When President Bush signed the Medicare bill into law, it signaled a beginning, not an end, to the battle to make prescription medicine affordable for older Americans ("ABCDs of Medicare reform," Dec. 22/29, 2003, p. 19). This legislation will leave millions of older Americans choosing between food and medicine. The congressional leadership and this White House are willing to sacrifice the health of older Americans for excessive drug company profits. The American people deserve better than that.
The next battle in Congress will be for prescription price parity with Canada. Medicine should not cost Americans twice what it costs Canadians. Congress should immediately repeal the prohibition on the federal government negotiating for lowest prices with drug companies. That would do more to make medicines affordable to people with Medicare than this legislation.
Medicare Rights Center
The databank needs deposits ...
Regarding your cover story "Killer credentials" (Dec. 22/29, 2003, p. 6), I think the answer to problem nurses is that all of them should be credentialed and that any improper behavior should be part of the reporting criteria of the National Practitioner Data Bank.
Medical staffs have that system available to them, but there is the need to ensure that hospitals, nursing staff agencies and others report information to the databank.
Furthermore, all the data-on physicians and nurses alike-must be current and more thorough than what is now available.
Manager, graduate medical education
and medical staff services
Children's Medical Center of Dallas
... but crimes hard to prevent ...
Regarding your cover story, "Killer credentials": I agree totally with the comment by Dennis Miller, president and chief executive officer of Somerset Medical Center, that "You can't prevent someone, no matter what you do, from doing criminal acts, no matter how hard you try."
Unfortunately hospitals cannot afford to be sued for giving too much information on a particular individual; in many instances termination of employment becomes a "he said, she said" scenario.
In many cases, problem employees are released by persuading them to resign in an effort to avoid litigation. Obviously when an employee commits a proven illegal act the situation is handled differently. Reform is necessary, it will help, but it won't totally eliminate intelligent perpetrators.
St. Joseph's Wayne (N.J.) Hospital
... and news hurts recruiting
I find the actions Charles Cullen is alleged to have committed deplorable. Nursing needs to continue to attract bright, talented people from all walks of life, and this kind of news makes recruiting that much more difficult.
I concur that the sharing of information on marginal employees needs to become a priority. I realize that the charges against Cullen make for sensational headlines. I just ask whether Modern Healthcare could find stories of nursing professionals who have made positive differences in patients' lives.
Almost all nurses believe in making patients healthier and safer. I have had the privilege to work with some amazing nurses over the years and believe they make up the majority of this caring profession, not the minority of marginal personnel that your article addresses.
Johnson & Johnson nurse executive fellow
Chief clinical officer
San Jose (Calif.) Medical Center
I think Todd Sloane needs to apologize to Gov. Arnold Schwarzenegger and the voters of California for his editorial ("Flailing in California," Dec. 15, 2003, p. 18).
In looking to jump on the new governor's perceived failure after two big successes (rolling back the vehicle tax and stopping the issuing of driver's licenses to illegal immigrants), Sloane did not give the new governor time to get the budget agreement completed. Rather, he felt the need to ridicule the new governor's background, as if we voters have not seen what politicians have done to our state since the last nonpolitician (Ronald Reagan) had our state in order.
Schwarzenegger replaced a politician who was the major cause of the financial problems California is now experiencing. Now state voters will be able to speak once again in support of the agreement the governor worked out with both Democrats and Republicans to put a cap on spending and approve a $15 billion bond issue to finance the excesses of the past.
Given time, maybe nonpolitician Schwar-zenegger will make California a Golden State again. If not, there will always be the professional politician ready and willing to do more damage to our state.
Information technology consultant
Palm Desert, Calif.
What AARP represents
I am a member of AARP, but in the Medicare reform debate, the organization was improperly referred to as a representative of the elderly (Editorial, "The Medicare follies," Nov. 24, 2003, p. 41). Not long ago AARP dropped its former name, which included the words "retired persons." Now AARP garners over 60% of its annual take from selling insurance. It makes other money from selling cruises and other sidelines. In other words, AARP is now in the insurance business and rakes in money from the under-65 and employed population.
Although I am an AARP member, let me tell you that it doesn't represent my views; it sells me insurance at rates that I find competitive. As an insurer, AARP isn't bad, but it doesn't represent the elderly, either. The groups that do represent the elderly were ignored by the promoters of this Medicare legislation. The lesson these less-endowed groups learned was that they'd better get some more money if they expect to play in this game next time around.
The elderly in this country are ready for representation by an organization that will represent them properly now that it's plain that AARP has other interests.
