A Big If

The health savings accounts (HSAs) you reported on in "Selection Time" [Oct. 26] will be the best approach to health insurance if insurance companies will bill at their negotiated rate instead of their so-called retail rate. A recent bill that arrived in our household will demonstrate.

The doctor's charge was for $87. The doctor actually received $54 -- $20 from us as copay and $34 from the insurance company. If our health HSA were to be charged the retail $87 instead of the negotiated $54, this would be an outrage, and it would prevent intelligent use of HSAs. I did not find any mention of this issue in the many words you provided about HSAs and their brethren.

Alan Willsey

Bethesda

The Many Sides of Medicare

The Oct. 26 "My Time" had a typically evocative headline: "Medicare's a Solution, Not the Problem." As a practicing physician I read the column thoroughly. What a disappointment!

Medicare's high satisfaction rate is due to the fact that its recipients are not paying the actual cost of the care that they receive. Rates are predetermined by Medicare and balance billing of patients is illegal. But the supposed affordability of Medicare is an illusion. Medicare reimbursement rates in my practice are less than a third of those paid by other third-party carriers, even though many Medicare patients, because of age and disability, have multiple medical problems requiring more extensive and more sophisticated care.

Individuals and businesses paying for conventional private health care and health insurance are supporting Medicare because Medicare does not even cover costs of direct care, let alone overhead and distributed costs. Most Medicare participants have plans allowing them to choose their own physicians, as opposed to plans with gatekeepers, which control access and referrals, which also contributes to a higher level of patient satisfaction.

The programs the column advocates already exist in Canada and Great Britain, where care is nationalized and available to everyone. The downside of these programs is that all types of care are not available to everyone, and some care is not available when patients require it or would like to receive it. Waiting times for elective procedures are common and lengthy, and not necessarily in the patient's best interest.

In a country where health care costs continue to rise while many people are uninsured or under-insured, the question of how to fix the system must be addressed in a sensitive and honest manner. Medicare gives the illusion of a solution, but it really is part of the problem. If Americans value the concept of universal health care, the questions of "who gets how much care and when" and "how will we pay for it" still need to be addressed.

Mollyann G. March, MD

Bethesda

From the medical office insurance coordinator point of view, I find that Medicare is the most predictable insurance system around. In fact, very soon it will be the only insurance that we accept on assignment. This is because we (doctor and staff) know how much will be reimbursed and the turnaround time. The customer service is pretty reasonable and you can appeal if the claim is not paid correctly.

There are strict guidelines to follow to be reimbursed, but they never require additional explanation for clean claims. They also let the provider know the rules for participation. Unlike Blue Cross or other private insurance, they don't normally play games and change the rules midyear to prolong the time the claim is unpaid and unprocessed. The physician in our office would certainly welcome a wider scope of Medicare, because they are easy to deal with even if the reimbursements are lower.

Andrea Karp

Bethesda

Enjoyed your column on Medicare. We have belonged to Medicare since we were 65; we are now 78 and 80. We think it is a wonderful program. We have supplemental insurance (Anthem Blue Cross & Blue Shield) at $167 a month for each of us.

My husband has a VA prescription plan. That is also a wonderful program.

I have no prescription coverage. Having read President Bush's prescription plan for seniors, I see no benefit whatsoever. As prescriptions are so expensive, there should be some way to lower the cost.

Barbara Miller

Stafford, Va.

Flu Steps

An Oct. 27 front-page article ["Workers to Get Flu Shots At Many Federal Offices"] emphasizes the urgency of vaccinating those most vulnerable. But the Oct. 26 "Flu News Update" in the Health section is less inflammatory about the consequences of the lack of enough vaccine, noting that there is agreement among public health experts that "vaccine is only one part of what ought to be a comprehensive effort to stay well during flu season," and advises the use of alcohol-based hand sanitizer to kill viruses. If vaccine is only one tactic in a comprehensive effort to stay well, please tell us what else we should be doing in the light of the current shortage.

Patty Sheetz

Vienna

Because of the small space devoted to the weekly Flu Update and our desire to touch on as many aspects of the story as possible, we didn't provide a complete list of general preventive health measures. The Centers for Disease Control and Prevention cites the following as key steps:

* Avoid close contact with people who are sick.

* If possible, stay home from work, school, and errands when you are sick.

* Cover your mouth and nose with a tissue when coughing or sneezing.

* Washing your hands often will help protect you from germs.

* Avoid touching your eyes, nose or mouth. In addition, public health officials urge people to make sure all other immunizations are up to date and to get sufficient rest and proper nutrition.

-- The Editors