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Letters

From the March ACP Observer, copyright 2005 by the American College of Physicians.

Pay-for-performance

Quality improvement via the practice of evidence-based medicine is certainly a desirable goal. ("Pay-for-performance takes off in California," January-February ACP Observer, page 1.) However, when insurers who are collecting the data start basing our payments on quality measures, I have to balk.

These are the same companies that have fraudulently denied millions of dollars in claims to physicians in recent years. They are the same companies as the one that recently sent me a clinical profile quality report, informing me that I'd neglected to perform a Pap smear on one of my male patients.

They can't get something as simple as gender right, but I'm supposed to freely allow them to use the same data to determine how much they'll pay me? No thanks.

James M. Kinsman, ACP Member
Colorado Springs, Colo.

Tort reform and access to care

I believe some recent ACP Observer articles have been misleading and have lacked data-driven rigor.

First, recent articles on tort reform have failed to mention that capping noneconomic damages in liability awards and settlements does very little to correct access problems, reduce rising medical liability costs or bring down the total cost of health care expenditures. ("Texas tort reform: One year later, some physicians say they're reaping big benefits," January-February ACP Observer, page 1.)

Studies indicate that noneconomic damage awards have only a marginal effect—less than 5%—on physician premiums. The disappearance of obstetricians and other specialists from regions is devastating and obviously must be solved. Yet have states with noneconomic damage caps seen those specialists return? I hope so.

Your piece in support of the Republican presidential candidate ("ACP members champion their presidential candidates," October 2004 ACP Observer, page 7) also failed to mention the minimal effect of capping noneconomic damages.

And that piece claimed that "[t]he number of Americans without health insurance has grown steadily under both Presidents Clinton and Bush"—a misstatement about growth trends among the uninsured in previous administrations. In fact, ACP Observer has recently reported little on the College's 20-year policy and advocacy record for universal health coverage. I'd suggest periodically listing the number of medically uninsured. I think it would be a useful reminder to our College and profession.

Finally, the College has authorized a political action committee (PAC), but I recall no coverage in ACP Observer about its mission and gift policies. I understand there are legal issues that govern the separation of the College and the PAC, but I hope the College membership will be informed regularly.

Whitney W. Addington, MACP
Chicago

Dr. Addington is a former ACP President.

Editor's note: Different studies provide conflicting evidence on how noneconomic damage caps affect physician liability premiums. A Jan. 8, 2004, Congressional Budget Office (CBO) brief stated: "Evidence from ... states indicates that premiums for malpractice insurance are lower when tort liability is restricted than they would be otherwise."

Dr. Addington is correct in saying capping damages does little to improve access or bring down total health care costs. The same brief noted that malpractice costs account for less than 2% of all annual health care spending in the United States.

As to the piece on presidential candidates, each of the two articles—one for President George Bush, the other for Sen. John Kerry—was an opinion piece reflecting the views of its respective author, not of ACP.

Regarding the PAC: ACP Services Inc. authorized the formation of the PAC, not ACP. ACP Observer—as an ACP publication—cannot report on ACP Services PAC news. More information about ACP Services PAC is online.

Flu vaccine shortage

Even before this year's flu vaccine shortage was announced, I'd decided not to offer flu shots to my patients for the first time in 22 years of private practice. ("Strategies for coping with the flu vaccine shortage," November 2004 ACP Observer, page 1.) We've had miserable experiences for the past several seasons, and I have come to the conclusion that it would be easier to just refer patients elsewhere.

Even in years when there is enough vaccine, production or distribution delays lead to a rash of patient phone calls and a crammed office once vaccine arrives. Local markets and pharmacies get their vaccine weeks before we do, even though we order well in advance. Many patients end up being vaccinated somewhere else before our supply arrives, leaving us with excess vaccine we paid inflated prices for but can't use.

As a solo practitioner, I simply don't have the profit margin to risk buying overpriced, underreimbursed vaccines. Instead, we'll continue to give our patients information about local flu shot clinics and hope the government will someday realize that immunization services in the private health sector need aggressive support to be effective.

Howard J. Homler, FACP
Carmichael, Calif.

Community-acquired MRSA

In your article on methicillin-resistant staphylococcus aureus (MRSA), Merle A. Sande, MACP, noted that community-acquired MRSA infections can cause necrotizing pneumonia, due to the presence of the PVL virulence gene. ("In a difficult flu season, another bug is a big worry," December 2004 ACP Observer, page 3.)

The article also noted that daptomycin is a highly effective therapy for community-acquired MRSA. It should be noted that the approved indications for daptomycin are currently limited to treatment of complicated skin and soft tissue infections, and that daptomycin is not indicated (nor FDA-approved) for treatment of community acquired pneumonia, on the basis of clinical trial data showing decreased effectiveness compared to standard treatment.

Craig S. Conover, FACP
Evanston, Ill.

Dr. Sande responds: Dr. Conover is correct. Daptomycin looks like a good drug for skin and soft tissue infections if parental drugs are needed. Studies are currently underway to evaluate it in MRSA bacteremia (like line sepsis).

I would not recommend prescribing daptomycin to treat patients with pneumonia because it was found to be less effective versus standard treatment in a large multicenter study. The suspected reason for this is the inactivation of the drug by surfactin. In another study of ICU MRSA pneumonia, linezolid was found to be superior to vancomycin in a retrospective subset analysis. This drug apparently achieves high concentrations in extracellular lung fluid.

Craig W. Borden, MACP

I read with sadness the obituary of Craig W. Borden, MACP (November 2004 ACP Observer, page 21).

Thirty-four years ago, I was assigned as a third-year medical student to Dr. Borden's service as my first clinical rotation. Senior students had warned me that his was not an easy rotation. Demanding of time and energy, Dr. Borden engaged in no small talk or levity on rounds, and was all business.

Dr. Borden was no ordinary attending. Massive and ursine, standing 6 feet 4 inches and weighing at least 250 pounds, he could be seen hulking over the chart rack at all times of day. He invariably arrived on the wards before the residents or students, and was never seen leaving before late at night. Though he spent less time bedside, he knew the patients better than any of us. He recognized the potential nuance of every aberrant lab value, each premature ventricular contraction and any change in physical finding.

And he demanded intense commitment from his team. We dreaded the question for which we had not formulated a sufficient answer. I found myself compelled to meet his expectations studying my patients' conditions, taking and then re-taking their histories.

I rarely remember seeing him smile and can't recall his ever complimenting a resident or student. Nonetheless, by the end of my three months, I had come to love this man and his commitment to patient care and to teaching. It was because of him that I chose internal medicine as a specialty.

As the years passed, I regretted never having thanked Dr. Borden for the personal impact he had on me. I did approach him on the last day of the rotation, mustering the courage to show my appreciation. Before I could say a word, Dr. Borden extended his huge hand to engulf mine, and said, "Raskin, it's been good having you on the service." He turned immediately, lumbering back to care for a patient in need.

Richard J. Raskin, FACP
Washington

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