I had a lump in my neck, midline, just below the jaw. It seemed to be slowly growing. I saw a surgeon who said it ought to come out (and my wife was insistent!) even though it was most likely a lipoma, a completely benign lump of fat.

He could have done the procedure in his office, but it was a bit big, and the neck is a delicate area, so he decided to do the surgery at our local hospital.

I arrived at 6AM and by noon I was having lunch with my wife, feeling fine. (It was a lipoma, after all.)

Later, speaking with the medical director of our local I.P.A. (which administers the H.M.O. insurance which I have), I told him I felt a bit guilty using up resources for something so minor and asked him if perhaps he should have told the surgeon to do the surgery in his office instead of the operating room in the hospital. He let me know that, had it been done in the office, the surgery would have cost more as the hospital is capitated (paid on a per member per month basis) for surgical procedures while had the procedure been done in the surgeon's office the group would have had to have paid the surgeon both his professional fee and a "facility" fee.

Just today I received the bill from the hospital. Over $11,000 !!! The full amount was "written off" because of the capitation agreement, but imagine if I had had a P.P.O. insurance with a $5,000 deductible and a 20% co-pay!

There has to be another way!

I also have thought carefully about how much money is used in the care of my patients towards the end of life and have thought about how one would go about reducing that expenditure.

Very often the expenditure couldn't be reduced significantly because, as you are providing that care, it is not at all clear when it is appropriate to end that care.

There are a few reasonable avenues for reducing the expense of end of life care, however. A few that I would favor include defining death as "cortical death" rather than as "whole brain death;" prohibiting the use of chemotherapy for metastatic solid tumors unless the chemotherapy is approved for a particular indication or if the chemotherapy is being administered in a clinical trial; investing in training doctors and nurses about end of life care; supporting a greater role for primary care providers (who are more likely to relate to patients as people, and hence more likely to assist with reaching a decision to avoid aggressive care in patients who have terminal disease, or poor prospects for a desirable quality of life in the future) within our health care system; fostering research on the costs/risks and benefits of medical interventions..... and more.

Nevertheless, it is often very difficult to know when the end is near.

It is best to focus our effort to save money where the savings are clear and where there will be no effect on quality. The obvious place to cut is the administrative waste produced by private health insurance....

I ask them if, and then register them to vote.

I pass out handouts, like this one:http://www.pnhp.org/news/2009/april/david_himmelsteins_.php

I ask them to write letters to their senators and congresswoman.

I follow-up office visits with an email that makes the point again and provides them with arguments, resources, and ways that they can get involved.

--shorten the piece,
--make the piece more focused on what you can do to work for change,
--make the piece more accessible, and
--improve it in any way.