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doi: 10.1001/jama.1986.03370100015002pmid: N/A
Evaluation and clinical testing of potentially useful therapies for the acquired immunodeficiency syndrome (AIDS) are entering a new phase. Until now, drugs or other strategies that might be helpful in the treatment of the disease have, by and large, been evaluated by independent investigators, by pharmaceutical companies that have developed possibly useful agents, or in clinical studies at the National Institutes of Health in Bethesda, Md. However, even though much has been accomplished, the number of AIDS cases continues to mount. As of this month, there are nearly 18,000 reported cases of AIDS with more than 9,000 deaths. So it is being recognized that the efforts to develop strategies for managing AIDS need more focus administratively and scientifically. The result has been the formation within the Public Health Service of a task force on AIDS. At the moment, it is headed by Walter R. Dowdle, PhD. "The idea of my
doi: 10.1001/jama.1986.03370100081010pmid: N/A
To the Editor.— Dr Angell,1 in her article, "Cost Containment and the Physician," outlines the growth of unnecessary medical care and the role of physicians in containing medical costs. A factor that is suggested as crucial is a "revision of fee schedules so that they no longer reward the use of tests and procedures." Dr Angell made it clear before this statement that she was not accusing the majority of physicians of performing "unnecessary tests and procedures simply to make money." I believe she is correct that the majority of physicians do not order tests simply to make money, but there are two significant reasons these tests are ordered. The first reason is society's expectations for these "little-ticket items." Common are lay accounts of initial vague symptoms that are appropriately dismissed as transient phenomena by a physician (eg, headaches). Later that patient sees another physician who, perhaps with relevant
doi: 10.1001/jama.1986.03370100081009pmid: N/A
To the Editor.— In her recent JAMA article, Dr Angell1 offers some thoughts on how to address the problem of the medical community spending too much money on health care. Among the several remedies suggested were the following. First, physicians should eliminate unnecessary medical care. I agree we should try, but given the amount of success that the Department of Defense has had in eliminating waste in the military I am not optimistic that physicians can do much better in medicine. Second, peer-review mechanisms would decide which new technologies are beneficial before funding is provided on a grand scale. Who will decide and how was not addressed. Meaningful peer review has not been one of medicine's great accomplishments in the recent past. Third, "fee schedules should be revised so that they neither encourage nor discourage the use of tests and procedures." I predict that this will be like tax
doi: 10.1001/jama.1986.03370100081007pmid: N/A
To the Editor.— Dr Angell1 provides thought-provoking, practical analysis and advice in her article, "Cost Containment and the Physician." She suggests that the profession support the revision of fee schedules so that they no longer reward the use of tests and procedures as the single most important reform to be made in the present system. This general statement could have been strengthened by examples, and I offer an important one. Perhaps half of all radiological examinations in the United States are performed in the primary physician's office. In this self-referral situation it is clearly impossible for the physician to be unbiased in deciding what needs to be done for the patient. A substantial reduction in the fee schedule for examinations performed in this setting would undoubtedly help to resolve this problem.
doi: 10.1001/jama.1986.03370100081008pmid: N/A
To the Editor.— Dr Angell1 is to be congratulated for pointing out that preventive health care probably will not save money, at least not in the America of today. I fear, however, that readers may draw incomplete conclusions from her reference to the possible savings from elimination of unneeded "little-ticket items." She notes, quite accurately, that her data are from teaching hospitals; the situation in nonteaching hospitals may be very different and more difficult to correct. Our 520-bed community hospital has no residents, and our laboratory does no "routine" tests—all must be ordered specifically. I have my suspicions that some of these are unnecessary. Our clinicians, however, come from diverse training programs all over the country. They are not all cost conscious, but they all think they are cost conscious, and most of them can emphatically quote literature to back their orders. If someone—though not I, it is hoped—were
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