Unethical business practices in U.S. health care alarm physician leaders.
JO I was just thinking ... do you know what's paying for these three days in Marrakesh? (Ben chuckles.) JO ... And the purse I bought in Paris? Bill Edwards' tonsils.... BEN All the way home we'll be riding on Herbie Taylor's ulcers. JO And Allida Markle's asthma.... BEN Now, if we could only get four cases of the seven-year itch, we could retire. Or, if Mrs. Yarros really has triplets, we could at least redecorate the house. JO (Laughs) Oh, Ben, what would they say if they heard us? --Dr. Ben McKenna (James Stewart) and his wife Jo (Debbie Reynolds), in Alfred Hitchcock's The Man Who Knew Too Much, 1956
No profession is more fundamentally rooted in an ethic than medicine. In the 21st century, almost every young American physician graduates from medical school by reciting some version of an oath of ethical behavior first sworn to by doctors in the fifth century B.C.
To be sure, the original formulation by the Greek physician Hippocrates is a bit outdated--starting with its invocation of obscure Greek gods and, among many anachronisms, equating treatment with "dietetic measures" and relegating surgery to barbers.
Many medical schools have adopted updated versions of the oath, in which not only the language and concepts are modernized but also considerations such as avoiding overtreatment and factoring the patient's economic well-being into the therapeutic relationship are explicitly included in the pledge.
Ethical guidelines are central to medical practice because of what one respondent to ACPE's recent poll of physician leaders summarized as the "inherent conflict of interest" between the physician's role as trusted healer and the physician's role as breadwinner--earning a living from the medical knowledge and ministrations applied.
That's precisely the push-pull affirmed so chirpily by the fictional Dr. McKenna and his wife in Hitchcock's mid-20th century thriller. It was a time when virtually all medicine was fee-for-service and a conscientious Indiana physician like Ben McKenna regarded his patient-neighbors as extended family, made house calls at all hours and shepherded his flock through the vicissitudes of life from birth to asthma, ulcers, seven-year-itch and the final, fatal accident or illness.
But even back then Ben and Jo could chuckle a guiltily over the dichotomy between his profession as selfless art and his practice as self-serving business.
"In managing their patients," noted that same ACPE survey respondent, "[doctors] can 'churn' for optimal financial success. [These days] the business of medicine has just added a few more layers of opportunity."
How have physicians--along with other health care providers--responded to the universal seep of commercial imperatives into the modern practice of medicine? To what extent have the insistent demands of profit and loss, of cost/benefit ratio and market opportunity, of quarterly earnings and reimbursement renegotiations encouraged behaviors in the health care sector that cross traditional ethical boundaries?
That was the issue the American College of Physician Executives addressed in a poll of physician executives that examined ethical business practices and behaviors.
"As a physician leader," the ethical behavior survey inquired, "how concerned are you about unethical business practices affecting U.S. health care today?"
Almost 1,500 ACPE members participated in the poll--or about 21 percent participation in the survey that was sent to 7,000 ACPE members.
More than half of the respondents--54.6 percent--described themselves as "very concerned" about unethical business practices in health care. Another 36 percent were "moderately" concerned. Only nine of 1,479 respondents dismissed the matter altogether.
Several survey participants were careful to couch their answers in context.
"In all categories above where I have indicated low concern," wrote one, "I have done so because I do not think that the vast majority of physicians would alter their behavior because of the potential conflict of interest. If they did alter their behavior to the detriment of patients, then I would be very concerned. In general, physicians compartmentalize these issues well and have the best interest of patients as their first priority. When that does not occur for any reason, I am deeply concerned."
Summarized another, "The second-hand-smoke-like effects of unethical business practices can cause ethical cancers to develop throughout health care, and diminish the ethical reputation/standing of all physicians."
Asked to select among a list of "potentially unethical" business practices ascribed to the health care sector and to indicate the degree to which it concerns them, the physician leaders chose "refusing to accept call on patients who don't have insurance" as most troubling. Fully 59 percent said they are "very concerned" and another 21 percent called themselves "moderately concerned" about this growing phenomenon.
