dr. solomon's dilemma






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Join the Discussion Should doctors have a financial incentive for keeping  treatment costs under control? How should the U.S. deal with the rising costs of health care?

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woman in a wheelchair being pushed

Dear FRONTLINE,

...Health care is a public necessity, and we as citizens and caregivers should not fearfully abide its chaos, anymore than the Californians should sit back and allow blackouts across their state in a newly-deregulated power market. The tragedy of the common describes the importance of a civic committment to ensuring a common good when no individual actor would be induced to see it that way on their own. Given the damage done by individually-acting hospital administrators, health plan executives and even doctors who sold their practices in a chaotic and frightening markeet, civic and governmental intervention will be required to prevent or at least control the unfolding tragedy of our common.

Stefan Kertesz
Brookline, MA

Dear FRONTLINE,

It is ironic that in a time when Doctor Solomon has to make choices about the heroic efforts required to keep the old and dying alive, our justice system strikes down an Oregon's law allowing the option to self terminate through lethal prescription. Do all 20% of the people that consume 80% of all Healthcare costs really want to spend their last days hooked up to hospital machines?

Ted Eliason
Denver, CO

Dear FRONTLINE,

As someone who has come through being on the frontlines of the AIDS epidemic, I couldn't help but juxtapose the incredible beautiful lessons I and so many others came to embrace about death against the painful desperate conclusions you led us to at the end of this powerful piece.

Our culture has institutionalized this notion of death as the enemy which must be fought at any cost, and that is what Dr. Solomon and your producer is telling us we simply can no longer afford.

We need to work to articulate that death is but part of life, and that moving towards it with grace can be one of the most profoundly spiritual experiences available to us as humans.

If we could lovingly and humanely declare that we won't squander resources at the end of life, we could afford to provide exemplary loving care to all our healthy people for a lifetime...

Dudley Cornell
Albuquerque, NM

Dear FRONTLINE,

Thank you for a thought-provoking examination of one aspect of the health care dilemma. I think a good part of the problem is the moral hazard created by years of employer-paid health care insurance...

We have all come to expect to be provided whatever services we demand, regardless of the cost to the insurer. The insurance companies and physicians are not the villians. We consumers of health care have created the current situation by our insistance on having the type of care we want, when we want it and where we want it.

In no other industry are consumers allowed to both set the price and demand an endless supply of services or goods regardless of the cost to the provider. Unfortunately, it doesn't make economic sense to use this model, yet we insist on continuing to demand health care without rationing or price controls.

Eve Cuny

Dear FRONTLINE,

In my own practice, the capitation model was a wonderful opportunity that empowered us, the physicians closest to and most knowledgeable about our patients, to make decisions. We looked at our capitation payments as an entire practice budget and our incentive was to eliminate waste and expensive mistakes rather than reduce necessary care...

In the capitation model, physicians have the freedom to focus on the aspects of their practice which need improvement, whether it is better telephone access for patients with questions, compliance with beta-blocker treatments after heart attacks or more preventive visits.

In my own practice, we worked as a team to improve systems and provide better care. For example, we instituted a nurse triage system so that sick patients could call and talk right away with an experienced clinician who could direct them to the right place for their treatment.

By making our phone system easier to use we found that we saw our patients earlier in the course of their illnesses. This allowed us to make earlier treatment interventions and keep the patients healthier and out of the hospital whenever possible. In this way capitation was a win-win for patients and for the practice.

Allen Smith
Waltham, Massachusetts

Dear FRONTLINE,

I greatly enjoyed Dr. Solomon's Dilemma. Like many others, I have little sympathy for someone who seems to have jumped at the chance to further pad his pocketbook, and lost. It would be nice to take chances with guaranteed outcomes, but then they wouldn't be chances, would they?

As an employee of the largest healthcare organization in the world Veteran's Administration, I have seen what happens when care is provided at any cost, and patient financial responsibility is kept to a minimum. This is not intended to represent all veteran patients of the VA, merely describe what happens when a medical system is created that asks little if no financial contribution of many of its consumers.

Patients with minimal income and assets are provided with free medical care, free prescriptions, free supplies, free surgeries, etc. As there is no financial consequence for irresponsibility, people have a tendency to 'no-show' for medical appointments and then use the 'urgent care' for 'primary care' purposes i.e. to have scripts refilled.

They will begin chemotherapy treatment for lung cancer and promptly step outside for a cigarrette...Some will present repeatedly with chemical addictions and be admitted for detox/treatment Blue Cross paid for one inpatient drug txt per lifetime.

To its credit, VA cares for the sickest population. Their average patient is older, sicker, and sustained with minimal financial and familial resources.

Nevertheless, the time has come for patient-accountable medicine. The health care consumer is done a great disservice when the medically compliant i.e. non smoker, exerciser, healthy diet, etc. patient must shoulder the burden...

