Bioethics Discussion Blog: AMA Report (2): Physicians' Self-Referral

REMINDER: I AM POSTING A NEW TOPIC ABOUT ONCE A WEEK OR PERHAPS TWICE A WEEK. HOWEVER, IF YOU DON'T FIND A NEW TOPIC POSTED, THERE ARE AS OF MARCH 2013 OVER 900 TOPIC THREADS TO WHICH YOU CAN READ AND WRITE COMMENTS. I WILL BE AWARE OF EACH COMMENTARY AND MAY COME BACK WITH A REPLY.

TO FIND A TOPIC OF INTEREST TO YOU ON THIS BLOG, SIMPLY TYPE IN THE NAME OR WORDS RELATED TO THE TOPIC IN THE FIELD IN THE LEFT HAND SIDE AT TOP OF THE PAGE AND THEN CLICK ON “SEARCH BLOG”. WITH WELL OVER 900 TOPICS, MOST ABOUT GENERAL OR SPECIFIC ETHICAL ISSUES BUT NOT NECESSARILY RELATED TO ANY SPECIFIC DATE OR EVENT, YOU SHOULD BE ABLE TO FIND WHAT YOU WANT. IF YOU DON’T PLEASE WRITE TO ME ON THE FEEDBACK THREAD OR BY E-MAIL DoktorMo@aol.com

IMPORTANT REQUEST TO ALL WHO COMMENT ON THIS BLOG: ALL COMMENTERS WHO WISH TO SIGN ON AS ANONYMOUS NEVERTHELESS PLEASE SIGN OFF AT THE END OF YOUR COMMENTS WITH A CONSISTENT PSEUDONYM NAME OR SOME INITIALS TO HELP MAINTAIN CONTINUITY AND NOT REQUIRE RESPONDERS TO LOOK UP THE DATE AND TIME OF THE POSTING TO DEFINE WHICH ANONYMOUS SAID WHAT. Thanks. ..Maurice

FEEDBACK,FEEDBACK,FEEDBACK! WRITE YOUR FEEDBACK ABOUT THIS BLOG, WHAT IS GOOD, POOR AND CONSTRUCTIVE SUGGESTIONS FOR IMPROVEMENT TO THIS FEEDBACK THREAD

Monday, May 12, 2008

AMA Report (2): Physicians' Self-Referral

The subject 2 Physicians’ Self-Referral is one of a series of 8 Reports of the Council of Ethical and Judicial Affairs (CEJA) of the American Medical Association. These reports have not yet been adopted as AMA policy; they will be discussed and debated in June 2008. If they receive the support of the majority of the delegates from the state and specialty societies, they will become policy. Anyone, including the general public, can provide testimony on CEJA reports either in person at the meeting or by writing to ceja@ama-assn.org.

I am presenting each Report as a separate thread on this blog. By clicking on the link above, you can gain access to the specific wording of the Reports, 1 through 6 are to be Amendments to the Constitution and Bylaws of the American Medical Association. Reports 7 and 8 are for Informational purposes. Why should the public be interested in these reports? They are part of the ethics of the system of medicine in the United States and may be reflected elsewhere in the world. Through the practice of medicine by all physicians, the rules presented in these reports can be applied to and may affect all patients. You may write directly your comments to CEJA at the e-mail address above and, of course, you are certainly welcome to post your comments on this particular Report here.

Should physicians refer patients to their own privately financed laboratories or services? Here is the Report’s discussion of a conflict of interest issue in such referrals:

SELF-REFERRAL: CREATING CONDITIONS FOR CONFLICT OF INTEREST

Physicians may lawfully enter into a variety of commercial and other relationships that can benefit both their patients and their own financial situation. , Physician ownership of specialty hospitals, for example, can ensure that patients have access to services that would not otherwise be available, thus also benefiting the wider community.1 Similarly, physician arrangements with diagnostic services, physical therapy or home care providers, opticians, or pharmacies can help ensure quality care and provide patient convenience while generating income for the physician. However, if such self-referral arrangements create conditions that do not promote the best interests of patients, they create an intolerable conflict. Hence the need for ethical scrutiny and guidance.

A conflict of interest is “a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain).” Primary interests are determined by the professional duties of the physician and are understood by the profession to be “the primary considerations in any professional decision . . . .”10 Secondary interests, financial or otherwise, are present to some degree in virtually every treatment decision a physician makes. Such interests are not necessarily illegitimate themselves and may even be desirable—provided that professional duties are the primary consideration. Because it can be difficult to recognize when secondary interests become inappropriate, both ethics and the law provide guidance.


The Report concludes with the following recommendations:

Business arrangements among physicians that encourage self-referral can benefit patients by enhancing access to health care services. However, these arrangements are ethically challenging because they create situations in which patients’ medical interests can be in tension with physicians’ financial interests. Such conflict-creating arrangements can have adverse consequences for patients and can undermine a robust commitment to professionalism in medicine. Physicians should generally avoid entering into such arrangements unless they provide definable benefits for patients.

