Since the online publication of my article in October 2009,1 I have received a number of personal e-mails with comments not always as mild as those of Dr Rochmis. As is the case with his letter, most vilified me for suggesting equity in payment for cognitive services considering the time, risk, and skill needed to treat. While I do not contend that the average internist can treat a patient with complex rheumatoid arthritis as well as Dr Rochmis, by the same token, I venture to say he probably does not have the expertise of a general internist in treating a noncompliant diabetic patient with hypertension and heart failure. Which service is worth more, given equal time spent? That said, all who contacted me missed the following facts: First, I found that almost all consults were billed as consults, while almost all referrals were billed as (the higher paid) consults. I will leave to the reader the ethical implication of this finding. To correct this problem, the Centers for Medicare and Medicaid Services needed to either monitor the billing more closely (at a cost that was not stated in the article) or eliminate the codes (which is what it has done, effective January 1, 2010). Second, I never said that physicians were paid adequately. I do lament, however, that there is not an adequate representation of primary care physicians on the American Medical Association's Relative Value Update Committee (RUC), which recommends rates for all physicians. In contrast to Dr Rochmis (who, until January, could bill the higher paid consult codes), in 24 years practicing as a primary care internist, my partners and I always accepted Medicare assignment and never turned away those patients, no matter how long it took to address their problems. Third, this letter and others I received ignore the ability of the consulting physician to bill a higher level service if the time component is more than 50% of the visit, eg, if a rheumatologist spends 60 minutes counseling a patient about his or her rheumatoid arthritis.