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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Dear FRONTLINE,

Yes, insurance companies, hospitals, and caregivers share the blame for the healthcare crisis; However, the group that shares the most blame seems to forget their responsibility - the consumer.

We all want the best possible care for the least possible price. It cannot in the long term be done. You would never go into a grocery store and receive NY strip for popcorn prices - Why do we expect it in healthcare? You get what you pay for. Quality healthcare is expense and until we, the consumer, are willingor able to pay a reasonable share the dilemma will continue.

John Kellner
Tulsa, OK

Dear FRONTLINE,

Congratulations on an excellent and thoughtful show. Do you have any statisitics on what has happened to incomes of physician specialists, eg rehabilitation and other experts for eldercare, in the Boston area in the last three years since this new trend has taken hold? My impression is that these highly skilled professionals are also being dislocated and experiencing severe difficulty being paid for their services. I would appreciate your comments and any statistics you might have.

Thank you.

Carolyn Kuhn

FRONTLINE's editors respond:

Current statistics can be hard to come by in this fragmented world. This is
especially true when it comes to personal income. There is no doubt that
rehab centers have taken a big hit from the federal government since the
Balanced Budget Act went into effect and that this has lead to many closings.

Many physicians in Boston described this to us as one of their most vexing
problems. How do you deal with someone who doesn't belong in the hospital
but can't make it at home when there are fewer and fewer good rehab places to
send them? It becomes a choice between spending more on them to keep them in
the hospital or sending them home before they are ready to go, hoping they
will be able to cope.

Dear FRONTLINE,

I work in a Managed Care field and was very interested in the programs that produced the reports that Dr. Solomon reviewed with Pod 11. I think that level of data would help any managed care field. Can I get more information about the software? I have never seen such extensive analysis of that type of data.

Casey Newton
Albany, GA

FRONTLINE's editors respond:

The organization that compiles that information is called the Providers Service Network. Information about them can be accessed through the a href="www.caregroup.org">CareGroup website.

Dear FRONTLINE,

It is interesting to note that most of the burden of managed care is being shouldered by the primary care physician. It is actually the specialist, the proceduralist, who has always made obscene incomes, while the primary care physician struggles to eke out a reasonable living--keep in mind, a six figure income for a highly trained, highly educated individual, who deferred making a living in most cases until age 30, is not the least bit obscene by U.S. standards in 2000.

Viewers would be fascinated to learn the incomes of some of the specialists in the health care system. Of note, the pods are mandated by most health care systems now, a mandate forced upon the primary care physician, who must spend hours each week reviewing data, while the specialist is churning up the health care dollar doing procedures.

Most reasonable docs I know realize that they really cannot practice medicine responsibly while constantly looking at the bottom line.

paul dufault

Dear FRONTLINE,

The doctors in Boston should never have signed on to a plan that forces the physician to give back money when the insurance company loses money.

No matter how bad the financial environment becomes, physicians must always put patient care first otherwise they should get out of the profession and do something else!!! Shame on the physicians who signed on to this plan for financial incentives to begin with. They got what they deserve.

Jonathan Finegold
Bronxville, New York

Dear FRONTLINE,

I found this show very informative and disturbing. These are issues I have trouble discussing with the doctor--don't want to upset him, right?

I heard "10 questions to ask your doctor" somewhere in the show, but can't find it on the site. Where might I find this information? Many thanks.

Melissa Baskett

FRONTLINE's editors respond:

It is very difficult to raise financial questions with our doctors. Such questions have always been considered to be rude and challenging.


Nonetheless, all of the doctors we spoke with in researching the show professed the importance of the patients understanding the financial incentives at work in their care. Here are some basic questions you might raise with your physician.


