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To the Editor: Drs Grumbach and Bodenheimer¹ did not discuss service to underserved communities. This encompasses not only the 41.2 million Americans (14.6% of US residents)² who are uninsured, but also those insured persons living in poverty. Primary care physicians, nurse practitioners, and physician assistants provide the bulk of health care for these individuals. The socioeconomic problems characterizing these populations further challenge the 4 functions of comprehensiveness, accessibility, continuity, and coordination.

Most physicians do not document the time spent in case management and rarely, if ever, bill for it. Indeed, the International Classification of Diseases, Ninth Revision (ICD-9) codes that describe psychosocial-economic barriers faced by patients are generally not reimbursed. In fact, use of a code describing a psychological diagnosis may even negate payment to the primary care physician, if the insurance company contracts behavioral services elsewhere. These issues represent yet another challenge to those on the front lines.

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