Doctors across the country say that health maintenance organizations (HMOs) routinely limit their ability to talk freely with patients about treatment options and HMO payment policies, including financial bonuses for doctors who save money by withholding care.

In interviews over the last 3 weeks, many doctors said such restrictions interfered with their ethical and legal duty to provide patients with information about the benefits, risks, and costs of various treatments.

Ill feeling over the restrictions is growing as more and more Americans join HMOs and employers encourage their use to control costs.

The doctors' complaints illustrate the tension between them and HMOs as health plans try to monitor and regulate the doctors' behavior.

Dr Daniel A Gregorie, president of Choice Care in Cincinnati, defended the confidentiality clause as a way to prevent doctors from sharing their frustrations with patients.

"Physicians are angry, frustrated and, to some extent, depressed because the world as they've known it is changing rapidly and radically," Dr Gregorie said.

"But physicians should not take out that frustration in a nonconstructive way by sharing it with patients. That does not help the patients. It just makes them more anxious about the care they are receiving."

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