President Union of American Physicians and Dentists
American Federation of State, County and Municipal Employees
Regarding your cover story "New Jersey experiment" (Dec. 1, 2003, p. 6): The phrase "aligning doctors' and hospitals' incentives" seems to have a felicitous ring among healthcare leaders, especially if it can be cloaked in the mantle of better quality. The experiment with alignment described in your article, however, comes across as a disturbing commentary on the professional ethics of New Jersey physicians.
As you describe it, the experiment is not aimed at enhancing the quality of patient care or saving the taxpayer money. Rather, doctors are to receive an average cash bonus of $340 per admission to help hospitals squeeze greater profits out of the flat fees per case Medicare pays them. If the sought cost savings enhance the hospital's profits without impairing the quality of care or-as is claimed by some hospital executives-by actually enhancing that quality, then we conclude that New Jersey physicians must be handsomely tipped to do what professional ethics should have compelled them to do in the first place: aim for good quality without wasting resources. I wonder how many physicians will sign on to this humiliating deal.
One can only hope that hospitals and the doctors who do participate in this scheme will feel duty-bound to apprise each and every one of their patients of the arrangement, or that Medicare will compel them to do so.
As a patient, I certainly would like to know whether or not my physician benefits financially from having me discharged earlier or forgoing certain diagnostic tests.
James Madison professor of political economy
Princeton (N.J.) University
More rural help needed
I completely agree with the letter ("Rural realities," Dec. 1, 2003, p. 24) from Tim Size of the Rural Wisconsin Health Cooperative, which stated that for years Congress has required rural communities to subsidize the federal government's obligation to the Medicare beneficiary.
This hidden tax or cost shift imposed by the current Medicare program through its pattern of paying less in rural areas has caused extreme structural cracks in our healthcare delivery system. Those of us in rural areas are quite accustomed to doing more with less, being required to meet the same standards for less payment and having to recruit on an uneven playing field.
The recently enacted Medicare Prescription Drug, Improvement and Modernization Act of 2003 will help rural hospitals some, but we can only hope that it is not too little, too late. Not all people are fortunate enough to live in wealthy suburban areas, and we must ensure that safe, high-quality care is available to our citizens who do live in rural areas.
I encourage those of us who are rural healthcare providers to continue to fight the battle and provide continuing high-quality care to our patients. We only ask for support from our communities, our lawmakers and other providers.
Halifax Regional Medical Center
Roanoke Rapids, N.C.
For the record
Pensions cut deep" (Cover story, Dec. 8, 2003, p. 6) misstated financial information related to Ascension Health's funding of its pension liability. The statement that "Ascension Health used $607.3 million of cash from its hospitals' operations to fund its pension liability in the fiscal year ended June 30" is incorrect.
Ascension did not make a cash contribution. Rather, it recorded an additional liability of $607 million for the year ended June 30, 2003. This recording of pension liability was in accordance with generally accepted accounting principles.
Director of communications
How to deliver the boot
Vince Galloro's article ("Giving the boot," Nov. 24, 2003, p. S18) on removing problematic directors seems not to distinguish clearly between not-for-profit organizations with true members who elect the board and self-perpetuating boards. Nor does he note the differences among the states.
Under New York law, such directors can generally be removed, but only for cause by vote of the directors or members or without cause by vote of members, if any, if authorized by the incorporating document or bylaws.
The article also fails to mention the virtue in having intelligent, informed and principal dissenting fiduciaries.
Assistant attorney general
New York attorney general's office
Some thoughts on rainmakers
Regarding Mark Taylor's story, ("Storm warning," Nov. 17, 2003, p. 26) concerning physicians known as "rainmakers" and two subsequent letters from readers Joseph Hawkins, chief executive officer of Merritt, Hawkins & Associates, and John Whitcomb, senior vice president of Magellan Management Group (Letters, Dec. 8, 2003, p. 24):
Hawkins makes some valid points. Some doctors do earn the badge of "rainmaker" by performing unnecessary procedures. And, yes, those exceptional physicians who do a large number of procedures well do provide high-level care and should earn a substantial living for their efforts. However, with due respect to Hawkins, I think the issues in Taylor's article are much larger than practitioners performing unnecessary procedures.
How are rainmakers treated by hospital administration when they err, for whatever reason? Are they provided special treatment? Are administrators neglecting their duty to protect patients, employees and the institution? Do administrators sell their integrity in order to protect their own careers because they fear the outcome of confronting rainmakers?
No doubt about it, in most any other industry the star performer who increases business or sells the most product or service is handsomely rewarded. Unfortunately, there are laws against hospitals' directly rewarding physician rainmakers. But there are ways to indirectly reward them, such as favoring their pet projects or funding their equipment needs.
Whitcomb contends that boards that fulfill their legal accountability should reduce the prospects for abuse. That assumes the board is made up of members familiar with healthcare or have a lot of time on their hands or both. Perhaps if more board members were remunerated as are for-profit boards, the quality of oversight might increase.