1. Are you "at risk" financially for my care?
2. Do you get paid a bonus based on performance measures?
3. Are you penalized financially if your costs are too high?
4. Does your practice follow a drug formulary? A drug formulary is a chart developed by a practice or a health plan that encourages physicians to prescribe less expensive drugs.
5. Is your practice owned by a larger conglomerate?
6. What specialists are you able to refer me to? Often the answer will involve certain medical centers or clinics with whom the physician has a contractual relationship.
7. Are you restricted in any way from referring me to someone I want to go visit? If they are and your specialist is important to you, you may want to consider choosing a primary care physician who is not restricted from referring you to your specialist of choice.
8. Does the cost of the care you give effect your colleagues income?
9. What emergency rooms can I go to without question?
10. What rehab/skilled nursing/hospice centers do you refer to?

Dear FRONTLINE,

Your show was terriffic but very disturbing. My health care plan is Blue Cross which is not an HMO. I am also a patient of Dr. Solomon. My understanding from my benefits office is that although Dr. Solomon is my primary care physician, I do not need his permission to see a specialist nor is he penalized if I do so. If I am hospitalized, I have to pay 20% up to a maximum of several thousand dollars. Again, as far as I know Dr. Solomon is not penalized findancially. So my question is, does the information presented in the Frontline program only apply to people who are in HMOs or are people like myself also effected?

Paul Zarchan

FRONTLINE's editors respond:

Every plan is different. Not all patients are under plans that put their physician at financial risk for care. Under some plans you are free to go wherever you want. The best way to find out your personal situation is by asking Dr. Solomon himself - clearly he is up-front with his patients about the financial constraints he feels. You can also ask your HMO.

Dear FRONTLINE,

FRONTLINE's excellent presentation shows us that the system does work. Our country wants value for its health care dollar. In the example of the Joslin Clinic, a world-renowned diabetic center, such smart people who are on the cutting edge of treating diabetes should be able to figure out how to care for patients in a more efficient manner. Why not spend 90 minutes treating 15 diabetic patients rather than 7 minutes treating only one patient?

As health care providers we need to rise to the challenge from our fellow citizens to give them more value for their health care dollars. To do otherwise runs the risk of hearing the kinds of complaints that have already been made: doctors, insurance companies, drug companies, hospitals, clinics, etc are greedy and self-serving.

In an ideal society each person would take financial and personal responsibility for her own health care. Politically our society has chosen a more circuitous route by involving government and other third parties to pay.

Those of us in positions of health care leadership need to step up to the plate and offer more appealing alternatives to our current health care morass.

Jon Sternburg
Honesdale, PA

Dear FRONTLINE,

The show clearly showed the distorted attitudes of certain physicians. If one listens to these medical doctors, one would think that they are heading to the poorhouse. In fact, physicians' salaries are excellent and, on average, several times higher than college and university professors.

It seems to me that the problem is the mindset of many physicians. Physicians complain that their reimbursements don't cover their costs.

It's time for medical doctors to stop blaming others and look in the mirror and realize that it is their greed and inflated financial expectations that has contributed to erosion of the patient-physician relationship. If physicians want to regain the trust of their patients, MDs must place patient care above financial gain.

If there comes a time when MDs start making less money than university profesors on average, then I will wholeheartedly agree that they are being underpaid.

A May

Dear FRONTLINE,

When doctors and accountants talk about financial losses and gallons of red ink, but have salaries in the 100,000 dollar range, I am in awe.

But I am truly troubled at the sight of "pod" meetings designed to use peer pressure to weed out frivolous spending habits.


If my HMO would allow me to pick a doctor, I'd definitely go for the one who unabashedly admitted to throwing his pile of stats into the rubbish bin! Bravo!

My personal choice as the low point of your report? The concluding comment that the gentleman who finally died was third on the list of patients who broke the bank with his $600,000 final illness. It is quite a legacy... perhaps his family could put that on his tombstone.

Kate Panckeri
Hazleton, PA

Dear FRONTLINE,

As a medical student and former physician assistant, I was very disturbed by this program. I don't feel physicians can ethically be involved in the management of cost/care perspectives for patients. I feel we are the advocates and provide the best possible care, but not to make an extra buck!

Our profession has been upheld centuries for our adherence to this policy, why should we let financial gain outway our primary goal -- the patient, the patient, the patient.


Jon Marti
Papillion, NE

Dear FRONTLINE,

I worked in critical care nursing for 15 years, beginning back in 1982 when prospective payment was just beginning. I am disabled now, but I probably wouldn't return to the system even if I could, because the way health care is run now is ethically repugnant to me.

