Tread lightly with patients on money matters

Two AMA ethics reports address how to avoid situations where money can intrude on the physician-patient relationship.

Posted Aug. 16, 2004.

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The relationship in medicine between doctor and patient should be sacrosanct. In these tumultuous health care times, it must be fiercely protected against the outside forces that threaten it. The big ones: managed care, the medical liability crisis and the fact that millions of people are without health insurance.

Yet physicians need to be careful that they don't become so focused circling the wagons against the enemy that they fail to recognize the ways the relationship can be irrevocably damaged when its two primary players interact with one another. Not surprisingly, money can be one of the biggest troublemakers.

It's no wonder, then, that the AMA's Council on Ethical and Judicial Affairs had money on its mind in forming two opinions recently adopted by the Association's House of Delegates.

The opinions -- one on offering financial incentives to patients for referrals and one on physician participation in soliciting contributions from patients -- should help physicians navigate two delicate issues. Together, they go a long way toward disarming money's potential to wreak havoc on the physician-patient relationship.

CEJA's opinion on offering financial incentives to patients for referrals is crystal clear. Don't do it.

To put it in the council's words, "Physicians should not offer financial incentives or other valuable consideration to patients in exchange for recruitment of other patients."

The reasons are plentiful. While the practice of providing incentives encourages patients to share positive experiences, it also gives them a motivation to persuade others to see their physician regardless of their actual opinion. That endows incentives with the potential to interfere with the truthfulness of a patient's recommendation. Some patients might be tempted to encourage others to seek unnecessary or unwanted care so they might get the reward. Physicians also receive a reward with a referral arrangement -- a new opportunity to bill for services -- that could be viewed with suspicion.

In addition, individuals who receive referrals should not have to worry that those referrals were bought. The bottom line is that such incentives can influence the information existing patients give to potential patients, distorting the expectations of those potential patients and compromising the trust that is fundamental to a successful physician-patient relationship.

That very relationship is also the focus of CEJA's more nuanced opinion on soliciting contributions from patients. While a physician's solicitation activities can help the community, they do not immediately help the patient's welfare -- the primary responsibility of a physician. The request falls outside this relationship and could give the impression that the patient's welfare is not the physician's first priority. That would likely diminish the patient's trust in the physician.

This can be avoided, CEJA points out, if physicians simply refrain from any involvement in the solicitation of their own patients.

Studies have shown that contributions from grateful patients have made up as much as 90% of private donations to medical centers in recent years. Acknowledging that fact, CEJA has offered these guidelines for those who might choose to wade into these waters: Make the information available in a reception area and by speaking at fundraising events; avoid directly soliciting your patients, especially at the time of a clinical encounter; and when patients initiate requests to contribute, refer them to appropriate fundraising personnel.

It is especially important to make sure that patients do not feel that contributing or not contributing will affect their care. That feeling would strike at the trust that is the heart of physician-patient relationship.

Following the guidelines in both these opinions will protect that relationship from forces that could destroy it from within, leaving physicians to concentrate their efforts on protecting it from the outside threats.

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