Dear President-Elect Obama

You have staked your political and personal reputation on your promise to reform health care, make it more effective and more cost efficient. My guess is that you have surrounded yourself with experts who tell you that the federal government can save enormous amounts by managing and coordinating disease care for high risk people. These high-cost patients, many of them poor, elderly and not well educated, with multiple diseases, use enormous amounts of government funds for their care. Obviously, your experts will say, spending money on managing disease care through insurers or other plans, telephonically or by personal contact (with such interventions as providing transportation, medication or social service support), makes sense.

As a lawyer and former President of the Harvard Law Review, you know very well that all that is in print is not true, that experts can honestly hold to strong but incorrect opinions, and that one should be skeptical of claims by anyone that he or she has "the" solution. Please use those skills in evaluating the hype about disease management.

The managed disease care solution falls apart under close scrutiny. The Fall, 2008 Health Care Financing Review, in an interesting series of papers growing out of disease management studies conducted by Medicare and Medicaid, shows that savings, if any are negligible. Brown and Peikes (15-Site RAndomized Trial of Coordinated Care in Medicare FFS") found that after two years, the treatment group experienced no gross or net expenditures savings when compared to the control. Esposito and Brown reported that a primarily telephonic patient monitoring and education service "show virtually no overall impacts on hospital or emergency room . . . .use" although for a subset of patients with congestive heart failure program reduced Medicare expenditures by 9.6 percent. In the paper "Evaluation of Medicare Health Support Chronic Disease Pilot Program," Cromwell and McCall's conclusions were consistent with the cited authors' interpretation of their data. Goldfield and McCullough's paper, "Identifying Potentially Preventable Readmissions" unsurprisingly showed that "readmission rates increase with increasing severity of illness and increaasing time between admission and readmission, vary by the type of prior admission, and are stable within hospitals over time."

Treating elderly individuals with near end-stage severe chronic disease and mental health illness, will absorb enormous resources with very limited benefits. Providing a significant portion of those resources to young Americans, and using less expensive culture-changing methodologies, may yield better long-term results. America needs to resolve its ambivalence over tobacco, alcohol, addicting substances, unhealthy food intake, exercise and work habits. It should facilitate education for all of our young people and devote adequate resources to building a healthy life foundation for our country.

Good luck, Mr. President-elect. My grandchildren's well-being will depend on the decisions you make.