I would love to see a really good investigative piece on health care finance that concentrates on the old Woodward/Bernstein advice: "Follow the money!" $25,000 for a bed. $15,000 for a defibrillator. Medications that are $5 a tablet. Good old American profiteering at its best, on the part of the unregulated participants: insurance companies, pharmaceutical firms, and biomedical equipment vendors.

I enjoyed your piece on Dr. Solomon, but I don't feel a bit sorry for him. He and I are the same age, and while he bemoans having to cover his "pod" losses out of his pitiful $300K salary cough! I collect my $1119 a month from Social Security. ...

Jane Harper, MS, RN, C
Berkeley, CA

Dear FRONTLINE,


I was both disturbed & alarmed to view your program of Dr. Solomon's Dilema. He has created his & the "Pod's" which would better be called "cell's" dilema which is a conflict of interest of enormous proporion. He is trying to balance off being a business man first against being a physician. Any physician of conscience knows that is impossible.

The whole"Pod" needs to stop being HMO stripers spending precious weekly meeting time on how to boost their "$-take" but return to being dedicated physicians & spend that meeting time on how to give better medical care & solving difficult medical problems.

As a physician, myself, I am alarmed that they are trying to rationalize that they have simply become Business Men who just happen to wear white coats.

We & they need to "rethink" "recreate" a solution, find a means where better albeit more expensive medical care becomes affordable but not by sacrificing the very quality of medical care one is trying to achieve.

Emma Lappat

Dear FRONTLINE,


So long as people neglect their health during youth and into middle age, eating fast food, living type-A lifestyles that include overindulgence and drug taking some of which, like tobacco, are unregulated without calming recreation and completely without regimen, they will end up on the healthcare doorstep in late middle age in failing health. Any system that takes on these patients is doomed from the get go

.Why did that gentlemanís coronary occlusions go unnoticed for decades as they built up to the level at which expensive surgery was the only remedy?

The only hope is a national healthcare system. The intervention arm of such a system would provide acute care for the gravely ill, long-term care for those who happen to comedown with chronic illness through no fault of their own, and occasional care for other types of patients.

But more important even than intervention would be the regulation and education divisions. Only by facing the fact that neglect of chronic health problems caused by substance abuse including the foremost culprit, tobaccois the torpedo in the side of our hospital ship can we hope to close off the watertight door that will keep it afloat.

What I am suggesting is that the alcohol and tobacco merchants' profits are in the black for them, but are the red side of the equation for any and every health care plan. With this debit dragging the doctors down, they will never make their plans pay. And only a huge nationalized plan can hope to cover the shortfalls on the exit side while regulating and educating away to narrow the input side in the hopes of eventually sending healthier clients down the healthcare pipeline.

thomas worthen
tucson, az

Dear FRONTLINE,

I am one of the 44 million Americans with no insurance at all. I recently underwent major surgery and now am faced with $25,000 of bills to pay - all on my own. My husband and I together make less than $28,000 per year, so I don't feel too sorry for the doctors who are making $120,000. They are driving in their brand new Lexus' and I'm trying to keep their collection agencies off my back.

I am really angry because this show really showed me that people like me are the ones who are picking up the tab on all the red ink. My care is not subject to the capitations and limits of some insurance company - I have to pay the whole thing!

I think these people are penny wise and pound foolish - they are complaining about the costs of that diabetic clinic for the pregnant woman - try paying for the care of her baby if it had been born underweight, premature and with multiple birth defects! We do that all the time. And the elderly woman Dr Solomon was complaining about - why doesn't CareGroup have some home health people who could manage her care at home so she didn't wind up in the hospital so much? And how about using Nurse Practitioners and Physician Assistants - they are less costly and can spend more quality time with patients?

Preventive care in the form of nutrition services by qualified nutritionists - not doctors who know nothing about nutrition, and the inclusion of other more holistic health practitioners can also help cut "sick care costs."

Kathie Pomeroy
McKinleyville, CA

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