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To the Editor: In his Editorial on improving accountability for the public investment in health profession education, Dr Goodman¹ states, "It is unreasonable to expect that market forces will self-organize an effective health workforce." The present market forces have generated the current specialty spectrum of clinicians, an array (as Goodman points out) increasingly mismatched to today's health care needs. He argues for planning through control of specialty training slots. However, no amount of such planning will be effective in the long-term while the current market forces persist.

Of particular concerns in shaping current market forces are (1) fee-for-service reimbursement (useful in a bygone era, but with an increasing number of sources of physician revenue has become highly inflationary, especially for certain specialties) and (2) cost control levied by payers through penury on physicians and patients. There are arguments and approaches for restructured market forces, such as that of Kaiser Permanente, . . . [Full Text of this Article]

Mitchell T. Rabkin, MD
mrabkin@bidmc.harvard.edu
Beth Israel Deaconess Medical Center
Boston, Massachusetts

John S. Cook, DPhil
Williamstown, Massachusetts

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