"I work at an academic medical center that is a Level I trauma center," one commented. "Neurosurgeons in our community (not our hospital) have given up intracranial privileges so they won't have to take trauma call. Orthopedic surgeons will not take care of acetabular fractures. Physicians in some small hospitals, particularly specialty physicians, refuse to take emergency call."
Noted another, "My biggest concern is the numbers of eye surgeons, ENT surgeons, plastic surgeons, etc. doing surgery at surgery centers, etc. so that they do not have to pull call at a hospital. In the 6+ years that I have been in (this city), for example, the number of ophthalmologists 'sharing' citywide call for the county hospital has dropped from 20+ to SEVEN!!!!"
Over-treating patients to boost income was another serious concern for 45 percent of respondents, while an additional third considered it to be of moderate concern.
"When half of the take-home pay of an oncologist comes from the mark-up on chemotherapy drugs, how can this possibly not affect the clinical judgment of that physician?" demanded one rhetorically. "When an orthopedist makes $100 per MRI ordered or 20% on all PT ordered through an owned PT provider, how can this not have an effect on clinical judgment?"
Two-thirds of the physician leaders who responded to the poll were either very concerned or moderately so about conflicts of interest among non-physician executive leaders. (about 10 percent were CEOs or the equivalent, 29 percent senior executives, 18 percent medical directors of hospitals or group practices, 25 percent department chairs and 19 percent practicing physicians or consultants)
Other primary areas of concern to respondents to the ACPE ethics poll were:
* Physicians being influenced by medical device companies to perform a certain procedure (39 percent seriously concerned, 40 percent moderately concerned)
* Physicians being influenced by pharmaceutical companies to prescribe a certain drug (36 percent seriously concerned, 40 percent moderately concerned)
* Board members with conflicts of interest (33 percent seriously concerned, 33 percent moderately concerned)
* Board members accepting gifts from vendors (27 percent seriously concerned, 29 percent moderately concerned)
* Physicians accepting gifts from vendors (24 percent seriously concerned, 36 percent moderately concerned)
* Physicians (who are not employees of a vendor) being paid to make promotional pitches for vendors (28 percent seriously concerned, 35 percent moderately concerned).
Issues in which "slight" concern was the predominant response included:
* Physicians under-treating patients to keep costs down and protect bonuses
* Non-physician executive leaders accepting gifts from vendors
* Physicians inappropriately admitting patients to a hospital
* Physicians discharging patients from the hospital too soon to avoid length-of-stay outliers.
The most common problems
Notwithstanding any disquiet they may harbor in general about the state of ethics in health care, more than half--54 percent--of the physician executives who completed the online survey indicated that a health care organization within their community was guilty of ethical breaches.
Similarly, although improprieties by board members and non-physician executives received frequent scornful mention in their comments, 80 percent of the respondents gave clean bills of ethical health to members of the governing board and administration in their own institutions.
They had strong views of their physician colleagues, however.
Fully a third said they believe a doctor or doctors within their own organization is engaged in an unethical business practice. But, as one observed, the clues are "often very subtle ... you suspect more than you know."
Echoed another, "While many physician execs like myself suspect unethical business practices, it's hard to find the examples. I think the environment is ripe for stricter enforcement (the culture is changing), but much of it is 'under the radar' until an audit or budget variance occurs. This makes awareness and enforcement difficult."
In fact, questions about ethical behavior or practices arise infrequently in their organizations, the physician leaders reported--fewer than five times a year, according to two-thirds, only once or twice a year for most of them (43 percent).
Pointing the finger
Seven out of 10 organizations represented by respondents to the ACPE ethics survey have a written code of ethical behavior, and almost three-quarters of those are enforced through "specific disciplinary actions or sanctions," respondents reported.
At the same time, only 60 percent considered enforcement to be consistent. Almost a third judged follow-through in their organization to be "occasional," and about one in 11 said their code of ethics is all bark with never a bite.
"My national organization has developed a code of ethics," explained one. "Unfortunately, because of possible litigation costs, there is no mechanism for enforcement."
Another problem echoed by several respondents is that "whistle blowing is dangerous for the whistle blower."
