Reply

In Reply: Chen and her associates and Smith mistakenly seem to think that we are against telepsychiatry. They ignore what we said and misinterpret the purpose of our analysis, although they do not seem to quibble with our figures. In an era of excess enthusiasm for technologic solutions to systems problems, we have simply cautioned people to examine the cost of what they are doing.

Chen and Smith support our contention that telepsychiatry is more likely to work in an integrated system. They then ignore the fact that we were describing the far more common problem of providing a service in an environment with many separate entities. They fail to address the problems we raised about costs. They also do not produce data to counter our analysis, and they sidestep our findings about the difficulties involved in decreasing costs in low-population, rural areas. Money comes from somewhere. There are no freebies from tax-funded sources. Our mental health center operates within a budget and covers costs for clinical services through Medicare, Medicaid, insurance, capitation funds, and managed care contracts. An expensive service or project can draw funds away from other services.

For the cost of a telepsychiatry medication management visit, we can send a case worker out to see several patients; we can have the worker transport several patients to the center; we can have a primary care physician, nurse practitioner, or physician's assistant examine patients under our direction. Patients do not have telepsychiatry hookups in their homes; they have to go somewhere and see someone to use the service.

Smith's uninformed comment about rural prejudice deserves a response. One of us (AW) along with several colleagues, has provided regular consultation and patient care to two rural mental health centers for more than 25 years. We have decreased hospitalization rates, set up care systems with on-site part-time psychiatrists, and trained and placed a large number of psychiatrists in rural communities. We reject the notion of a negative rural prejudice.

Szeftel's welcome comments suggest the kind of detail and support that is necessary for a viable telepsychiatry service. The specialty setting certainly makes it easier to provide the service. We are uncertain how her program relates to services in rural areas.