OPINION

Letters to the Editor - Aug. 5, 2002

Smallpox prevaccination figure should be set higher - Medicare drug benefit likely bad news for doctors and patients - Plaintiff's expert witness should not be paid if the case is lost, or no trial

Regarding "No broad smallpox vaccination" (AMNews, July 8/15): While the Advisory Committee on Immunization Practices has promulgated advice on limiting prevaccination for smallpox to some 10,000 to 20,000 individuals on "smallpox response teams," they have missed the mark on actual response needs in the event of a release of variola in a bioterrorism event.

The number of prevaccinated medical personnel and first responders clearly must exceed those figures. Such teams would need to be available quickly, in essence on continual alert status, if this smallpox terrorist threat is to be taken seriously.

If a variola release were very small scale, perhaps one or two cases, this may be viable approach. But if dozens or hundreds of cases, or more, present rapidly, similar to the Dark Winter exercise conducted last year, such teams will be quickly overwhelmed. Further, I doubt that those infected with smallpox will self-direct themselves to a designated smallpox isolation facility. We are all aware that recognition of such an event will take time, during which infected individuals likely will be admitted to multiple facilities in a given area.

In addition, protecting public safety will become a complex issue. While medical personnel agree that bioterrorism will not be a "lights and sirens" event akin to the sarin attacks in Japan in 1994 and 1995, a policy of vaccinating only medical personnel may leave other vital public safety personnel feeling very vulnerable. That vulnerability could easily have a negative impact on how a city or state responds to a smallpox outbreak.

The ACIP and the Centers for Disease Control and Prevention are to be applauded for addressing this issue. But limiting prevaccination to such small numbers in a country as large as the United States does not seem to be the wisest approach, even given the proclivity of smallpox vaccine to cause complications.

--Thad Zajdowicz, MD, MPH Chicago

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Regarding "Medicare drug benefit fight delays physician pay relief" (AMNews, July 1): One could reasonably expect that once a Medicare drug benefit is provided, doctors can forget any hope of pay relief and should expect to see reimbursements fall rather than rise.

Traditionally, when the government has provided any benefit, it has attempted to shift the cost to anyone other than the taxpayers. This has certainly been true of Medicare, and we can all recall the ruckus several years ago surrounding the attempt to increase premiums to cover the cost of a long-term care and a prescription drug benefit. There is no reason to expect a different outcome this time.

The money to pay for prescription drugs for Medicare patients almost certainly would come from reduced Medicare payments to physicians and hospitals to let Congress avoid the unpleasant task of actually requiring beneficiaries to pay for something they receive. As Medicare reimbursements fall, we can expect to see a similar fall in reimbursements from insurers since they tend to follow Medicare's downward pay spiral.

If the Medicare drug benefit is passed, the ultimate losers may be the Medicare patients themselves. When the federal government became the largest buyer of immunizations, they "cornered the market" and so reduced reimbursements that many of the pharmaceutical companies withdrew from the market, creating significant supply problems.

There is no reason to think the situation with prescription drugs would be any different. Once the federal government is the largest buyer and once that becomes such an unattractive market because of inadequate reimbursements, drug companies will either focus their sales overseas or otherwise steer themselves away from pharmaceuticals and into a more profitable business.

--Edwin H. Charnock, MD DeSoto, Texas

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Copyright 2002 American Medical Association. All rights reserved.