Under those circumstances, more than 80 percent of respondents said they'd welcome efforts by large professional groups like the American Medical Association and other medical specialty associations to "promote tougher ethical standards."
And how about the government? Is it time, the survey asked, to invite state or federal authorities to crack down with stiffer rules and regulations against unethical behaviors and business practices in health care?
"No," urged almost two-thirds of respondents, "keep the government out of it."
The consensus comments were impassioned.
"The worst offenders are the government and other organizations." fumed one. "Cannot have the fox in charge of the hen house."
"There are already too many laws about physician behavior," groused still another. "You feel like you cannot take a pen or some donuts."
"The federal government needs to address its own unethical practices before attempting to tackle those outside its house," argued another. "Physicians for the most part have to deal with the unethical practices of the insurance companies, and many decisions such as early discharge, admission denials, etc., stem not from practices of physicians but from actions of the health care facility or insurance provider."
Indeed, there was plenty of finger pointing at those deemed responsible for sowing the minefield through which today's physicians have to try to pick a righteous path:
* Health care plans with restricted formularies
* Prosthetic device manufacturers dangling "high-dollar kickbacks, expensive vacations and even cash payments for 'research ...'"
* Health insurers who "make huge profits by charging double-digit increases in premiums and paying officers tens of millions of dollars while using market share to ratchet down physician reimbursement ..."
* Health systems whose "purchase decisions are based strictly on price ..."
* Hospitals that "try to become masters of all subspecialties, competing with nearby hospitals for the same patients and thus performing procedures too infrequently to really develop a true 'center of excellence' ..."
* Pharmaceutical companies with direct-to-consumer advertising, detailing, questionable research and promotional largesse ...
* Malpractice attorneys and the "litigation pressures, real and imagined" they exert, causing physicians to perform "unnecessary procedures, consultation, imaging ..."
In sum, "the corporate practice of medicine. Those who pay for health care," railed one respondent, "now make the rules almost unfettered by good sense."
Dr. Ben McKenna was a proud member the most respected group of professionals in his hometown of Indianapolis. In 1976, when the Gallup Poll began assessing the public's perception of the honesty and ethics of those in various occupations, medical doctors ranked first, ahead even of clergy.
Today, physicians rank fifth, surpassed in esteem by nurses, elementary school teachers, pharmacists and military officers, the latest Gallup Poll shows. (They still nose out clergy, who've also fallen behind police officers.)
Regaining that lost ground will not be easy. Nor will it be remunerative. As one respondent to the ACPE survey warned, "Our health care system is designed to encourage unethical behavior by its misplaced financial priorities. The one sure way NOT to make money in our health care system is to specialize in treating old, poor, sick people with proven therapy."
Cynicism is always a temptation.
"Current medical practice on a corporate level is schizophrenic," lamented one respondent.
"Ultimately," wrote another, "the bottom line corrupts absolutely!"
Declared a third, "'Business ethics' ... an oxymoron? The move towards a 'market-driven' health care system inevitably involves motivations that are less-than-clinical."
Perhaps the first-person antidote lies in one optimist's counsel: "There's a simple test--if you would be OK reading about your action in the newspaper the next day, it is probably OK."
"This is an area that we as professionals should monitor and correct without governmental intervention," declared another cool head. "We are well-educated, articulate and intelligent individuals as a group and we all know the difference between right and wrong. It is up to the leaders to model the behavior and correct it when it occurs within the ranks."
That's the kind of thing Ben McKenna would have proposed. And Jo would have nodded admiringly. Maybe it's just that simple.
