Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Health Care Wasted On The Young

I feel Sandra Boodman’s thesis is inadequate without a historical comparison to how young people accessed health care five, 10 or 20 years ago (“Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model,” Oct. 9). As a family medicine doctor practicing for 33 years, my experience is that healthy young people use medical services only for urgent care and pregnancy until they develop chronic conditions. And, as a society in general, we have become more demanding about receiving services “now.”

Why should medical care not change as our expectations change? Certainly we have the technological ability to provide a portable health record one could take from site to site to improve continuity. We also have the ability to have a single electronic medical record or shared information hub so one’s health info can be accessed by any provider anywhere.

However, demanding “now” care at any convenient site does not allow one provider to get to know a person in a way to better inform them of how that individual’s situation (emotional-social-economic) impacts their health. So, convenience has its price.

— Dr. Kevin Walsh, Ellensburg, Wash.

Family physician Ajoy Kumar of Florida led a lively debate on Twitter and, in a series of tweets, emphasized how important it is to build doctor-patient relationships early because “nobody is young and healthy forever.”

“In the first 30 years of your life, you make your habits. For the last 30 years of your life, your habits make you.” Sure, everyone looks and feels great when they are young, and while you may think it will be that way forever choices and lifestyle in adulthood creep up on you. — Ajoy Kumar, MD, FAAFP (@ajoykumarmd) October 10, 2018

— Dr. Ajoy Kumar, St. Petersburg, Fla.

It’s not so much the new generation as it is the age group. I didn’t have a primary care physician from the time I entered university until I was 42. I also only went to the doctor when I had a particular problem to deal with. Even back then (25-30 years ago), a $200 deductible meant I could pay for insurance but could not afford to use it for anything other than a dire emergency. Of course, back then almost everything was traditional indemnity, so we all paid full-freight unless you were covered by one of the nascent HMOs (which often controlled costs by denying care).

— Brenda F. Bell, North Plainfield, N.J.

Another primary care doctor bemoaned the trend as part of a larger move away from generalized medicine:

Part and parcel with how much medicine has changed with regards to specialization and fragmentation of care . As a primary care physician for over 20 yrs, I find this trend less satisfying — H Mitchell (@Hollyfrog88) October 10, 2018

— Dr. Holly Mitchell, Amarillo, Texas

As long as we are talking about new models for medicine, here’s a plea for “human-centered design thinking”:

The young immortals are clear about how they want to access care. Now how to support Primary Care in making the connection? Seems ripe for Human Centered Design Thinking. Spurred By Convenience, Millennials Often Spurn The ‘Family Doctor’ Model https://t.co/FNosdacs6o via @khnews — Julie Schilz (@J_Schilz) October 10, 2018

— Julie Schilz, Northglenn, Colo.

Laryngitis On The Campaign Trail?

It isn’t surprising that health care is a priority issue for voters (“Health Care Tops Guns, Economy As Voters’ Top Iissue,” Oct. 18). After all, the chief cause of personal bankruptcy is medical bills. Nor is it surprising that voters have not heard much about health care from midterm election candidates, who know the future success or failure of the health system and their political futures depend on how they respond to voters’ top concerns. It is much safer for our political leaders to leave the administration of the health system to the insurance companies.

But, so far, private insurers have shown they are more concerned with shareholders’ concerns than patients’. The result is a fragmented, impersonal health system overrun by multiple insurance plans, each with different copays, deductibles and insurance panels — where doctors are held captive by insurers’ regulations. If we vote people into office because we believe they will respond to our needs, why are so many of them so quiet on health care?

— Dr. Edward Volpintesta, Bethel, Conn.

Metrics Show Medicaid Is True To Its Mission

Both Medicaid enrollees and taxpayers see real results from Medicaid health plans — despite contrary claims (“As Billions In Tax Dollars Flow To Private Medicaid Plans, Who’s Minding The Store?” Oct. 19). Medicaid plans are held to high standards by the states, improving health, quality and savings for millions of Americans, including children, veterans, seniors and people with disabilities.

Medicaid plans run many programs to improve patient health — driving quality, coordinating care, and helping patients stay compliant with treatment. The vast majority of every Medicaid dollar pays for care, while Medicaid plan profit margins average less than 2 percent.

Medicaid plans report metrics that are made public. Results show that insurance providers saved states about $7 billion in 2016 alone — helping states realize the highest value for their Medicaid investment. Research shows that Medicaid enrollees have access to care that is similar to those who have coverage through their jobs, and are satisfied with their coverage.

Medicaid serves nearly 75 million Americans. Insurance providers know that Medicaid must work for those who rely on it — and the hardworking taxpayers who pay for it. We are committed to working together to ensure that Medicaid is effective, affordable and accountable.

— Matt Eyles, president and CEO of America’s Health Insurance Plans (AHIP), Washington, D.C.

A tweeter reading the same story noted the outsize level of Medicaid oversight compared with that of corporate America.

For people getting healthcare via Medicaid: tight scrutiny, work requirements, etc. For corporations getting hundreds of billions (more than military contractors!), not so much. https://t.co/xMxA6BRXiL via @khnews — Fran Quigley (@FranQuigley) October 19, 2018

— Fran Quigley, Indianapolis

Imagine No Big Pharma

I know that we are all supposed to think the pharmaceutical industry is the savior of our country and that without them life itself would not be possible. What if we instead began to think of them as just the manufacturers of medication? What if we did our own drug research (maybe researching medication to treat millions instead of medication to make millions) and collected bids from every drug manufacturer for production only? What if we used tax dollars to pay for the manufacturing of the medications, and patients had to pay only a token pharmacy fee? I wonder what that would look like.