Michael Michaels

Dear FRONTLINE,

Dr. Solomon has basically sold out. Nobody forced him to sign contracts with managed care companies and insurance companies where he gets a set amount of dollars to take care of a patient capitated rates. Now that he has done so, he seems to expect his patients to understand and accept that he is shortchanging them on the care they need so that he can make money.

If he doesn't like capitated care, then why doesn't he start an alternative rather than deny patients the care he needs so that he can make a living?

As a healthcare provider myself, I certainly understand the dilemma. But it is certainly possible to make a decent living while not selling out your ethics to an insurance company.

Peter Barach
Cleveland, OH

Dear FRONTLINE,

There's a definite conflict of interest if the physician who you are required to see is being paid incentives to keep costs down.

Perhaps the change we need is for employers to choose plans that cover major medical leaving the routine costs to be borne by the employees. The routine costs could be paid from medical savings accounts without the current age restrictions. This way, doctors can give you all the options with the associated costs and you can decide how important it is for you to undergo one or the other treatment. The doctors' income and bonus would not then be tied to restricting your access to routine quality care. Hopefully, then they may be able to spend more than 5 minutes with you during your visit.

Evelyn Fong

Dear FRONTLINE,

I thought "Dr. Solomon's Dilemma" was a clear-eyed presentation of the conflict that confronts both doctors and hospitals: to do the right thing for patients today and yet remain financially viable to be able to do the right thing for patients tomorrow. With respect to rationing of care, it's easy enough to argue for more but I don't see many people offering to pay for more. We need a system of care that delivers the right care, prudent in spending the resources to deliver the right care, and fair in the payment for those resources. This will require involvement of those who provide care, those who pay for it, and the patients who benefit from that care. But even with an ideal system there will have to be some limits; otherwise we'll be right back at uncontrolled inflation followed by the same sort of onerous dilemmas that confront us today.

Mitchell Rabkin
boston, ma

Dear FRONTLINE,

As a Family Physician in practice 20 years I agree with the dilemma presented on the telecast.

Although not directly at risk financially as Dr Solomon, the results are the same when caring for patients and not getting reimbursed enough to meet overhead.

I was disappointed by the interviewer's avoidance of the obvious question to the patients--why aren't you willing to pay what it takes to get the quality health care you demand for mama or for last ditch efforts to stay alive when there is little hope for survival.

Why don't patients demand the old system--pay premiums through the nose, get all the health care, medicines and fancy machines you care to pay for. What?? You mean money is NOW a factor. Hypocrites, unite.

Bill Barringer,MD
Lake Wales, FL

Dear FRONTLINE,

A possible solution would be national health insurance with a lifetime cap. Folks could spend on prevention, alternative medicine or conventional modalitiews as they choose. Folks could donate from their allocation to assist family members/friends who have exhausted their benefits.

Folks need greater incentives for better self-care, hence less need to draw upon the lifetime capped benefit. I argued for national health insurance as a high school student 50+ years ago. I wonder if it will be realized in the next 50+ years. I fervently hope so.

Thomas Dolan
Honolulu, Hawaii

Dear FRONTLINE,


While your program demonstrated the conflict between doctor role and service vs monetary incentives/disincentives to the doctor to improve the financial position of the institutions and managed care insurance programs, it failed seriously by not putting this in the larger context of the for-profit corporate managed care environment and modus operandi that prevails today in health care, whether or not the employer/or institution is nominally for profit or not-for profit----EG

1 What are the salary scales of the top administrators and executives?

2 What percentage of the premium dollar goes for profit and administration to run and control the system, manage doctors and nurse behavior vs that for health care and how has this increased and consumed money resources since managed care began?

3 All of these programs are the product of for-profit corporate capitalist enterprise, naturally driven by motive to maximize return to investors, which may or may not yield maximum care and service to the patient-consumer. This was not even hinted in the program. Are Hedrick Smith or the producers afraid of the insurance industry?

4 There was not mention or hint of patient-consumer-doctor/nurse resistance centered in Boston, exemplified by the Ad Hoc Committee initiative in the Massachusetts legislature to oppose these developments?

Daniel Fine
New Kensington, PA

Dear FRONTLINE,

For the past five years or so I have been living at home, helping to care for my ailing father. He, too, is on Secure Horizons.

It puzzled my mom and I that each time my dad had a problem that necessitated a hospital stay, we were given assurances by his doctor that everything would be done for him, only to see him discharged after three days - sometimes still ill. On the occasions that he went to "rehab" we were again given assurances that he would receive the therapy necessary to build his strength and get him home. But after a week sometimes less of cursory therapy he would be sent home, often over our objections. The most recent time Feb of this year he was actually sent home with conjuntivitis and a very nasty fungal infection - both contracted at the rehab hospital. The infections necessitated our paying out of pocket for medications.
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Doctors once went into medicine because it was a calling. But for the past twenty years or so they've chosen it for the money.. And the ones with a real political and financial agenda are the ones who leave private practice and run the hospitals and HMO's.

