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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To be sure, the original formulation by the Greek physician Hippocrates is a bit outdated--starting with its invocation invocation,
n a prayer requesting and inviting the presence of God.
 of obscure Greek gods and, among many anachronisms, equating treatment with "dietetic dietetic /di·e·tet·ic/ (di?ah-tet´ik) pertaining to diet or proper food.

1. Of or relating to diet.

 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 mod·ern·ize  
v. mo·dern·ized, mo·dern·iz·ing, mo·dern·iz·es
To make modern in appearance, style, or character; update.

To accept or adopt modern ways, ideas, or style.
 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 healer Mainstream medicine A romantic synonym for physician. See Traditional healing.  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 chirp·y  
1. Characterized by chirping tones: a bird with a chirpy song.

2. Tending to chirp: a chirpy parakeet.

 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 vicissitudes
Noun, pl

changes in circumstance or fortune [Latin vicis change]

vicissitudes nplvicisitudes fpl; peripecias fpl 
 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 chuck·le  
intr.v. chuck·led, chuck·ling, chuck·les
1. To laugh quietly or to oneself.

2. To cluck or chuck, as a hen.

A quiet laugh of mild amusement or satisfaction.
 a guiltily over the dichotomy di·chot·o·my  
n. pl. di·chot·o·mies
1. Division into two usually contradictory parts or opinions: "the dichotomy of the one and the many" Louis Auchincloss.
 between his profession as selfless self·less  
Having, exhibiting, or motivated by no concern for oneself; unselfish: "Volunteers need both selfish and selfless motives to sustain their interest" Natalie de Combray.
 art and his practice as self-serving business.

"In managing their patients," noted that same ACPE ACPE Accreditation Council for Pharmacy Education
ACPE American Council on Pharmaceutical Education
ACPE American College of Physician Executives
ACPE Association for Clinical Pastoral Education, Inc.
 survey respondent, "[doctors] can 'churn' for optimal financial success. [These days] the business of medicine has just added a few more layers of opportunity."

Second-hand smoke second-hand smoke Passive smoking, see there

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 in·sis·tent  
1. Firm in asserting a demand or an opinion; unyielding.

2. Demanding attention or a response: insistent hunger.

 demands of profit and loss, of cost/benefit ratio and market opportunity, of quarterly earnings and reimbursement Reimbursement

Payment made to someone for out-of-pocket expenses has incurred.
 renegotiations encouraged behaviors in the health care sector that cross traditional ethical boundaries?

That was the issue the American College American College is the name of:
  • American College Dublin, Dublin, Ireland
  • The American College in Madurai, Tamil Nadu, India
  • The American College of the Immaculate Conception, Leuven (also known as Louvain), Belgium
 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 unethical

said of conduct not conforming with professional ethics.
 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 com·part·men·tal·ize  
tr.v. com·part·men·tal·ized, com·part·men·tal·iz·ing, com·part·men·tal·iz·es
To separate into distinct parts, categories, or compartments: "You learn . . .
 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."



Top concerns

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 In the United States, a Level I trauma center provides the highest level of surgical care to trauma patients.

A Level I trauma center is required to have a certain number of surgeons and anesthesiologists on duty 24 hours a day at the hospital, an education program,
," one commented. "Neurosurgeons in our community (not our hospital) have given up intracranial intracranial /in·tra·cra·ni·al/ (-kra´ne-al) within the cranium.

Within the cranium.
 privileges so they won't have to take trauma call. Orthopedic surgeons will not take care of acetabular acetabular /ac·e·tab·u·lar/ (as?e-tab´u-lar) pertaining to the acetabulum.


pertaining to the acetabulum.

acetabular dysplasia
see hip dysplasia.
 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 ENT ears, nose, and throat (otorhinolaryngology).

ear, nose, and throat


ear, nose and throat.

ENT Ears, nose & throat; formally, otorhinolaryngology
 surgeons, plastic surgeons plastic surgeon A surgeon specialized in reconstruction or cosmetic enhancement of various body regions, most commonly the face–nose, chin, and cheeks, breasts and buttocks; PSs remove fat deposits through liposuction; PSs reduce scarring or disfigurement , 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 take-home pay
The amount of one's salary remaining after federal, state, and often city income taxes and various other deductions have been withheld.
 of an oncologist Oncologist
A physician specializing in the diagnosis and treatment of cancer

Mentioned in: Retinoblastoma

 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 1. (application) MRI - Magnetic Resonance Imaging.
2. MRI - Measurement Requirements and Interface.
 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 scorn  
a. Contempt or disdain felt toward a person or object considered despicable or unworthy.

b. The expression of such an attitude in behavior or speech; derision.

 mention in their comments, 80 percent of the respondents gave clean bills of ethical health to members of the governing board Noun 1. governing board - a board that manages the affairs of an institution
board - a committee having supervisory powers; "the board has seven members"
 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 according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 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 Code of Ethics can refer to:
  • Ethical code, a code of professional responsibility, noting what behaviors are "ethical".
  • Code of Ethics (band), a 90's Christian New Wave/Pop band
 is all bark with never a bite.

