To the Editor: In their recent articles on rising health carecosts, economists Paul Ginsburg (Oct. 14 issue)1 and JosephNewhouse (Oct. 21 issue)2 and presidential candidates John Kerryand George Bush (Oct. 28 issue)3 do not directly address thewell-known fact that approximately 10 percent of patients accountfor 70 percent of costs.4 To control costs we must acknowledgethis skewed distribution and honestly address the major factordriving costs: the growth of technology.5 Managed care's lackof candor undermined its efforts to control costs and led topatient backlash.6 Since rationing is politically untenable,government has retreated from these issues. And current effortsat patient cost-sharing with caps will not curb spending forthose with high utilization.
However, in order to obtain basic health care, some patientsare willing to accept limits on care. We need efficient insurancesystems in which patients willing to accept such limits arelinked with caring physicians who use innovative practice stylesand consider both costs and benefits as they care for theirpatients. Although this approach may make some uncomfortable,it is both ethical and necessary.
Elmer D. Abbo, M.D., J.D. University of Chicago Chicago, IL 60637 eabbo{at}medicine.bsd.uchicago.edu
References
Ginsburg PB. Controlling health care costs. N Engl J Med 2004;351:1591-1593. [Free Full Text]
Newhouse JP. Financing Medicare in the next administration. N Engl J Med 2004;351:1714-1716. [Free Full Text]
Bush GW, Kerry JF. Health care coverage and drug costs: the candidates speak out. N Engl J Med 2004;351:1815-1819. [Free Full Text]
Berk ML, Monheit AC. The concentration of health care expenditures, revisited. Health Aff (Millwood) 2001;20:9-18.
Newhouse JP. An iconoclastic view of health cost containment. Health Aff (Millwood) 1993;:152-171.
Havighurst C. How the health care revolution fell short. Law Contemp Probs 2002;65:55-101.
To the Editor: Dramatic advances in medicine and technologyhave resulted in widespread benefits from lifesaving but expensivedevices and drugs such as implantable cardiac defibrillators,drug-eluting coronary stents, and new chemotherapeutic agents.Interestingly, three of the four options for reducing risinghealth care costs proposed by Dr. Ginsburg would require peopleto obtain less medical care. If our society continues to rejectlimitations on health care acquisition, one reality must befaced by all: whenever technological advances occur, there areincreased costs to individuals (for example, automobiles costmore than horses and buggies, televisions cost more than radios,and air travel costs more than rail travel). Our hope is that,over time, cost containment can occur as a result of three mechanisms:reductions in the price of technologies through free-marketcompetition, medical-liability reform (which will reduce thepractice of defensive medicine),1 and the growth of informationtechnology, leading to a more efficient system.2,3 Until then,the American people must assume some personal responsibilityfor financing the most advanced health care system in orderto continue to reap its benefits.
Steven G. Coca, D.O. Elliot Ellis, M.D. Yale University School of Medicine New Haven, CT 06520
Kirk N. Campbell, M.D. Mount Sinai School of Medicine New York, NY 10029
References
American Medical Association. Medical liability reform: a compendium of facts supporting medical liability reform and debunking arguments against reform, December 3, 2004. (Accessed January 6, 2005, at http://www.ama-assn.org/ama1/pub/upload/mm/450/mlrnowdec032004.pdf.)
Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003;139:31-39. [Free Full Text]
Dr. Ginsburg replies: Dr. Abbo correctly points out that thelarge proportion of spending for the relatively small groupof patients with high medical expenses limits the role thatpatient cost-sharing can play in containing costs, and his pointabout some patients' willingness to accept limits in returnfor access to important care is well taken. However, I mustdisagree with the prediction of Dr. Coca and colleagues thatwe can contain costs without some sacrifice — that easygains in efficiency are possible if only we pursue them. Inevitably,the gains do not pan out. Today's promises are that expandedinformation technology and malpractice reform will yield largeenough savings that trade-offs will not have to be faced. Thesesteps are worthy ones, but we should not oversell the likelycost savings.1
The challenge of effective cost containment is to encourageaccess to new medical technologies that provide important improvementsin outcomes while discouraging the use of high-cost treatmentswith small or unknown benefits. Too often, our health care systemallows the rapid diffusion of new technologies without rigorousexamination of their effectiveness in comparison with that ofexisting treatments. Sometimes, much-heralded new technologiesturn out to have small benefits or even to cause harm —Vioxx comes to mind. The reality is that we as a society donot have the resources to provide all the care that patientsmight want and physicians might want to provide. Without effectivecost containment, the result will be increased rationing onthe basis of ability to pay, rather than rationing based onclinical effectiveness. In the end, we have to answer this question:Is it better for many to do without low-value services or forthe few who cannot pay to go without important care?
Paul B. Ginsburg, Ph.D. Center for Studying Health System Change Washington, DC 20024
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