Perhaps these facilities might run a little more efficiently and be more financially solvent if they lowered their CEO's salaries and put some of that money into caring for people.

And I do know of what I speak. My father was a practicing surgeon, and very well respected in his time. He is still beloved by the many patients who he once cared for. Granted, he did not have to face the problems of today's doctors, but the organization was different in those days - as was the motivation. Doctors have always made good salaries, no doubt. But we did not resent them for it as a society, because we knew what they had to go through to get their M.D. We also knew that doctors had to work long hours and often on weekends. Not to mention the trust factor - if you needed a doctor he was there, and you could trust that he would do his best to care for or cure you.

Doctors opened Pandora's box and now they do not know how to close it. They wail and whine all the way to the bank. If they don't like the situation as it is, they do have the power to change it.

Robin Douglas
Beverly, MA

Dear FRONTLINE,


You presented a thoughtful snapshot of some of the problems in todays medical climate. Important points and perspectives were missed:

How much did Dr. Solomon receive for selling his practice to Caregroup? If he hadn't done that, he could negotiate prices, and deal much more kindness to his patients. Instead he is trying to recoup his losses while the hospital is trying to maximise its investment in him and his practice.

- For a smart man, Dr. Solomon seems oblivious to the idea of re-insurance. Most doctors minimize their risk by paying high premiums to insurance companies to re-insure cases costing over a certain abmount. Didn't he, or is he keeping that from us?

Gerald Corcoran

Dear FRONTLINE,

Thank you for your thoughtful glimpse into the stressful world of a modern family doctor.

Your portrayal of Dr. Solomonís Dilemma creates the impression that he and his colleagues are battling a nameless monster that is somehow bent on destroying the sacred doctor/patient relationship. In truth however, Dr. Solomon and his colleagues have created their own dilemma. They are not the whole problem, but they are a major part of it and that should be made known to the public and to their patients.

Here is one example. The introduction of capitated payment schemes stimulated the formation of ìnetworksî of medical care organizations as CareGroup or Partners which could negotiate and manage large capitated contracts more efficiently and profitably than small medical practices. In order to maintain the necessary stream of referrals, the networks purchased primary care practices like Dr. Solomonís. The doctors then accepted 3 or 5 year contracts to practice in the network. The doctors jumped at this arrangement because under it 1 many of them became instant millionaires, 2 they allied themselves with what seemed to be the winner in the health care consolidation war, and 3 they stood a good chance of making a substantial entrepreneurial profit. So it seems to me that Dr. Solomonís Dilemma bears an eerie resemblance to that of a famous former colleague, Dr. Frankenstein. And it deserves just about as much sympathy from his patients.

Perhaps a future Frontline could explore the economic origins of Dr. Solomonís Dilemma and their impact on patients and other health professionals who care for them. For example, you might ask about the effect on the network of its purchases of primary care practices. An article in your web site reports that some networks are loosing $100,000 on each buyout. And that cost is now being born by patients, nurses, and employees of the networks. In your program you mentioned the salary range of Dr. Solomonís pod mates but you did not mention their buyout arrangements or other efficiency incentives. I think that patients would be interested in that information.

Of the HMOís you might ask about what fraction of the patientsí premium dollar now goes into actual patient care. I think a consulting actuary will tell you that negotiations between big hospitals and HMOís and insurance companies now start at around 50%. In the halcyon days of the Blues, upwards of 90% of the premium dollar was paid out for patient care. And you might ask why nobody is watching the store. With the introduction of capitated contracts supplemented by excess risk coverage, HMOs and insurance companies have blurred the line between health insurance and casualty insurance to the point where state insurance commissions have become befuddled and ineffective regulators. And to top it off, you might ask why HMOís are not required to disclose their true operating costs or the percentage of patient premiums they pay out for actual health care. One of your program participants observed that ìif you canít measure it, you canít manage it.î That principle also applies to regulators, patients, and the public.

Edward Heck
Arlington, MA

Dear FRONTLINE,

Your article was excellent, but the readership should be aware of the fact that not all physicians in the managed care system today are well paid.

In New Mexico where 90% of the patient population is covered by an HMO plan, there are doctors who are simply breaking even or are using their savings and retirement funds in order to survive. I know because I am one of them. I stay here simply to be close to my son and to see if I can make my medical practice of 15 years survive.

It is an enormous struggle and it is my choice to stay in it and fight, however I must say in my opinion, that the HMO is flawed in concept and execution and without enormous government support would most likely not be in existence.

The real culprit in the rising cost of health care is pervasive government funding. Until the healthcare industry is "deregulated", it will be overregulated, inflationary, and ultimately responsible for the continuing problem of the economics of medicine

Douglas Krell MD
Santa Fe, NM

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