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IN BOX
letters to the editor
UCLA Health
David Geffen School of Medicine
SUMMER 2014
As a practitioner
and an educator,
82% I was delighted
to read about
34% innovative
patient-education 21%
PARTNERS mechanisms
IN CARE
designed to prepare
patients for informed
decision making regarding their healthcare, as
presented in Shari Roan’s article “Partners in
Care” (Summer 2014, page 18). The programs
described in the article offer accessible,
interactive and personalized education aimed
at yielding better patient comprehension,
compared to traditional handouts or time-
consuming face-to-face conversations. Follow-
up by trained professionals such as health
coaches provides patients with an opportunity
to assess their learning and understanding
and devise the best plan of action for their
healthcare. I look forward to integrating some of
these concepts into my practice. Nonetheless,
it is important to point out that simply educating
people does not ensure that they become equal
partners in decision making. Partnership and
shared decision making must be valued and
desired by both sides of the partnership. As
patients benefit from learning more about their
improvement in people’s accurate perception of risk
“No decision
about me
without me”
reduction in people who were
considered passive about
decision making
reduction in people who chose major elective surgery
in favor of more-conservative options
options and clarifying their values and choices,
physicians, too, must become proficient in
facilitating partnerships that promote shared
decision making. Learning how to collaborate
with diverse patient populations requires
commitment and specialized training for all
healthcare professionals.
Through shared decision making, patients
and their physicians become true collaborators
in determining the best course of care.
Liat Gafni
Assistant Professor of Occupational Therapy
Saginaw (Michigan) Valley State University
Dr. Robert Vinetz hit it on the head
(“In Box,” Summer 2014) when he pointed
out that a big reason why U.S. healthcare is
so costly, compared to other countries, was
the comparative overhead costs. He cites the
example of Medicare’s overhead cost of less-
than 3 percent versus insurance-companies’
costs of 15 percent to 25 percent. That extra
cost will never be overcome as long as the
insurance companies can influence the
legislators and in so doing preclude them
from fixing the system. The Accountable Care
Act is a small step forward, but there’s still
a long way to go.
Dan Olincy
Los Angeles, California
In response to Dr. Robert Vinetz (“In Box,”
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2 U MAGAZINE
Summer 2014), who favors a single-payer
system for healthcare, I’m unconvinced.
Granted, a “Medicare-for-all” system would
eliminate the costly middleman — the private-
insurance company, with its inherent conflict
of interest (profit vs. claims payment) — but
I doubt that it would lead in the long run to
high-quality care with efficient utilization of
resources. Remember, in a national system
of single-payer health insurance, the payer
will be the government. This is the same
government whose ever-compounding
missteps have gotten us doctors to where
we are today; the same government that
fostered health insurance in the first place,
irrationally linking it to employment, and
then monopolized elder care; foisted HMOs,
PPOs and managed care on doctors and
the public; fixed physicians’ fees; instituted
an extravagant, unfunded prescription-drug
scheme; and topped it all off with the
non-affordable Affordable Care Act.
I’d sooner believe that pigs can fly. It’s
more likely that regulations will proliferate,
bureaucratic inefficiency will thrive, claims
will increasingly be denied and therapeutic
innovation will be stifled. Toward the end of his
letter, Dr. Vinetz cites the need to “engage the
patient from the get-go” in order to develop
his/her understanding. The goal is laudable,
but universal Medicare won’t achieve it for the
reason that the patient will remain (as now)
the only passive member on the healthcare
team, disconnected from the costs of care,
uninformed of alternatives in care and, at best,
only dimly aware of how things work or why
they are done. Instead of universal Medicare,
I propose two complementary innovations:
medical scrip and personalized medicine.
Medical scrip (or vouchers for healthcare)
would put the power of the purse into patients’
hands, creating a free market in care and
maximizing choices. Scrip could be spent at
a medical-doctor’s office, local hospital, HMO
or with an insurer. It would be dispensed by
the government on the basis of demographics,
medical needs or both. Unused scrip could
be saved for future health needs, in the
manner of a health-savings account. By way of
comparison, vouchers for food (food stamps)
keep indigent families well-nourished, if
used wisely. Vouchers for education promote
educational quality by offering more choices to
consumers and thereby fostering competition.
Medical scrip should enjoy success similar to
that of vouchers for other basic human needs.
The other innovation, personalized medicine,
has been gaining traction for several years.
A quick Google search reveals a dozen
prestigious institutions with established
or nascent programs in genetically based,
individualized medicine. Clinical application is
sparse at present, but when widely available,
personalized medicine will stand in stark
contrast to our statistically based, one-size-
fits-all medical model predicated on the fallacy
of the “average human.” Human beings are,
because of Mendelian genetics, by nature
diverse and individual, not interchangeable.
A system that recognizes that will maximize
patients’ choices, lower costs and achieve the
best outcomes.
Richard P. Huemer, MD ’58
Palmdale, California