Dr. Himmelstein offers “a ban on for-profit medicine” as part of a solution. However, simply adjusting the current RBRVS system would drive change in the right direction. Incentivize physicians for choosing primary care specialties; pay doctors more for talking longer with their patients, rather than ordering more tests; reduce the RVU conversion factor for overutilized procedures; and add RVUs for coordination of care and medical home oversight, which pediatricians have been doing long before it was trendy or recognized as actual “work.”

Physicians bill for procedures because they are more lucrative than cognitive tasks. However, invert the current skewed pyramidal fee schedule, and watch med students flock to primary care again. As Dr. Himmelstein points out, once you build it, they will come.

Suzanne Berman, MD, FAAP
Crossville, Tennessee

It was interesting, therefore, that when working as an activist and researcher trying to get improved HIV care in underfunded public hospitals in Central America, the Caribbean, or in India, I often found myself on the other side of this important debate. I and others, particularly people living with HIV and some physicians, were the ones demanding better access to very costly, but also lifesaving medicines. Later, once antiretroviral medicines became more widely available, we petitioned for hospitals and governments to urgently provide less toxic and more tolerable but more expensive second-line drugs, administer improved access to viral load tests, and better monitoring of CD4 counts, all of which were costly, but have become standard in HIV care in the United States and most developed countries. We also raised demands for the introduction of new technology for expensive genotype and phenotype tests to better identify and track drug resistance. Such drugs, tests, systems, and technologies could significantly improve individual clinical management for people living with HIV/AIDS as well as the government’s drug resistance and treatment surveillance efforts which are critical to the lives of millions and the battle against the AIDS epidemic, but most are too expensive and are often priced well beyond the budgets of health ministries in resource poor settings.

In each instance we knew that demands for more costly technology and drugs would be met with considerable and perhaps, in theory, also prudent and reasonable resistance by cash strapped governments and health systems, which were failing to provide even the most basic health services to the population, let alone advanced and expensive care for people living with HIV/AIDS. Yet from a human rights perspective, people with AIDS were needlessly dying and receiving substandard care.

Rationing and efficient planning will likely be needed improve coverage and costs and health outcomes and reduce disparities in the US health care system. However, even before this would be necessary, restructuring physician’s salaries, the pharmaceutical industry, and the medical devices market, could prove much less painful and more efficient to the majority of patients. How health services are structured, how the latest and best technology and how innovation is driven and paid for, and how such technology is utilized, are essential areas where the market and status quo, particularly in the United States, has been unable to provide the best solutions. Substantial changes are absolutely essential. Sometimes, more technology and medicines will be needed, and such tools, in addition to more cost effective, evidence based primary care must be made more widely available and affordable to those who need them, not just in the United States but also worldwide, where the needs are greater and the resources far fewer.

Eugene Schiff
Tufts MD/MPH Candidate