Readers' Responses to the Webcast Video Editorials Entitled "The American Healthcare 'System' in 2005" -- Parts 5 and 6

Wayne A. Pickard, MD; Cherrie Evans, RN, MSN; John Kochevar, PhD; Joe Polaschek


April 15, 2005

To the Editor,

Unmentioned in your editorial[1] is why increasing the percentage paid by the government would be a good thing . Government programs are so often associated with the phrase "waste, fraud, and corruption," mainly because they are so often associated with waste, fraud, and corruption. This is not something that we need expanded. Experience tells me that the role of government in healthcare should be kept small, just enough to ensure that cripples and incompetents are not turned out into the streets -- which, come to think of it, it's already doing. But to expand it? Public healthcare would become odious, like public housing; and stupid, like public education; and wasteful, like space exploration; and bureaucratic, like no bureaucracy outside of government. I could go on and on.

Wayne Pickard, MD
Brandon, Florida


  1. Lundberg GD. The American healthcare "system" in 2005 -- part 5: 2 good options for fixing our broken system. Medscape General Medicine. 2005;7(1). Available at: Accessed February 25, 2005.

To the Editor,

I have enjoyed reading your editorial comments up until you said that you would favor a universal equivalent of "Kaiser Permanente America.[1]" Having lived under the Kaiser "roof" for 5 years and experienced Kaiser care (or lack thereof) personally and professionally, I have to strongly disagree with you. Kaiser is an efficient organization for the masses if nothing goes wrong with you. Please don't dare to have a complication or something that requires intelligent clinical judgment outside of the "cookie cutter" medicine that Kaiser performs.

Cherrie Evans, RN, MSN
Salt Lake City, Utah


  1. Lundberg GD. The American healthcare "system" in 2005 -- part 5: 2 good options for fixing our broken system. Medscape General Medicine. 2005;7(1). Available at: Accessed February 25, 2005.

To the Editor,

Thank you for your straightforward list of criteria for evaluating the quality of healthcare systems.[1] For the last year, I have been asking physicians and MCO [managed care organization] executives why the US healthcare system rates so poorly compared with most other OECD [Organisation for Economic Co-operation and Development] healthcare systems.

Several weeks ago, I posed the question to 3 friends, all department heads at major local hospitals. The answer was, uniformly, "What do you mean? The US has the best healthcare system in the world."

I described the results of the recent RAND study. They knew the study and said, "'Best' depends on the outcomes you use to rate the system."

They were all well traveled, and they all had the same winning evidence. "If I had anything wrong with me I would rather walk into any hospital in Boston than into any hospital in any foreign country in the world."

None of your quality criteria matched their quality criteria.

Now that you have a good list of criteria for judging healthcare systems, you need a list of barriers to change. At the top of that list, put "Clinicians and Clinical Judgment." One of the great strengths of our healthcare system is one of the greatest barriers to change. Clinicians use limited evidence for judging medical care. As long as they and their families get the best medical care in the world, they are not going to be change-oriented.

On a more positive note, we did conclude that "medical hodgepodge" was a better descriptor than "medical system."

Thank you again for your lucid analysis and clear writing.

Best regards,
John Kochevar, PhD
Charlestown, Maryland


  1. Lundberg GD. The American healthcare "system" in 2005 -- part 6: how to grade the current system and proposed reforms. Medscape General Medicine. 2005;7(1). Available at: Accessed March 11, 2005.

To the Editor,

Regarding the judging of proposals for true health system reform based on your 11 evaluation characteristics,[1] a model proposed for California should be put to the test of those elements.

Senator Sheila Kuehl, Dem-Santa Monica, has authored SB 840, the California Health Insurance Reliability Act (CHIRA).[2] This measure deserves to be reviewed and discussed beyond the State's borders, as its success in the world's sixth largest economy would signal a shift in healthcare delivery systems toward fiscally sound, comprehensive, affordable, and consistent health insurance coverage.

So, based on my attempt at applying your evaluation elements, let's see how this program might measure up compared with your grade of the 2005 American system of 52 and my grade of the current American system:

1. Access for all to basic care: CHIRA eligibility is based on residency, not on employment, income, or insurability. All residents will have coverage of all care prescribed by a patient's healthcare provider that meets accepted standards of care and practice.