— Dr. David Herring, Staunton, Va.

Unamusing Cartoon

The publication by Kaiser Health News of a Nick Anderson cartoon with the caption “Inadequate Mental Health Services” above a picture of a prescription bottle reading “RX for Violence” from which bullets spill forth, is both surprising and deeply disappointing (‘Alternative Treatment’? Oct. 18).

How easy it is to imply that gun violence, indeed violence of any type, is largely attributable to untreated or undertreated, mental health conditions. But the facts, which I and millions of readers have come to expect from KHN, say otherwise. Mass shootings, the thought of which this cartoon invokes, account for less than 1 percent of gun violence, and for which mental health is a factor in but a small minority of cases. And while suicides are in fact increasing, and 85% of completed suicides involve guns, this too is only a small fraction (about 2%) of gun violence in the U.S.

It would be expected that KHN editors would be familiar with the oft-cited statistic that only about 4% of all violence may be attributed to people with serious mental illness, and the fact people with mental health conditions are far more likely to fall victim to violence than to perpetuate it against others.

As a trusted source of factual news, it is shocking that Kaiser would perpetuate and reinforce the erroneous, albeit widely held belief, that mental illness (treated or not) equates to gun violence.

— Debbie Plotnick, vice president for mental health and systems advocacy, Mental Health America, Alexandria, Va.

I appreciate the perspective that inadequate mental health services can lead to negative consequences for the individual and, ultimately, for society. However, the implied connection between mental illness and violence is unfairly stigmatizing and not supported by evidence. In addition, the use of a prescription bottle seems to suggest that medication is the prescription for “adequate mental health services,” which vastly oversimplifies the need for a range of services that should be included in an effective, comprehensive system of care. I hope that you will consider removing this cartoon from your website, as it is harmful to engaging and truly supporting people with mental health needs.

— Jenifer Urff, Northampton, Mass.

A Call For Deeper Reporting

I was disappointed by Phil Galewitz’s reporting on the negative aspects of Medicare Advantage HMOs (“Medicare Advantage Plans Shift Their Financial Risk To Doctors,” Oct. 8), although it was nice that he quoted me and that you incorporated “risk shifting” into the headline. Galewitz cites a Health Affairs report but should have mentioned years of reports by the Government Accountability Office and the Medicare Advisory Payment Commission detailing overpayments and risk analysis and overpayments. There is a big dark side to Medicare Advantage plans that patients/consumers do not understand. They think it’s all about “free” care. It is hard to sue these HMOs for medical malpractice and failure to coordinate and manage care — which is what they promise to do. Medicare Advantage needs more critical reporting.

—Dr. Brant S. Mittler, San Antonio, Texas

For a Georgia reader, the story raised more questions:

Isn't this just going to encourage doctor's to do the cherry picking now that insurance companies can't? And what happens when those patients age and have serious health issues? Will those doctors just close practices and dump those patients? — cminmd (@cminmd) October 9, 2018

— Colleen Mahaney, Woodstock, Ga.

On Shooting Down Sky-High Bills …

We in Montana were frustrated in our process to address the balance billing issues for air ambulance, with little success (“Will Congress Bring Sky-High Air Ambulance Bills Down To Earth?” Sept. 27). But the issue arises from insurance companies inserting a coverage cap in the policy, stacking deductibles for in- and out-of-network carriers. Much about this issue is aimed at air companies. They are solely responsible for their charge practices. But insurers also share the responsibility for their decisions to put those who are insured at risk as they seek to constrain premiums by policy design.

— Bob Olsen, Helena, Mont.

… And Missing The Mark?

The Oct. 19 Facebook Live broadcast (“Facebook Live: What About Those Sky-High Air Ambulance Bills?”) failed to note critical facts and provided misinformation. Alarmingly, this may cause patients to question whether they should board an air medical flight even when their physicians or first responder requests the transport based on patient need. We’d like to set the record straight.

1. Insurance Coverage

FACT: Dr. Naveed Kahn’s insurer’s payment was far lower than the actual bill, and air medical services, like all health care providers, are required by federal law to “balance bill” the patient the remainder. Dr. Kahn’s insurance company failed to adequately cover his bill.

[Editor’s note: KHN’s coverage did not focus on the mechanics of “balance billing,” but rather the prohibitive amount of the original bill.]

2. State Regulation

FACT: States can and do regulate air ambulances. Court decisions and Department of Transportation opinions have reaffirmed states’ authority to regulate all medical aspects of air medical transportation. This includes standards and coordination of patient care, including protocols controlling which air medical operator is called to a scene. Air medical operators never self-dispatch; they are called by trained first responders and medical personnel, operating under state authority.

3. Medicare Fee Schedule

FACT: The implementation of the Medicare Fee schedule did not increase rates for air ambulance services; it changed the way air ambulances are reimbursed, increasing the rates for some and dramatically decreasing the rates for others. While the data demonstrates the industry has grown over the last 37 years, according to “An Economic Analysis of the U.S. Rotary Wing Air Medical Transport Industry”, 22 of those growth years occurred before the implementation of the Medicare Fee Schedule.

Industry growth, over a 30-year period, reflects growth in demand for air medical transport services in response to continued closures of rural hospitals and trauma centers. Air ambulances are filling that gap — more aircraft means better coverage and better outcomes.

— Carter Johnson, SOAR (Save Our Air Medical Resources) Campaign, Washington, D.C.