The article in the October 1 issue on HCFA’s one-hour rule concerning the use of seclusion and restraint underestimates the problems. Many psychiatrists work in hospitals where there are no interns, residents, or house staff. The only person available to do the evaluation is the admitting psychiatrist. Some hospitals are looking into employing on-call nurse practitioners to conduct one-hour evaluations. Moreover, even if Medicare would pay for such evaluations, private insurance companies would not necessarily follow. Why should they pay for a visit that is medically unnecessary? Indigent patients as usual will remain uncovered.

Sending violent patients to state hospitals is not the answer. The waiting list for the state hospital in my area is three to six months. There is nowhere else to send patients who are difficult to manage. The crisis units are usually full and certainly would not accept a patient who is likely to take up a much-needed bed for months.

The General Accounting Office recently released a report on the use of seclusion and restraint. The cited cases of patients dying in restraints were appalling. Obviously existing rules on seclusion and restraint were not being followed. Why would a hospital that ignores the existing rules so blatantly follow a new, more burdensome rule?

I hope that APA will continue to send the message to HCFA that the one-hour rule is unworkable.

Louise Buhrmann, M.D.

Orlando, Fla.