A large and growing number of physicians in today’s managed care market are paid for their services according to incentive schemes that offer financial rewards for the provision of less, and less expensive, medical care. Such schemes typically reward physicians for reducing their own costs of care and reward primary care physicians for reducing the number and cost of referrals for inpatient and specialty care. Consumers, fearful that such schemes will prompt physicians to deny them medically necessary care, have protested the implementation of such incentive plans. Various states are considering bills to ban or to limit physician incentive payments.

Federal policy with regard to incentive schemes has been confused and contradictory. On one hand, regulators concerned with controlling health care costs and limiting the provision of unnecessary care have encouraged such financial incentives. For example, federal Stark regulations, which ban referrals tied to physician compensation, include explicit exceptions for incentive schemes.

Throughout history, those in power have feared the consequences of unfettered discourse within their society. The empowered have restricted and directly manipulated discourse in the context of doctor-patient discussions with surprising frequency, resulting in disturbing curtailments of individual autonomy. During the Cultural Revolution, the Chinese government dispatched physicians to peasants’ homes to convince them to use contraception. In the 1930s, the Soviet government expedited the completion of the Siberian railroad by ordering physicians to deny workers’ requests for medical leave and to conceal this order from those workers. Recently, Nicolae Ceausescu sought to increase the Romanian birth rate by prohibiting physicians from advising patients about birth control and barring the dissemination of information about condom use to prevent HIV transmission.

Restraints on doctor-patient discussions have not been limited to socialist regimes. In 1988, the Bush Administration implemented a federal regulation prohibiting physicians from discussing abortion with patients in federally funded clinics.

Society has long associated acquired immune deficiency syndrome (AIDS) and human immunodeficiency virus (HIV) with homosexual men. One reason for this association is the statistics that establish a close connection between the homosexual lifestyle and HIV infection and AIDS. While there are an abundance of statistics and widespread perceptions that indicate a strong correlation between AIDS and HIV and homosexual males, there are statistical justifications that oppose the assertion. According to projections, the majority of gay and bisexual men will not develop AIDS. Reports show that in many foreign countries, AIDS is largely a heterosexual phenomenon. In addition, the percentage of AIDS cases resulting from transmission through heterosexual contact is rising dramatically. Furthermore, groups such as racial minorities and intravenous drug users also constitute a large proportion of AIDS cases.

Statistics also demonstrate the high costs associated with treating AIDS patients and people infected with HIV. As the AIDS epidemic unfolded, the health insurance industry developed fears concerning the financial crisis that would result due to an increase in the number of AIDS cases and the emergence of expensive treatments.

Tuberculosis (TB), “the world’s most neglected health crisis,” has returned after decades of decline, but has only gradually caught the attention of governments as a formidable threat to public health. By 1984, when TB cases hit an all-time low, federal and state governments stopped supporting the medical infrastructure that once served to contain the disease. State officials around the nation began dismantling laboratory research programs and closing TB clinics and sanitoria. Since 1985, however, TB rates have steadily increased to 26,673 reported cases in 1992, and some have estimated that by the year 2000, there could be a twenty percent increase. By 1993, Congress, realizing that TB could pose a major public health threat, allocated over $100 million to the Department of Health and Human Services for TB prevention and treatment programs. Those funds, however, were sorely needed years before and amounted to only a fraction of what public health officials believe necessary to control TB today.

George Eastman may not have been a father, but to the residents of Rochester, New York, the principal founder of Eastman Kodak was a doting uncle. In addition to donating millions of dollars to Rochester-area schools and hospitals, Eastman reportedly paid to remove the tonsils of every child in town. Even after his death in 1932, his company looked after of its employees and retirees. For example, Kodak refused to use its size to negotiate for cheaper medical care for its Rochester employees. If it had, most small businesses in the area would have likely faced higher insurance rates and the prospect of eliminating health benefits for their employees entirely. Only about seven percent of Rochester residents do not have health insurance today, compared with fifteen percent nationally.

That may change, however. Faced with growing foreign competition and demands for higher returns, last summer Kodak threatened to desert its long-standing approach to buying insurance and encouraged its 44,000 retirees to join a health plan that excluded two high-priced hospitals.