The Economics of Good Health Care

Regarding Benjamin H. Natelson's Aug. 3 Outlook article, "Lost in a System Where Doctors Don't Want to Listen":

As internists whose practice includes many patients with complex medical histories similar to those Dr. Natelson described, we share his concern that these patients have trouble getting adequate medical evaluation. Caring for such patients is exactly what we train to do in internal medicine. In fact, it's what we like to do.

The problem is that physicians run small businesses and are facing the financial pressures every other small business does. The difference for medicine is that payments are highly regulated and expenses are not. Dr. Natelson overlooked the fact that Medicare and private insurance companies are responsible for this mess.

The patient whom Dr. Natelson described would be in our office for a full hour. Our hourly fixed costs are $84. The Medicare reimbursement rate for the moderately complex patient described is $96. Commercial insurance in Maryland pays a fraction of what Medicare does. We would keep $12, an hourly rate not commensurate with the training or responsibility of a physician.

The most outrageous assertion in the article was that greater numbers of women in medicine would resolve the crisis. While we are aware that studies reveal that female physicians listen to patients more fully, to assert that women -- who complete the same training, have the same amount of student loans and the same economic pressures in their practices as male doctors do -- can be bought more cheaply than men is preposterous.

AUDREY P. CORSON

JANE H. CHRETIEN

Bethesda

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Benjamin H. Natelson argued that we're misallocating medical personnel because Medicare pays sophisticated diagnosticians a net $86 per hour for listening to a patient but pays neuroradiologists a net $216 per hour. To establish that this is a problem, Dr. Natelson should first demonstrate that shifting money from the latter to the former would purchase greater health improvements.

But suppose Dr. Natelson's diagnosis is correct. He then prescribes loan forgiveness for medical school grads who choose primary care. Wouldn't it make more sense to attack the disease (i.e., Medicare's Rube-Goldbergian price-fixing formulas) than to treat the symptoms by creating yet another subsidy for doctors?

MICHAEL F. CANNON

Director of Health Policy Studies

Cato Institute

Washington