Physicians who enter into legally permissible contractual relationships—including acquisition of ownership or leasehold interests in health facilities, products, or equipment; or contracts for service in group practices—are expected to uphold their responsibilities to patients first. When physicians enter into arrangements that provide opportunities for self-referral they must:

(1) Ensure that referrals are based on objective, medically relevant criteria.

(2) Ensure that the arrangement:

(a) is structured effectively to provide appropriate, high quality health care services or products not otherwise available in the community;

(b) does not require the physician-owner to make referrals to the entity or otherwise generate revenues as a condition of participation; and

(c) adheres to open, fair business practices vis-à-vis the medical professional community—for example, the arrangement permits investment by nonreferring physicians.

(3) Take steps to mitigate conflicts of interest, including:

(a) ensuring that financial benefit is tied to the physician-owner’s equity interest, not volume of referrals for services or sales of products;

(b) establishing mechanisms for utilization review to monitor referral practices; and

(c) making alternate arrangements for care of the patient when conflicts cannot be appropriately managed/mitigated.

(4) Disclose their financial interest in the facility, product, or equipment to patients, inform them of available alternatives for referral, and assure them that they will not be treated differently if they choose to obtain the recommended services/products elsewhere.

(5) Disclose their financial interest to third-party payers or other stakeholders on request.


Go to the link above and read the entire Report. Do you think that these recommendations would make physician self-referral more likely to be in the best interest of the patient? ..Maurice.

4 Comments:

At Saturday, March 28, 2009 7:10:00 PM, Anonymous Anonymous said...

Physicians have their own infusion suites and refuse to allow their patients any choices. They MUST use the physicians infusion clinic, or the doctor will not care for them AND the patient must come to the clinic every day rather than receiving their medications at home. they create a monopoly so that no other provider can competeon a fair landscape, as they get EVERY referral that comes out of the hospital where they practice. These are infectious disease physicians that I am speaking of. They do whatever they want, and money is all they are concerned about, NOT patient comfort. Why wont someone put a stop to this?

Tony

 
At Saturday, March 28, 2009 9:28:00 PM, Blogger Maurice Bernstein, M.D. said...

Tony, it is hard to argue against your point. Whatever the argument would be would be that there is substantially more benefit for the patient than any benefit for the physicians and the clinic. So what would be the benefit for the patient?

Locality convenience for the patient?
More immediate attention by a physician who knows the patient or has records available in case of an adverse reaction during therapy and generally more efficient followup after therapy?
Less expense to the patient for the therapy?

Are there any other benefits to the patient that visitors can find?

..Maurice.

 
At Tuesday, April 07, 2009 3:54:00 PM, Anonymous Anonymous said...

As a former home infusion nurse and having worked for a home infusion provider I can tell you this:

The core of the issue is CHOICE...PATIENT CHOICE. This is never a consideration in the equation. I have seen still acutely ill patients be required to hobble into the physicians suite every day to receive their IV antibiotics. Even if the patient lives 30 or more miles out of the way. The patient never gets one on one care, as their are MANY patients that are all in the same infusion room being seen by one or two nurses. The doctor is rarely even around. The patients are weak and tired and if you asked them, they would rather have an experienced home infusion nurse come to their home to administer their IV antibiotics or IVIG infusions. I worked for one ID doctor that when told that he could not get auth to do the meds in his office. He said, "Fine, but I won't write orders for the drug then."

It is simply a matter of these doctors make an incredible amount of money. This is always their ONLY consideration. They let their pocket book influence their practice decisions, bar none.
They create a monopoly, which is always bad for everyone, especially the consumer, as monopolies result in declining quality of care over time.

If hospitals were at least required to tell the patient of ALL of their options and then let the patient decide where they want to recieve their infusions, WITHOUT undue influence from the ID doctor (aint gonna happen), then their might, and I mean, might be more of a fair shot.

It is disgusting how these ID docs self refer, and I gaurantee you that they hwve little care for what their patient wants, if it interferes with their bottom line. They are getting unbelievably rich off of their infusion clinics, and god forbid anyone gets in their ways. The AMA is totally supportive of this self referral, and their SPIN doctors say that it is "better for the patients". Tell them to visit a doctors infusion suite and just take a look around. It looks like a bus station or a McDonalds.

 
At Tuesday, April 07, 2009 4:09:00 PM, Blogger Maurice Bernstein, M.D. said...

Maybe there should be part of the informed consent for the infusion a straight answer by the physician to the patient's question: "What do you get out of my treatment in a clinic that you have invested in?" and then the question: "What is the benefit for me to be going to your clinic for the treatment?" Patients deserve clear and true answers to both questions. ..Maurice.

 

Post a Comment

<< Home