The June 7 op-ed article "Return to Medical Inflation" by Patrick G. Hays emphasized containing medical costs by "allowing health plans to manage scarce dollars equitably. In a world of limited resources, a health plan occasionally has to say no to an initial recommendation of the physician."

I have several questions for Mr. Hays:

Whom should I trust to determine my medical care, a doctor who is educated and experienced and whom I trust, or a gatekeeper who is interested in the bottom line?

How much of that bottom line goes into the pockets of Mr. Hays and other administrators of insurance companies? Is Mr. Hays prepared to cut his salary, which I would guess is considerable, in order to keep costs down?

It is kind of him to inform us that "only 5 percent of all claims are denied." But how would he feel if he or a loved one were among that 5 percent denied care in order to keep costs down?

ANN W. JOSELOFF

Silver Spring

Patrick Hays's op-ed article was a magnificent demonstration of how not to solve the problem of health care financing. Mr. Hays, the CEO of Blue Cross and Blue Shield, suggested that the managed care bureaucracy rather than patients and their physicians is best able to decide patient care.

The core problem is the disconnect of the user of medical services -- the patient -- from the purchaser of medical services -- the employer, government or managed care/insurance bureaucracy. The purchaser in the current arrangement wants to control costs and provide either profit or power to the controlling bureaucracy. The patient's agenda, namely the best care, always will be in conflict with that. The physician in the current scenario tries to do what's best for the patient but is beholden to an insurance bureaucracy.

The solution is to return to a free medical marketplace, which requires that the user of the service determine its value and has the freedom to seek it. The United States has not had medical free markets since the World War II Powers Act, which for economic reasons established an employer-based health benefits system. For free markets to occur again, the functions of both user and purchaser of the medical service must be reunited in the patient. This cannot happen until health benefits are taxed equally and the patient assumes ownership and control of the health benefits package from the employer. This also requires that the insurance industry return to true cost-effective insurance products (e.g., coverage for unanticipated events) rather than the rationing cost control by managed care service contracts inappropriately called health insurance.

Our financing system is based largely on the presumption that medical services are too complex for the patient to act in his or her best interest in a cost-effective direct doctor-patient relationship. The reality is that in the current system, the employee transfers salary to the employer, who chooses a managed care intermediary, who in turn chooses physicians pressured to ration care, placing the patient at increased risk.

The proposed legislative remedies although palliative are far from curative since they do not empower the patient by restoring a true doctor-patient relationship.

ROBERT P. NIRSCHL

Arlington

The writer is a medical doctor.