasonable about our treatments and expectations. We should not be like sheep, writing prescriptions for the latest recommendation from the drug-company representative or paid speaker; instead, we need to look critically at new information and seek the most economical treatment for our patients' problems.

The entities that own the gold (government and insurance companies) can obviously make the rules, but the entities spending the gold (us) can have the greatest impact on how fast and where it is spent. I realize that many of our habits result from rules made by the paying entities, but still, our physician community needs a period of serious self-examination.

Drury M. Stith, M.D.
Shore Health Services, Nassawadox, VA 23413
dstith@shs-inc.org