An open letter
Koller, Christopher F.
itary officers responsible for the crime, the same officials who another voice to the din. I ask you to consider the following consistently stonewalled the administration and led it by the four...
...can some get all they want...
...As Dwight desperately needed social and public characteristics of health Eisenhower warned us about military technology, we can do care while forsaking little of the individual freedom and none more with medicine than we know how to handle ethically or of the technical competence we value in the current system...
...alysts, pundits, insurance executives, and others have given you 3. Keep it simple...
...is marked by excessive complexity...
...Those trative overhead...
...We pay for this negligence coneight graduated from the U.S...
...Any health-care reform must steer next to the ghetto is dwarfed by the prospect of an uninsured patients and providers alike toward preventative and primary mother with the poor prenatal care giving birth to a child fourcare and away from subspecialization...
...tive nature of health care: in public health initiatives that allow In my work, I have decoded creative billing practices where the sick and the healthy, the poor and the wealthy to particiservices are broken into increasingly smaller units with invented pate with equal freedom and access...
...They come from my nose...
...CHRISTOPHER F. KOLLER the terms...
...It must-as Oregon's Greetings...
...Health-care services in the U.S...
...Health care is a commodity...
...Health-care reform must foster an acceptance of the limits to our lives and our choices-by reimbursing for hospice care and eliminating incentives to perform or seek intensive levels of treatment as patients grow older...
...Another funny thing happened Chicagoans are desperately seeking answers...
...prices...
...ments...
...Fears of missed diagnoses and hopes of cures notwith- Health care deals with what we hold sacred-human life and standing, utilization of laboratory, imaging, pharmaceutical, and spirit-in fundamentally different ways from other material consubspecialty services in the U.S...
...spiritually...
...It must eliminate pay for their tummy-tucks and young people receive more agperverse incentives by ceasing to pay providers on a piece-work gressive treatment than the elderly for similar conditions, but basis and letting health-care professionals do what their voca- at some point our collective health suffers when our individution calls them to do-care and cure...
...Clinically, patients and providers alike often forsake the colIt is about the encounter with compassionate, skilled person- lective art of caring for the individualized science of curing...
...But you The UN report documents what has long been charged...
...al care varies...
...lic housing projects is an ongoing scandal, and 4. Keep it in the community...
...uates include Manuel Noriega, Leopoldi Galtieri (who led Ensuring universal access must be the primary priority of any Argentina into the Falkland War), and Joseph-Michel Frangois reform...
...Waste and fraud contribute to these costs, but the crux of the HEALTH CARE PRIORITIES problem lies elsewhere, in the simple truth that we can do more than we can afford...
...I ask you to consider the following consistently stonewalled the administration and led it by the four principles for health-care reform...
...You and the colleagues you are Medicaid waiver experiment, Canada's limits on specialty care working with are now very close to your May training programs, and Great Britain's prohibition of certain deadline for presenting a health-care reform pro- procedures on certain patients all attempt to do-allocate care posal...
...As a society this is FOUR THINGS TO KEEP IN MIND easier to ignore then to address...
...Substantive aid to the als...
...Health care has much more important things to offer than The level of crime and violence in Chicago's pubthe false hope of immortality...
...the late Roberto d' Aubuisson, charged with the food, clothing, education, and shelter, a full and healthy life is 1980 assassination of Archbishop Oscar Romero, studied at a necessary precondition for life, liberty, and the pursuit of hapthe International Police Academy, a Washington institution later piness...
...Like by the U.S...
...Our collective PUBLIC HOUSING CAN WORK expectations have changed-in many ways we no longer have SMALL IS BETTER a health-care system but a sick-cure system...
...nel who want to help and heal...
...Unfortunately, 6: 23 April 1993 Commonweal...
...managed competition...
...Was the administration willfully blind or worse...
...Fifteen percent of our population women, three were trained in the U.S...
...and the numerous solutions (single-payer or Canadian- Even ignoring these emotionally laden topics, health care in style...
...It means some parts of health care must be considered nonessential-wants, not needs...
...By now, patients, providers, policy an- in publicly accountable ways...
...Our response is no more virtuous: hire more staff to query A central question remains to be addressed in any healthpatients and providers, rebundle services, reattach our own in- care reform: how much inequity in the distribution of health vented prices, and rebill other insurers who might also be re- care can we tolerate as a society...
...and of the twelve of- lack any sort of insurance against excessive health costs...
...church not provide this guarantee...
...the equivalents of a good wine, a good watch, an Ivy League education, or a guest bedroom...
...Good health care reform must foster the recognition that our Dear Hillary, resources to pay for health care are limited...
...We Currently, massive police sweeps of the projects are being imfelt less like a patient with a doctor, and more like a diagnosis plemented by the Chicago Housing Authority...
...In 1990, experience with providers and patients as a manager for a staff a congressional commission headed by Moakley specifically model health maintenance organization (yes, I am adminiscalled for the reform of the Salvadoran justice system...
...Let the wealthy development, and distribution if necessary...
...milficers accused of responsibility for the 1981 Mazote massacre, lions more are poorly insured...
