I would like to thank Dr. Roger Shenkel for his insightful input in “1-800-Chronic Disease Management” [November/December 2005].

Even when insurance companies employ disease-specific, outside case management, physicians end up footing part of the bill. These third-party “services” require physicians and their staff to spend significant nonreimbursable time completing paperwork and responding to various issues. While I am busily switching patients from one angiotensin receptor blocker to another, I do not get the sense that quality of care is improving. Because of the extra work that patients with chronic conditions require and the lack of reimbursement for this work, many primary care physicians are screening these patients out of their practices. It is much more profitable to see two level-III patients in 30 minutes than one level-IV patient in 35 to 45 minutes.

In the name of case management, we are chasing doctors away from patients with chronic conditions, and we are avoiding funding services that could really help patients as well as save money. Meanwhile, we are placating the insurance oversight commissions by providing something we call case management. It's time for a change.