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Punch Protection 

Thanks to Dr. John Riffle, I was afforded the privilege of serving in the Retina Clinic at West Point and can confirm his findings of never having encountered eye injuries secondary to boxing—a mandatory course for cadets at the U.S. Military Academy (Letters, February).

His observation that the use of thumbless gloves and protective headgear were the operative factors in this prevention is a vital wake-up call to boxing authorities.

Danny Hirsch-Kauffmann Jokl, MD   
Bronxville, N.Y.   

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Another Take on Rationing 

Two points in “Revisiting Rationing” (Letters, April) require rebuttal.

Dr. Mackool and the other authors write that “our health care system is the finest in the world.” While we have many wonderful doctors and some great hospitals, there is a vast literature that documents that we have by far the most expensive, most inequitable, least efficient and one of the most unpopular systems in the developed world. Furthermore, our outcomes compare unfavorably with those in many other countries. For example, among the 19 countries for which the Organisation for Economic Co-operation and Development publishes deaths preventable by medical care, our numbers are the worst.

As regards the authors’ opinion on rationing, it all depends on how you define the word. Every developed country including the United States limits access to care by determining what care is reimbursed. This may be done directly or indirectly by the government or by private-sector insurance plans. It always involves tough choices that affect all but the rich, who can afford to go outside the system. If that is rationing, we have done it for 60 years and will always need to do it.

Humphrey J. F. Taylor   
Public Trustee of the Academy’s   
Board of Trustees   
New York, N.Y.   

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Open to Debate 

I read with great interest Dr. David Chang’s call for a return to balance billing (Feature, November/December). I must admit that my own personal sympathies lean toward Dr. Chang’s position, but I do find myself convinced that a return to balance billing in addition to a continued decrease in Medicare allowable charges will create widespread financial difficulties in patients of Medicare age.

Judith Stein and Drs. Michael Repka, William Rich and Paul Ginsburg barely touch on this point, however. Judith Stein and Dr. Paul Ginsburg raise the specter of unlimited, capless balance billing with all of the onerous consequences one might imagine if it were to come to fruition. This is more than a little bit disingenuous—since Dr. Chang is not calling for limitless balance billing. Indeed, he suggests freezing the limiting charge—the highest amount that a physician can charge for a service—at 2010 rates.

Finally, Dr. Chang bemoans the burdens caused by reporting for PQRI and the meaningful use requirements for EMR. This prompts Mr. Ginsburg to take a gratuitous shot at Dr. Chang, in some fanciful way suggesting that he is pining for the good old days—and even worse that he is somehow not willing to be accountable for the care he delivers. Mr. Ginsburg not only missed Dr. Chang’s proposal to cap balance billing, but also apparently missed his suggestion that ophthalmologists “reallocate the administrative time savings [of not using EMR or doing PQRI reporting] to more chair time for your patients.”

Is this what stands for reasoned debate of these issues? It is hard to put in words just how disappointing it is to read these replies to Dr. Chang. I find it even more so that this is published in an official publication of the organization that is supposedly charged with representing me and my fellow ophthalmologists. We are left with little that is positive save for the empty platitude offered by Ms. Stein that we “seek a more equitable and effective approach for all involved.”

Darrell E. White, MD   
Westlake, Ohio   

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WRITE TO US Send your letters of 150 words or fewer to us at EyeNet Magazine, AAO, 655 Beach Street, San Francisco, CA 94109; e-mail eyenet@aao.org ; or fax 415-561-8575. (EyeNet Magazine reserves the right to edit letters.)

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