In his letter to the editor in the December 3 issue, our colleague Edward Hughes, M.D., expresses his feelings of futility about bringing change to the current system of managed care. He suggests as a solution that we "accept the slavery to managed care," "adapt to the less-than-ideal treatments they dictate," and "make a living without working yourself to death."

Unless Dr. Hughes has his very cynical tongue in his very burnt-out cheek, I hope that many of us will write to tell him that we should never give up. But my reason for writing is a bit different.

Just last week my office manager, who is an accountant, finished examining our books for 1999 and said to me, "Get out of managed care!" Her reasons were that the administrative costs of dealing with a multitude of plans, most of which require reauthorization after just a few visits, have become so high relative to the paltry, below-Medicare remuneration that we are actually losing money on this segment of my practice. As I have accepted more patients from these plans, what was originally a part-time job managing the paperwork has become a full-time one.

Dealing with these companies is a time sink not only for her but for me, and I must pay her out of the shrinking revenues I receive. Everyone reading this must know the many ways in which dealing with these companies wastes time: unanswered phone calls, being placed on "hold" for 45 minutes, frequent errors in authorizations, far-too-frequent authorization requests, endless credentialing paperwork, formulary advisories, and a multitude of others.

In light of these problems, I question whether it is even possible to "make a living without working yourself to death" through managed care. My office manager thinks the answer is "no." Far better in any case is to get out of all the plans if you can, offer a deeply discounted fee to needy patients who are willing to pay cash, and maybe take a part-time job if one is available to make ends meet.

By doing better in this way, we will also be doing good, for if we feel like slaves ourselves—cynical, defeated, resentful—how much good can we do our patients as healers or role models?

Richard A. Ratner, M.D.

Bethesda, Md.