The following letters are published as a response to the article, "Topics in Medical Economics: Lessons of the Prisoner's Dilemma", by Joseph Bernstein, 82-A: 595-598, April 2000.

To The Editor:
The JBJS is to be commended for acting as a forum for issues that are not strictly orthopedic or scientific. The adverse effect of managed care and government rules, regulations, and bureaucrats; and a discussion of these issues and coping strategies, are all more relevant to patient care than some arcane article on cartilage metabolism in the dog's knee. The best policy is to "just say NO" to managed care and Medicare money. The person who does it alone risks financial peril, and if we do it as a collective policy we risk a visit from the Justice Department. Until we get a level playing field, through legislation, we do have a powerful tool to effect change: the bully pulpit of our office. My exam room walls are plastered with letters and editorials; patients read them, make comments, and ask questions. Only by a constant din of grass roots opposition do we have a prayer of doing anything to change the status quo. Managed care and Medicare have become a form of legal slavery; we must strike off the shackles, and take back our profession. Ayn Rand's classic, 'Atlas Shrugged', explores this theme in depth, and should be required reading for all physicians. In the meanwhile, here and there brave souls are shrugging off managed care and heading back to the future of fee for service medicine. We should support their efforts and emulate them. It will be a brave new world!
Sincerely,
Richard Hurd, Jr. M.D.;
3400 A Old Milton Parkway; #450
Alpharetta, GA 30004

To The Editor:
I applaud the Editor's decision to offer "The Orthopaedic Forum" as a means to give the readers of The Journal of Bone and Joint Surgery a venue to express our thoughts on timely issues of interest to orthopaedic surgeons.

In "Topics in Medical Economics: Lessons of the Prisoner's Dilemma" (82-A: 595-598, April 2000), Dr. Bernstein gives us an excellent insight into the conundrum of physicians' dealings with health-care plans. The "game" of medical payment is indeed one-sided, with the "set of rules" defined solely by the health-care plans. There is little or no opportunity for negotiation. However, Dr. Bernstein's description of physicians as being in a less-than-desirable position is an understatement. Because we are not permitted to communicate with one another, physicians are at a distinct disadvantage and are held hostage by existing antitrust laws. Attempts by physicians to solve the dilemma can, in fact, cause us to run afoul of the United States Justice Department and become real prisoners. This is, indeed, not a game!

Health-care plans would be terrified by Dr. Bernstein's recommendation, in his discussion of the iterated prisoner's dilemma, that "players do better when both are cooperating." If that were the case, our patients would be helped and the corporate profits of health-care plans would be adversely affected.

I offer two suggestions to solve the prisoner's dilemma. One is a legislative solution, and the other is simply not to play the health-care plans' game.

First, Dr. Bernstein, as a salaried employee, may benefit from the existing National Labor Relations Act that allows salaried employees to be members of a union. Such a union could negotiate on behalf of its members for a more favorable contract with a health-care plan. The vast majority of practicing physicians cannot form such a union at present. If the United States Congress were to pass the Campbell-Conyers Quality Health-Care Coalition Act of 1999 (H.R. 1304), self-employed physicians could negotiate with health-care plans and receive an exemption from antitrust laws without belonging to a union. With their "take-it-or-leave-it" contracts, health-care plans have placed restrictions on medical testing and treatment options and, in some respects, have limited the time we can spend with our patients. H.R. 1304 will level the playing field by giving physicians the opportunity to hold effective negotiations with health-care plans and to act as advocates on behalf of our patients.

Second, consider not participating with health-care plans at all! Years ago, the great majority of physicians signed every contract that came along because they were fearful of losing their patients. Our incorrect logic has placed us in the position in which we now find ourselves, and it has led to a loss of collegiality among physicians. However, there is a new trend around the country, which suggests that "doctors who never before dared to abandon health insurance plans were taking the plunge" and returning to a fee-for-service arrangement¹. The prisoner's dilemma may yet be solved.

Alan H. Morris, M.D.
522 North New Ballas Road, Suite 199
St. Louis, Missouri 63141

Dr. Bernstein replies:
I thank Dr. Morris for his comments and insights, and I too applaud the Editor's decision to offer "The Orthopaedic Forum" as a place for topical discussion.

Dr. Morris and I agree on the central point: doctors would be better off financially if all of us would simply decline to participate in the "race to the bottom" proposed by HMOs. However, declining to participate must be a cooperative decision--even if that cooperation is only tacit. Unilateral disarmament will spell financial disaster for you if other doctors swipe your patients. That is, you should not simply decide not to play (as Dr. Morris suggests) if the game can go on without you. Rather, I advocate vigorous play, with a provably winning strategy: cooperation at first and brutal retaliation thereafter, if needed.

Outside the realm of medical economics (the topic of my column), Dr. Morris' advice is especially on point. Specifically, patients would benefit immensely if doctors could resist the pernicious lure of HMOs and, as Dr. Morris suggests, "consider not participating . . . at all."

Managed care exerts great pressure on doctors to increase so-called clinical productivity (that is, to see more patients), and this means that, absent heroic efforts to the contrary, doctors will have less time for each patient. Also, patients may confuse the worth of what they receive with its price and thus may derogate the value of the care they get simply because it did not cost much out of their pocket. Through the magic of a psychological phenomenon called cognitive dissonance resolution, a patient can convince himself or herself that a sham treatment works simply because he or she paid a lot of money for it. Unfortunately, the process can work in reverse.

The New York Times, in the article Dr. Morris cites, recently reported that there are small pockets where fee-for-service medicine is making a comeback in orthopaedics¹. I think this is good news not because doctors will make more money under such an arrangement (though some will) but rather because this trend will lead to greater choices by buyers in a freer market. On the whole, this is a very positive development.

Joseph Bernstein, M.D., M.S.
Department of Orthopaedic Surgery
Leonard Davis Institute of Health Economics
424 Stemmler Hall
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania 19104-6081
E-mail address: orthodoc@mail.med.upenn.edu

1. Kolata, G.: For those who can afford it, old-style medicine returns. New York Times, p. A1, March 17, 2000.