The Health-Care System Needs Suggestions for Alternatives, Not More Criticism

The American health-care system is in serious need of reform. It is not, as Dr. Alan J. Steinberg suggests [“A Dose of Reality,” Aug. 29], merely a question of whether physicians should be compensated under a capitated or fee-for-service payment system.

Both systems lend themselves to abuse on the part of physicians who are more focused on their own financial gain than on providing treatments that effectively alleviate the ills of their patients. Both systems could be called “fundamentally flawed” in that respect.

The Medicare system is a good case in point on the woes of fee-for-service medicine. Fraudulent claims and the unmonitored provision of services has nearly driven the system into bankruptcy.

The HMO system has been the target of much criticism, not all of it warranted. To launch one more attack without offering a reasonable alternative is self-serving. The system needs reformers, not critics.

SANDRA WOOLARD

Long Beach

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Like Dr. Steinberg, I am an internist formerly associated with Kaiser Permanente. But I disagree with him that HMOs really have any “laudable promise.”

The Kaiser HMO got started when health benefits became a part of employment, thus another corporate expense. Its physician group contracts exclusively with the HMO to provide medical care at a cut rate.

Other HMOs proliferated as they preached the virtues of “cost-effectiveness” so that corporations can compete better.

It is no secret that quality of medicine suffers. Both physicians and patients feel trapped in the system.

Physicians still sign up in droves, because they need the certainty of a paycheck. This is not out of “greed,” as Dr. Steinberg suggests, but out of fear and stupidity. They avoid a fair competition by lowering the price of their services. They may see more patients, but they also get less respect and satisfaction. No one forced them into “capitation” with a loaded gun. So they should not complain.

Patients still sign up in droves because their employers do not offer any choices. A large part of their earnings are given to the HMOs so that they can have a $10 co-pay at the doctor’s office. This is not a bargain, because they have already paid hefty premiums. Worse yet, this money goes to the administrators who decide whether they can go to a specialist or have whatever tests their doctors decide they need.

In the meantime, the medical directors and the CEOs draw fat salaries without practicing medicine. Do you think they will join an HMO when they retire?

I hope Dr. Steinberg’s new book will suggest alternatives to HMOs.

Dr. CHRISTINE H. PARK

Laguna Beach