I submit that Hall and Berenson's "red-faced test" [1] should be applied with at least equal vigor and consistency in the world of private practice. For example, what shade of pink will the face of the cardiologist be when informing his patient that he will earn several hundred dollars more today if he inserts a Swan-Ganz catheter? This is of particular importance in light of major recent studies [2, 3] showing that the outcome of such an intervention is likely to be worse than if care is conservative (that is, if the procedure is denied).

Hall and Berenson have made a thoughtful contribution to this subject, but they err in perpetuating the folklore of "gag rules." Alain Enthoven has publicly referred to a study by the General Accounting Office of more than 500 health maintenance organization contracts, in which no gag clauses were found. Moreover, as a practical matter, I believe that most physicians in California do not shy away from discussing treatment alternatives with their patients and indeed use their utilization review committees as the independent arbiter to resolve such questions.

The authors' call for "discretionary judgment by someone with the appropriate expertise who is entirely removed from the treatment setting" has superficial appeal, but there are at least four major problems with the approach. First, such decisions will typically be made by a panel whose members will differ among themselves. We have already had this experience in California because of recent legislation requiring similar review of requests for experimental treatment in patients with terminal illnesses. Second, who will pay for this additional administrative layer of care? Third, complete and timely transfer of medical records for review is very challenging. Finally, this process will be yet another gravitational force removing decision making from the bedside.