In response to "Who will take care of my dogs?"
I wrote:
==The moral which I draw from this anecdote
==is not that all elderly patients should be kept
==alive by all means until the bitter and inevitable end,
==but that the delivery of medical care requires decisions
==not by impersonal rule or regulation but
==by a skilled and knowledgeable individual
==who is personally, professionally, legally and
==morally accountable for his/her actions.

You responded:
>By giving the physician even more power over the purse,
>how could that possibly solve the health financing problem?

I answer:
Unlike some other contributors to this list, I do not consider
myself capable of solving the health care financing problem
on the national scale.  I would like to cooperate, but my
primary task is to care for individual patients.  I solve
the local health care financing problems of my patients by
treating all of them for whatever they or their insurance companies
are willing or able to pay; so that sometimes I take care
of them for nothing, not even thanks. I hope you do the same.

You wrote:
>How can someone be accountable for spending
>large sums of money to keep a patient alive
>for a short amount of time?

I ask:
How can someone *not* be accountable for spending
large sums of money to keep a patient alive
for a short amount of time?

You declare:
>If the consensus is that we should
>save and extend lives at all costs,
>then this is the only solution.

I ask:
What is the only solution?

You qualify:
>However, I don't believe this is the consensus
>or there would be no arguments about it.

I observe:
Please forgive me for pointing out
that you contradict yourself:
You say there is a certain consensus
in consequence of which there is an only solution.
Then you say that there is no consensus.
If there is no consensus,
what happens to the only solution?

But never mind the consensus.
It is my opinion that the task of a physician
is to do everything medically and surgically possible
to help his patients live happy, productive and creative
lives; and when such efforts are no longer availing
to help his patients to accept the biological limitations
of their existence, and to accept inevitable illness and
natural death as unavoidable concomitants of life.
Not all patients, but most, will reciprocate such
respect for their personalities.
My statements reflect the manner in which I have
tried to practice medicine for the past forty years.
Over the years I have saved my patients, their insurance
companies, and their government, hundreds of thousands of
dollars, by dissuading my patients from having operations
which I believed they did not need,
the performance of which would have made me wealthy.
I hope you have done the same.

I wrote:
==The limitation of bureaucratic medicine is that neither
==the individual who makes the regulations
==nor the individual who interprets them
==has hitherto been held morally or legally accountable.

You replied:
>The regulations you are discussing covers (sic) only the
>financial aspects, not the actual delivery of medical care.

I ask:
How do *you* know what regulations I am discussing?

Are you telling the readers of this list
that if the regulations of the managed care plan
for which I must work in order to keep my patients,
prevent me from obtaining help for my patients from the
physicians or surgeons in town whom I
consider competent to deal with a difficult problem,
and send them instead to someone whom I believe to be
inexperienced or indifferent, those regulations cover
only the financial aspects, not the actual delivery of
medical care?

Are you telling the readers of this list
that if the regulations of the managed care plan
for which I must work in order to keep my patients,
require me to work in a hospital operating room
with inadequate facilities, 
and prevent me from operating in a hospital operating room
with adequate facilities,
those regulations cover only the financial
aspects, not the actual delivery of medical care?

Are you telling the readers of this list
that if the regulations of the managed care plan
for which I must work in order to keep my patients,
permit me to examine a patient with a given disorder
only twice a year, when I believe it desirable
that he be examined four times a year,
those regulations cover only the financial
aspects, not the actual delivery of medical care?

You write:
>If an insurance plan refuses to pay
>for a particular medical procedure,
>the doctor isn't sued, the plan is sued.
>If a doctor screws up a procedure,
>the plan isn't sued, the doctor is. 
>I think this is the way it should be.

I ask:
Where did you get *that* information?

I haven't been sued, even when
I have "screwed up" (your expression) an operation.
Where the operation isn't elegant, I suppose
the language to describe it needn't be elegant either.

At least one of the managed care plans for which
I work forces me to sign an agreement
holding the insurance company harmless
for claims against it arising out of services
which I have rendered or failed to render.
Thus, if the insurance company fails to provide
a necessary service to one of my patients, is sued,
and loses, it will force me to "hold it harmless",
i.e. to pay the damages for breach of contract
or whatever, that may be assessed against it.
In this way the insurance company protects itself
against legal challenges to its conduct
by intimidating the physicians whom it abuses
from telling it how it really is.

I wrote:
==So let's begin by demanding of our legislators
==that they pass laws making the administrators,
==the CEO's of insurance plans, their boards of directors
==and *all* their employees legally accountable
==for the consequences of their actions
==in just the same way in which practicing physicians
==have been held legally accountable.

You ask:
> Legally accountable for what?

I answer:
Legally accountable for the practice of medicine;
because practicing medicine is what the clerks and
secretaries from whom we have to take directions
are doing. And practicing medicine is
what the Boards of Directors and the CEO's are doing,
and all the middle management personnel
that do their bidding.
For more than a century, the corporate
practice of medicine was deemed a crime.
The rationale given by one judge who outlawed
the corporate practice of medicine, was that
corporations couldn't practice medicine,
because they didn't have souls.
((Let me ask you in confidence, with nobody listening,
Do you believe insurance companies have souls?))
Our laws still specify that only natural persons
may be licensed to practice medicine,
but our states' attorneys
find their enforcement politically inconvenient.

I wrote:
==There are a lot of underemployed lawyers out there.
==Let's give them something to do.

You wrote:
>They already have too much to do.

I answer:
I regret my lapse into stylistic exuberance.
However, you underestimate the importance of law and lawyers.
All contracts to which we are parties and all regulations
that are imposed on us are legal documents, written by
lawyers, interpreted by lawyers, enforced by lawyers.
The insurance companies have virtually unlimited resources
to hire lawyers. We physicians as individuals lack the funds
to litigate, and our professional societies lack the decisive
leadership of business corporations which protracted litigation
requires.  Nonetheless, the most direct and potentially the
most effective means of protecting our professional independence
is by carefully crafted and accurately targeted litigation.
A single favorable Supreme Court decision could go a long way
to setting us free. But then, I suspect that's not really what
you had in mind.