The American College of Physicians made a grievous error in coming out in favor of a prospectively, globally budgeted national health care system.

The major supposed advantage is the elimination of such things as preadmission certification and postservice review because Canada's prospectively budgeted health care system has no such micromanagement. However, the Canadian health care system was developed at a time when technology was much less "overdeveloped" than is the case here, leading to rationing of care by unavailability. We have far more magnetic resonance imaging machines, computed tomographic scanners, catheterization laboratories, and so forth. In addition, the Canadian health care system has a safety valve; patients can come south of the border. There would be no such safety valve for Americans.

Because the level of services that would be desired by the patients and their providers will continue, this will require some form of care assessment or hassling physicians.

Finally, the assumption is that the new system would result in the provision of a greater proportion of "appropriate" care and a lesser proportion of "unnecessary" care and thus would save money. This is erroneous, as the following example illustrates,

Physician A, whose main interest is in generating the largest possible income, will do thallium stress tests because they are more profitable on as many patients as he can justify in evaluating them for coronary disease.

Physician B will examine some patients and treat them. He will do a plain stress test when a question of arrhythmia arises or where a need to assess prognosis exists (by the ability of a person who clearly has typical angina to exercise for a certain period of time), and will do thallium stress testing on relatively few patients.

Because Physician A is ordering tests that are, generally speaking, not really emergent or urgent, but are usually appropriate, he will do as many stress tests as he can before the money in the budget runs out. After that, he will simply wait until the start of the next budget year and start all over again, given that his tests can generally wait awhile.

However, Physician B will no longer receive the money that both he and Physician A have received up to this point, because he will have done extensive evaluation while the money was running out. (This is very frequently a fact of life when dealing with the Florida Medicaid system.)

The results will be that Physician B will start to behave more like Physician A, to increase his income, and the money will run out earlier and earlier. Or, Physician B will continue to care appropriately for his patients, and Physician A will continue to profiteer from his patients, and the next generation will consist of people who behave like Physician A.

More careful retrospective evaluation of the clinical strategies of these physicians could result in the quick discovery of the excessive use of testing by Physician A and his sanctioning. However, such review is labor intensive and would worsen the micromanagement problems (hassles).

Finally, arguing that health care reform, which will result in restrictions on the potential earnings of physicians is inevitable and therefore we should participate in the process, does not justify arguing for a shortsighted, foredoomed, and poorly conceived ACP consensus statement.

The greatest equity to both the provider and the consumer communities would be achieved by a program of national insurance coverage, as I will term it, that sets up a cap on the amount of out-of-pocket and insurance expenses an individual pays before a catastrophic insurance government program takes over. This would be keyed to a given percentage of income above some reasonable floor.

Some form of a salaried approach, with people buying their own low-expense health care with pretax dollars, is the only system that can result in true limitation of the ever increasing health care budget.