Problems With Medicaid

To the Editor.—Regarding the study "Large Medicaid Practices and Medicaid Mills" (1980;244:2433), I share the concern of the authors that the Medicare-Medicaid legislation has not fulfilled the proposed principle goal of the incorporation of the elderly and the poor into "mainstream" medicine. However, the only sign of the failure according to the authors is an employment of less-qualified physicians by the Medicaid programs.The analysis of the study brings to mind additional comments. Despite the fact that nonsubsidized market of patient care is better paying, the income of physicians involved in small and large Medicaid practice is higher (authors' Table 1). The income is generated by seeing a larger volume of patients with substitution of nursing time for physician time. This perpetuates second-class care as we have suggested in an earlier publication (1980;243:123). Other sources of relatively high income are probably derived from inpatient hospital visits, emergency room visits,