As a physician leader, how concerned are you about unethical business practices affecting U.S. health care today? Response % Response Total Very concerned 54.6% 807 Moderately concerned 35.6% 527 Slightly concerned 9.2% 136 Not concerned at all 0.6% 9 Total Respondents 1479 (skipped this question) 3 [c]ACPE 2005 Ethical Behavior Survey Is there a physician--or physicians--WITHIN YOUR ORGANIZATION who you believe to be involved in unethical business practices? Response % Response Total Yes 33.1% 464 No 60% 840 Not applicable 6.9% 96 Total Respondents 1400 (skipped this question) 82 [c]ACPE 2005 Ethical Behavior Survey Is there a board member WITHIN YOUR ORGANIZATION who you believe to be involved in unethical business practices? Response % Response Total Yes 11% 153 No 79.6% 1111 Not applicable 9.4% 131 Total Respondents 1395 (skipped this question) 87 [c]ACPE 2005 Ethical Behavior Survey Is there a non-physician leader or administrator WITHIN YOUR ORGANIZATION who you believe to be involved in unethical business practices? Response % Response Total Yes 14.2% 198 No 79.8% 1110 Not applicable 6% 83 Total Respondents 1391 (skipped this question) 91 [c]ACPE 2005 Ethical Behavior Survey Generally speaking, questions concerning unethical behaviors and business practices arise within my organization: Response % Response Total Once or twice a year 42.8% 594 3 to 5 times a year 23.7% 329 More than 5 times a year 10.5% 145 Monthly 8.1% 113 Weekly 4.3% 59 Daily 2.7% 37 Never 7.9% 110 Total Respondents 1387 (skipped this question) 95 [c]ACPE 2005 Ethical Behavior Survey Do you have a WRITTEN code of ethical behavior at your organization that specifically spells out ethical policies? Response % Response Total Yes 70.1% 969 No 19.1% 264 Don't know 10.8% 149 Total Respondents 1382 (skipped this question) 100 [c]ACPE 2005 Ethical Behavior Survey Does your code of ethical behavior include specific disciplinary actions or sanctions for unethical behaviors? Response % Response Total Yes 73.2% 703 No 26.8% 258 Total Respondents 961 (skipped this question) 521 [c]ACPE 2005 Ethical Behavior Survey When a problem with potentially unethical business practices arises in your organization it MOST OFTEN involves: Response % Response Total Physicians being influenced by 19.7% 246 pharmaceutical companies to prescribe a certain drug. Physicians being influenced by medical 7.8% 97 device companies to perform a certain procedure. Board members with conflicts of interest. 5% 62 Board members accepting gifts from vendors. 0.1% 1 Physicians under-treating patients to keep 2.7% 34 costs down and protect bonuses. Physicians over-treating patients to boost 18.7% 234 their income. Non-physician executive leaders accepting 1% 12 gifts from vendors. Non-physician executive leaders with 5.1% 64 conflicts of interest. Physicians accepting gifts from vendors. 5.7% 71 Physicians (who are not employees of a 4.6% 58 vendor) being paid to make promotional pitches for vendors. Physicians refusing to accept call on 13% 163 patients who don't have insurance. Physicians inappropriately admitting 4% 50 patients to a hospital. Physicians discharging patients from the 2.7% 34 hospital too soon to avoid length-of-stay outliers. Other 10% 125 Total Respondents 1251 (skipped this question) 230 [c]ACPE 2005 Ethical Behavior Survey Is the code of ethical behavior enforced? Response % Response Total Yes 59.7% 571 No 31.8% 81 Occasionally 304 Total Respondents 956 (skipped this question) 524 [c]ACPE 2005 Ethical Behavior Survey Is there a health care organization IN YOUR COMMUNITY that you believe to be involved in unethical business practices? Response % Response Total Yes 53.8% 743 No 46.2% 638 Total Respondents 1381 (skipped this question) 100 [c]ACPE 2005 Ethical Behavior Survey Do you believe the state or federal government should adopt tougher rules and regulations addressing unethical behaviors and business practices in health care? Response % Response Total Yes, the government needs to step in. 24.7% 343 No, keep the government out of it 63.3% 879 Not sure 12% 166 Total Respondents 1388 (skipped this question) 94 [c]ACPE 2005 Ethical Behavior Survey Do you believe large professional organizations should take a tougher stand against unethical business practices? Response % Response Total Yes, professional organizations need to 80.8% 1123 promote tougher ethical standards No, the current ethical standards promoted 13.5% 187 by professional groups are adequate Not sure 5.7% 79 Total Respondents 1389 (skipped this question) 93 [c]ACPE 2005 Ethical Behavior Survey
David Ollier Weber is a freelance health writer and frequent contributor to this journal. He can be reached by e-mail in Mendocino, Calif., at email@example.com