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Another view on medical care delivery.

To the Editor: In their alternative view on medical care delivery in the December issue of the American Journal of Physical Medicine & Rehabilitation, Drs Bach and DeLisa make a number of important points about the inefficiencies of the United States medical care system that are disturbing yet true. However, this reviewer is less optimistic than they are. The reviewer may have a rare perspective having moved to Canada (University of Toronto) this summer after 25 yrs at the University of Washington in Seattle. There, he served at various times as a faculty physician, department chair, and vice dean for clinical affairs and graduate medical education. In the latter capacity, he had experience working with state and federal legislative offices as they were seeking (unsuccessfully so far) to expand graduate medical education capacity for underserved areas in the United States. As Drs Bach and DeLisa point out, many other systems have significant advantages over the American healthcare system. For example, the reviewer has been surprised at how efficient it is to practice in Canada. There are essentially no denials, preapprovals, unwieldy billing codes, or uninsured, all of which contribute to inefficiencies in the United States system. Although patients can wait months for some elective procedures, those who need urgent interventions get them. It is simply a matter of calling the other physician (not an insurance company representative) to explain why the referral is urgent. Canadians generally tolerate the queues and appreciate the fact that a serious illness does not also carry the risk for financial disaster. In fact, Canadians get better health outcomes at less than two-thirds the price of the American system. Thus, the reviewer agrees with Drs Bach and DeLisa that there are many other systems, including Singapore and Canada, that have far more efficient and fair systems than what Americans have in the United States. However, one does not stand a chance of substantially changing the United States system in the foreseeable future. If anyone thinks that all that needs to be done is to come up with a better system or emulate that of another well functioning country, it is likely that one has not been exposed to the United States political system very deeply. The reasons are right in the article. For-profit insurance companies, pharmaceutical companies, for-profit hospital systems, and many others make far too much money from the current system to let it change. With this money comes strong political influence. As what has been seen repeatedly since President Clinton proposed the Health Security act in 1993, any proposed change that threatens a financial stakeholder in the current system is strongly opposed and ultimately rejected. Although some local initiatives, such as accountable care organizations or healthmaintenance organizations, mightmake limited progress on select (healthy and wealthy) populations, national healthcare system reform simply lies beyond reach, no matter how many superior examples or models exist. The reviewer wishes it were different, but the current United States healthcare system is here to stay for a long time.