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,” Share Your Thoughts with Us Like us or not, we want to hear from you. Your input is important, so please give us your comments and feedback. Include your name, e-mail address, city and state of residence and, if you are a UCLA medical alum (MD, PhD, Resident and/or Fellow), your degree(s) and graduation year(s). Letters and/or comments may be edited for clarity and length. Don’t be a stranger. Write to us or post your comments on our social-media pages. Submit letters to: magazine.uclahealth.org uclahealth.org/getsocial 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