CHIRA score:   9         Current system score:   5

2. Produce real cost control: The plan not only involves no new spending on healthcare; this measure will make the healthcare system more reliable and secure by stabilizing the growth in health spending, linking spending increases to the state GDP [gross domestic product], population growth, employment rates, and other relevant demographic indicators. Administrative costs will be capped by statute.

CHIRA score:   9         Current system score:   5

3. Promote continuing quality: "Quality" is an elusive characteristic. Current systems attempt to fill the quality measure gap, but I believe that the best measure of quality is when consumers vote with their feet, given the opportunity to do so. In CHIRA, providers will be free to apply their medical training and skills, and patients can choose their providers based on their perceptions of those providers' quality of care. Also, the plan will invest in statewide medical databases to assist in improving healthcare quality and in creating programs to encourage personal responsibility for good health. However, even a program like CHIRA can't effect this change completely on its own. Consumers still must choose healthy lifestyles, including educating themselves and adopting appropriate nutrition and exercise programs.

CHIRA score:   6         Current system score:   4

4. Reduce administrative hassle and cost: Providers and consumers will not have to deal with the maze of confusing healthcare delivery system bureaucracies. The estimate of the current system is that half of every dollar spent on healthcare is squandered on clinical and administrative waste, insurance company profits, and overpriced pharmaceuticals. The CHIRA model is based on independent studies showing estimated savings of about $20 billion through reduced administrative costs in the first year alone. Analyses also show estimates through systemwide bulk purchasing of $5.2 billion in the first year.

CHIRA score:   9         Current system score:   4

5. Enhance disease prevention: The plan will combine needed cost controls with medical standards that use the best available medical science and place an emphasis on preventive and primary care to improve California's overall health in a way that also saves billions of dollars. CHIRA gets an A for effort, but again, an educated, motivated, and involved consumer is essential to disease prevention.

CHIRA score:   7         Current system score:   4

6. Encourage primary care: With some limited exceptions, consumers will be required to select a personal primary care physician. Access to primary care providers could save $3.5 to $6 billion in unnecessary emergency room visits and preventable hospitalizations.

CHIRA score:   9         Current system score:   4

7. Consider long-term care: Considerable expert analysis on long-term care is included in the development of the plan. Beyond the 100 days of skilled nursing facility care post hospitalization, it is not a part in the initial benefits, but it is planned for subsequent inclusion with further review and incorporation of appropriate guidelines.

CHIRA score:   2         Current system score:   1

8. Retain patient autonomy: All licensed providers and accredited facilities may participate. Every Californian will have the right to choose his or her own personal primary care physician. Some limited continuing service arrangements will be allowed for patients under specialist care initially, but generally a referral for specialist visits will be required from a consumer's primary care physician or emergency physician.

CHIRA score:   7         Current system score:   5

9. Retain physician autonomy: Physician freedom from the profit-driven motives of most managed care plans is a major feature of the plan. It will put medical decision making back in the hands of medical professionals and their patients. Overall governance will be from an elected commissioner and the State Health Agency that, while having physician and other healthcare provider representation, will have boards that include others, such as members of the public, consumer advocates, policy experts, and labor leadership.

CHIRA score:   8         Current system score:   6

10. Limit professional liability: The information system enhancements, inherent controls, and quality-improvement measures of the plan will present a foundation for malpractice premium stabilization and reduction. Any specific malpractice reform would be a separate issue.

CHIRA score:   6         Current system score:   4

11. Possess staying power: A plan, such as CHIRA, has the balance of incentives and controls necessary to maintain the stability and assurance of consistent health insurance delivery over long periods of time with fluctuating personal, societal, and economic conditions. It has the mechanisms to account for the inevitable changes that will arise in healthcare delivery operations and technology.

CHIRA score:   9         Current system score:   6


CHIRA points:   81         Current system points:   48

Well, as you say, no reformed healthcare system can be perfect nor satisfy all the constituencies. But CHIRA could be on the right track as a model plan for ensuring and stabilizing health insurance coverage for a large and diverse population base.

Thank you,
Joe Polaschek
Salinas, California


  1. Lundberg GD. The American healthcare "system" in 2005 -- part 6: how to grade the current system and proposed reforms. Medscape General Medicine. 2005;7(1). Available at: Accessed March 11, 2005.

  2. Senate Bill No. 840. California Health Insurance Reliability Act. February 22, 2005. Available at: Accessed April 6, 2005.


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