"My national organization has developed a code of ethics," explained one. "Unfortunately, because of possible litigation An action brought in court to enforce a particular right. The act or process of bringing a lawsuit in and of itself; a judicial contest; any dispute.

When a person begins a civil lawsuit, the person enters into a process called litigation.
 costs, there is no mechanism for enforcement."

Another problem echoed by several respondents is that "whistle blowing is dangerous for the whistle blower Whistle Blower

An employee who has inside knowledge of illegal activities occurring within his or her organization and reports these to the public.

Although whistle blowers are protected under federal law from employer retaliation, there have been cases where

Under those circumstances, more than 80 percent of respondents said they'd welcome efforts by large professional groups like the American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science.  and other medical specialty medical specialty Any specialty that provides non-interventional Pt management, ie with drugs, or with minimum intervention–eg, balloon catheterization Examples Internal medicine–allergy and immunology, cardiology, gastroenterology, hematology/oncology,  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?

Absolutely not.

"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 fume  
1. Vapor, gas, or smoke, especially if irritating, harmful, or strong.

2. A strong or acrid odor.

3. A state of resentment or vexation.

 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 donuts - (Obsolete) A collective noun for any set of memory bits. This usage is extremely archaic and may no longer be live jargon; it dates from the days of ferrite core memories in which each bit was implemented by a doughnut-shaped magnetic flip-flop. ."

"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 Not to be confused with sewing.
Sowing is the process of planting seeds.

Hand sowing is the process of casting handfuls of seed over prepared ground: broadcasting. Usually, a drag or harrow is employed to incorporate the seed into the soil.
 the minefield through which today's physicians have to try to pick a righteous right·eous  
1. Morally upright; without guilt or sin: a righteous parishioner.

2. In accordance with virtue or morality: a righteous judgment.


* Health care plans with restricted formularies

* Prosthetic pros·thet·ic
1. Serving as or relating to a prosthesis.

2. Of or relating to prosthetics.


serving as a substitute; pertaining to prostheses or to prosthetics.
 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 Verb 1. ratchet down - move by degrees in one direction only; "a ratcheting lopping tool"
rachet up, ratchet

advance, march on, move on, progress, pass on, go on - move forward, also in the metaphorical sense; "Time marches on"
 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 direct-to-consumer advertising Drug industry The use of mass media–eg, TV, magazines, newspapers, to publicly promote drugs, medical devices or other products which, by law, require a prescription, which targets consumers, with the intent of having a Pt , detailing, questionable research and promotional largesse lar·gess also lar·gesse  
a. Liberality in bestowing gifts, especially in a lofty or condescending manner.

b. Money or gifts bestowed.

2. Generosity of spirit or attitude.

* 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."

'Simple' solutions?

Dr. Ben McKenna was a proud member the most respected group of professionals in his hometown home·town  
The town or city of one's birth, rearing, or main residence.

Noun 1. hometown - the town (or city) where you grew up or where you have your principal residence; "he never went back to his hometown again"
 of Indianapolis. In 1976, when the Gallup Poll Gallup Poll

a sampling of the views of a representative cross section of the population, usually used to forecast voting [after G H Gallup, statistician]

Gallup poll n
 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 elementary school: see school.  teachers, pharmacists This is a list of notable pharmacists.
  • Dora Akunyili, Director General of National Agency for Food and Drug Administration and Control of Nigeria
  • Charles Alderton (1857 - 1941), American inventor the soft drink Dr Pepper
  • George F.
 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 mis·place  
tr.v. mis·placed, mis·plac·ing, mis·plac·es
a. To put into a wrong place: misplace punctuation in a sentence.

 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 schiz·o·phren·ic
Of, relating to, or affected by schizophrenia.

One who is affected with schizophrenia.
," lamented la·ment·ed  
Mourned for: our late lamented president.

la·mented·ly adv.
 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 antidote

Remedy to counteract the effects of a poison or toxin. Administered by mouth, intravenously, or sometimes on the skin, it may work by directly neutralizing the poison; causing an opposite effect in the body; binding to the poison to prevent its absorption,
 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

                            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
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
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
COPYRIGHT 2005 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Weber, David O.
Publication:Physician Executive
Geographic Code:1USA
Date:Mar 1, 2005
Previous Article:Welcome to a special issue of The Physician Executive.
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