To the Editor:

My thanks to Robert Edsall for calling attention to the inmates climbing the walls of the asylum in which we ply our trade [“Exploring the Limits of an Insane System,” July/ August 2004, page 11]. In a rational world, physicians would charge for their time, just as lawyers and accountants do. It wouldn’t matter whether the 20 minutes were spent counseling the fearful, excising a mole, performing a physical exam or answering a question by e-mail. The nuttiness of insurance reimbursement, which was designed to prevent financial ruin from surgery or catastrophic illness, comes from covering services for which it is ill-adapted.

In a rational world, physicians who deal with difficult patients over the long haul – family doctors and general internists – would find themselves at the top of their profession in prestige and reimbursement. Merely technical pursuits such as interpreting EKGs, performing colonoscopies or reading mammograms would devolve to lower-paid technicians. And presto! Primary care residencies would be overrun with applicants and the hinterlands would no longer go begging for coverage.

In a rational world, patients would scream bloody murder when a podiatrist charges $450 for a biopsy of a mycotic toenail, a general surgeon bills for an extensive consultation after a two-minute interview or a neurosurgeon claims to have performed bilateral carpal tunnel releases when only one wrist bears a scar. These are but a few of the outrages to which my patients have submitted like sheep, because a third party pays the freight.

In a rational world, patients who habitually make bad lifestyle choices would bear large financial consequences for their behavior; and when I offered them help or direction, I would have their full attention. Instead, obesity is about to be named a disease and therefore worthy of my sympathy and (through insurance payments) financial support.

What disturbs me most is not so much the present insanity as the failure of the AAFP leaders to put an ax to the root of the tree. Whatever their skills, lobbying for fair reimbursement is not among them. America desperately needs an insurance system that puts cash and decision-making back in the hands of patients who are, after all, wise, tight-fisted and steely-eyed when purchasing barbecue grills or salad dressing. Instead, it seems our physician-politicians are desperately trying to shoulder their way to the front of the trough, when the trough is the fount of these problems.