Letters

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To the Editor:

HCFA and a band of AMA bureaucrats have made it impossible to take care of any complicated Medicare patients (see "Exam Documentation Just Got Harder," October 1997). There is no way anyone can find the time to take a history, perform the 18-bullet-point exam, write it down and hope to recover anything even close to overhead expenses. Essentially, this means shipping any complicated patients to someone else who can charge for a consultation and thus be partially compensated for the work it takes to perform and document all the minutiae HCFA is being allowed to demand. For the AMA to prostitute itself to this task and not demand that suitable adjustment be made for primary care reimbursement is unconscionable.

I presume that about 3 percent of medical practitioners will be going to jail in the next year and for the foreseeable future if they try to bill for a 99215. This level of visit has become unbillable in my opinion. These latest revisions in the Medicare documentation guidelines are an idiotic maneuver performed seemingly to disenfranchise most of the primary caregivers in the United States. The AMA CPT Editorial Panel has succeeded where the RBRVS failed.

Richard H. Lovell, MD
Vista, Calif.

The mental health care maze
To the Editor:

We were pleased to read the September 1997 article "Mental Health Care: From Carve-Out to Collaboration." It has been amazing to watch mental health services become less available to patients as an expensive labyrinth of administrative forces has been created to access mental health carve-outs and discourage competent, coordinated care of the patient.

We have a psychologist located in an office between exam rooms in our clinic. The psychologist is able to consult several times a day on mental health issues with residents and faculty. Often, he can be introduced to patients in need of mental health services during a regular clinic visit. The access and coordination of care is obviously clinically better than what carve-outs provide. Ultimately, we believe competent, coordinated care is less expensive than no care or poorly coordinated care.

David C. Spendlove, PhD, and Scott Young, MD
Salt Lake City

On bread baking and managed care
To the Editor:

It is not the fault of George Bernard Shaw that he was unable to follow his line of reasoning a little further (see his quote from The Doctor's Dilemma, July/August 1997, p. 27). An unreconstructed socialist, Shaw notes that "you could provide of the supply of bread by giving bakers a pecuniary interest in baking for you" but was unwilling to extrapolate what would happen to the bread supply if the baker had no pecuniary interest in baking for you.

Adam Smith could have informed him of the likely outcome. Indeed, the current famine in North Korea and the collapse of the Soviet Union and its eastern European empire bear eloquent witness to the results of uncoupling work and economic incentive.

While unrestricted fee for service may indeed provide perverse incentives to cut "your inside out," the kind of harassment, micromanagement and fee cutting documented in this magazine provides incentives of another sort that could eventually do to medical care what not paying the baker would do to the bread supply.

David E. Hanson, MD
Savanna, Ill.

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