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Take next, harder, step: a single-payer plan (MS)

DR. JAMES Mongan, quoted by Liz Kowalczyk in "State seeks to revamp way doctors, hospitals are paid," is absolutely right in believing that the state’s proposed global payment plan would require a different healthcare system. The current system has few organizations that could receive annual payments for a given patient and divide the money equitably among all the doctors, hospitals, and ambulatory facilities that provided care. Who would decide on the services to be provided, and how much each provider would be reimbursed?

The state’s Special Commission on the Health Care Payment System correctly identifies the current fee-for-service system as an incentive to oversupply medical services in an uncoordinated fashion, but the proposed global payment plan isn’t the answer because it could not be implemented in today’s fragmented delivery system with so many independent doctors and facilities.

The most effective way to control costs would be through a single-payer universal funding plan, connected to a care delivery system based on nonprofit, multi-specialty groups of salaried physicians and government-paid, nonprofit facilities. But this would require major reforms at the national level, and would not be politically possible until the futility of piecemeal tinkering with the present system became obvious to policy makers, the general voting public, and the medical profession.

Dr. Arnold S. Relman
Dr. Marcia Angell

Relman is an emeritus professor of social medicine and Angell is a senior lecturer in social medicine at Harvard Medical School. Both are former editors in chief at the New England Journal of Medicine.