Dear Editor.

I enjoyed Kent Bottles' insightful article on genetics in the March/April issue of The Physician Executive.

I am the Chief Medical Officer for Chronic Disease and Health Promotion for the state of Wisconsin. I am also the Chair of the Council of State and Territorial Epidemiologists Group on Genetics (based in Atlanta) and Chair of the Epidemiology and Data Workgroup on Genetics for Public Health Competencies for the Centers for Disease Control and Prevention.

In June, I am scheduled to talk on Genomics and Public Health Practice to state epidemiologists and other public health/laboratory professionals in Portland. With your permission, I will quote Kent's article.

Thank you,

Peter D. Rumm, MD, MPH, FAAP 

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Head in the sand abdication?

Thank you for the infomercial on defined contributions in the November/December issue. Finally, the elite have figured out how to get top quality health care for themselves without having to pay for it for everyone else. Judging from the experience of MediCal, drug lords and crime bosses will be at the top tier, as well as the rich and socially well connected. Defined contribution means letting the "proles" (1984 by George Orwell) die of cancer and epidemics because, "oh well, it's their own fault that they didn't choose to pay 20 percent of their salary for the health plan that covers those new genetically engineered treatments."

This isn't responsible leadership, it's head in the sand abdication. Mulling over the last year in The Physician Executive, I don't see how the "advanced consciousness" and "spirituality" that's comfortable with this state of affairs is anything more than an advanced state of wishful thinking and denial--Peter Pan, MD, CEO.

Robert J. Cantor, MD

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Of myths and medicine

This is in response to "Of Myths and Medicine" by Ed Lowenstein, MD, published in the January/February issue of The Physician Executive. The idea that health care benefits are a birthright came about when government encouraged employers to provide benefits by making them tax free to the employee and tax deductible to the employer in lieu of wage increases. Conventional indemnity programs with deductibles and 80-20 structures, as well as disproportionately low out-of-pocket costs (relative to income), liberal reimbursement, and a sense of entitlement created little incentive to restrain utilization and encouraged abuse by employees and health care providers at the insurers' expense.

Once these entitlements were entrenched, they became difficult, if not impossible, to curtail. HMOs trimmed some of the abuses, but brought with them administrative costs and patient preference issues that neither patients nor providers were happy with. Additionally, the system, in its infinite wisdom, found ways to circumvent lower reimbursement, making the HMOs' dream of cost containment short lived.

Because of rising costs, there is a movement toward employees purchasing health insurance to insulate the employer from liability for premium increases and to sensitize the employee since, as a tax free benefit, the employer does not "feel the pain." Unfortunately, it is difficult for employees to know exactly what they are purchasing because policies are so variable and difficult to interpret. A defined benefit policy is needed--a standardized policy mandated to all insurers outlining covered services, non-covered services, patient and insurer responsibility, and maximum benefits payable in clear, easy to understand language, something akin to Truth in Lending.

An even better idea would be for government, through expert medical consensus, to develop the definition and include the minimum requirements for all policies by insurers. This would ensure that a purchaser could receive a standard policy with benefits to cover recommended services at an agreed upon price and could compare costs to get the best buy. Non-approved services could not be reimbursed by any insurer and procedures deemed investigational would be reimbursed for eligible patients via pooled funds at selected institutions. Preventive services, such as mammography, would carry no cost to the patient. If a patient was diagnosed with an illness for which early detection was recommended and available at no cost but declined, he or she would pay a higher patient percentage for the cost of treatment

This is a better role for government--to develop expert consensus on medical care and technology and, via legislative power, ensure that all citizens are able to obtain those services through easily understandable standardized policies outlining provided services, as well as patients' and insurers' financial and participatory responsibilities.

Peter Kuzmick, DO

Sea Girt, New Jersey 

Reflections on physician report cards

Many of my staff physicians have voiced concerns over the organization making it easier for patients to access physician data and performance profiles via the hospital's website. Many, if not most, state medical boards provide a great deal about a physician's track record on their websites. As VPMA, I am challenged by the need for accountability at all levels in health care versus the non-edited information available to almost anyone with minimal cyberskills. I shared this memorandum with them:

Just the thought of sharing our "grade" with others conjures up fears of not "measuring up" to someone else's expectations. We were once unaccustomed to practicing with the rest of the world looking over our shoulders. Now, the examination room resembles a crowded bus depot. The payers, nurse reviewers, cyberchondriacs and their families, trial lawyers, case managers, medical directors, credentialing and performance improvement/peer review bodies, JCAHOs, HCFAs, etc. Like it or not, it's the way the world has turned. Accountability rules. We do not practice in a vacuum. Our performance is there for all to see, dirty laundry included.

The fairness versus unfairness argument is legitimate, but becomes moot if physicians cannot make the rules. So, who gets to decide how to grade our clinical expertise and performance? How do you measure physician performance and how do you profile physicians? These are probing and timely questions to ask in this Information and Informed Consumer Age. The answers do not always satisfy our concerns. Data is data, just numbers and words. Applied data is knowledge, and a little knowledge can be a dangerous thing. It is a challenge in the area of medical management to help parties understand and interpret data gathered from physician performance. It is a duty to be sure that the data is fair.

Insurers are infamous for their economic profiling of practice patterns. They use markers such as length of stay, cost, and resource utilization. It befuddles one's mind to understand any conclusions that can be reached from claims forms data. These do not routinely reflect risk-adjusted patient outcomes or patient satisfaction. Hospitals traditionally measure parameters such as licensure, CME, numbers of admissions, malpractice cases, sanctions, infection rates, and blood utilization. But are these quarterly or biennial measurements conducive to effecting performance improvement or even pinpointing the need for improvement?

If the measures do not always paint an accurate picture of performance, why report the data at all? Because it is all we have to report, and we physicians are truly accountable for our actions. Physicians need to be well-informed about their data, because it can easily become public knowledge (applied data). Practicing medicine on a stage with the world as our audience is not necessarily all bad, nor should it intimidate us. Good training and accurate credentials, following the rules, staying current in our respective fields, increasing our sensitivity to our patients' personal, emotional, as well as physician concerns, and striving for our personal best will result in others recognizing our quality and dedication to patients.

Practicing quality medicine and caring for people (our core purpose) translates into data and knowledge, which we should gladly share. Perfection is not the expectation. There are hardly any better marketing tools beyond open and honest communication, compassion, caring, and dedication to the ones for whom we really work--our patients. It is up to each physician to generate data that translates into quality. And quality is personal.

Michael Lachina, MD, MMM 

Vice President of Medical Affairs

FirstHealth of the Carolinas

Pinehurst, North Carolina 

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