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