...What need could be greater tory to nobody...
...lic health measures than virtually any other industrialized country...
...specialists, all of whom billed our insurance companies...
...Last year that school-whose grad- preventable conditions, and in an impoverished social spirit...
...The current disparity is sigsponsible...
...But death happens, no matter how principles such as the ones offered here as guidelines for their much we want medical care to help us hide from it or dictate work...
...Courageous reformers will, however, maintain than the one to stay alive...
...increasing costs and decreasing access...
...total health-care ex"madness to hope"-is for Washington to make it clear that penses of over $3,600 per person in the U.S...
...And there is Administratively, we have lost the sense of health care as a pubplenty of dross-from tests of questionable value to rampant lic good-where healthy people subsidize sick people and subspecialization to Byzantine payment systems that often cre- wealthy subsidize poor...
...pay-or-play...
...compromises from aggressively entrenched interests...
...when the internist who replaced our old general practitioner Many people wonder if boarding up and ultimately started referring us for all these tests and then sent us to more tearing down the high rises is the only solution...
...We have ignored this to our peril, willfully denya school for thugs and war criminals...
...A funny thing hapAs you sort through these stories and proposals, attempt- pened to our archetypal family doctor-he specialized in obing to paste together a comprehensive proposal, please admit stetrics and gynecology, joined a physicians' group, hired a Commonweal 23 April 1993: 5 billing service, bought a share in an imaging center down the and an insurance-form clerk...
...The results-medical-care prices rising more than the truth commission-the only way Salvador will turn from twice as fast as the general inflation rate...
...When we can guarantee only needs, for attention...
...Because had a budget of $4.2 million and trained 2,000 Central and Latin our resources are limited, provision and financing are inextriAmerican soldiers...
...It have to know what you want before you can decide what you was U.S.-trained Salvadoran officers who perpetrated most of can give away...
...Army School of the Americas stantly-in sick kids who can't learn, in acutely ill patients with at Fort Benning, Georgia...
...Take them as criteria to evaluate proposrecommendations were not heeded...
...a key player in the overthrow of Haiti's Aristide government)- 2. Can't have it all...
...ty-five-year-old patients or nursing home care for ventilatordependent car accident victims are only the most obvious costs REPORT FROM THE PROJECTS associated with the refusal to accept the end of life...
...and poorer pubthere is no alternative...
...What is the Army running at Fort Benning, cably linked...
...Some level of health care should be conofficers implicated in the murders of the Jesuits were trained sidered a fundamental material right for all U.S...
...Christopher F. Koller lives in Buffalo, New York, where he The expenses associated with bypass operations on seven- works for a health-maintenance organization...
...The cats and mice play on while the patient waits nificant, costly, and unjust...
...the U.S...
...Medical science's ability to keep the body going Of course, the details of any health-care reform will by defcorresponds with our culturally conditioned desire to control inition be sticky, arcane, and, hopefully, completely satisfacthe terms and conditions of our life...
...Reforms must emphasize the collecate transparent incentives for physicians to over-treat patients...
...How can any part of health care be conearfuls about the numerous problems with the current system sidered a want and not a need...
...Institutional kind-creating smaller pools of healthier patients, leaving the health care, however, remains about the experience of human residual sick to pay higher premiums...
...All else is dross...
...ing the resource implications of the use of any health-care The only way the Cristiani government will fully implement treatments-from diagnostic technologies to pharmaceuticals the UN-sponsored peace accord and the recommendations of to surgeries...
...More insidious are the psychic costs-inflamed fears of dying alone, before one's time, or hooked up to machines...
...Shut it down...
...shut down by Congress for teaching torture techniques...
...A second constellation of perceived needs involves life-threat- I am optimistic that good reform can reclaim some of the ening or potentially life-threatening conditions...
...the war's most notorious acts: Nineteen of the twenty-seven 1. Gotta have it...
...citizens...
...It follows that in the best and fairest of sysAN OPEN LETTER tems, everybody cannot have everything...
...of the We are one of the very few industrialized societies that does five officers cited for the 1980 murder of four U.S...
...Insurance companies reacted in street, and took out loads of malpractice insurance...
...the many malefactors are structured to proliferate needs-the fear of a missed diag(bureaucratic insurers, gouging pharmaceutical manufacturers, nosis and the hope of a miracle cure are powerful trump cards greedy physicians, overdemanding patients, meddling govern- that continuously raise the ante of health care...
...Reform must also wean weeks premature while, several floors below in the same hosus from our collective addiction to high-priced diagnostic tech- pital, an endocrinologist is evaluating a boy for synthetic nologies of limited marginal value, by limiting their growth, growth hormones to improve his self-esteem...
...The injustice of the mansion ability: supply drives demand...
...They won't tell you how to handle the messy business of Cristiani government should be contingent upon reform of both how to reform the current system or explain how to extract the military and the judiciary...
...remain a function of their avail- cerns (food, clothing, housing...
...frailty and weakness, and the fear, pain, and uncertainty it brings...
Vol. 120 • April 1993 • No. 8
