AMA House of Delegates

AMA meeting: Doctors told to reveal financial stake in referrals

■ Physicians should spurn any ownership or leasing arrangements that require patient referrals or prohibit recommending competitors.

By Kevin B. O’Reilly — Posted Dec. 1, 2008

Orlando, Fla. -- Physicians who refer patients for services at facilities in which they have a financial interest should disclose the conflict to patients, according to ethical guidelines on physician self-referral adopted at the AMA Interim Meeting in November.

The new ethics policy goes beyond restrictions laid out in federal anti-kickback laws and regulations, and declares that physicians must put patients first when making referrals. In addition to disclosing self-referrals, doctors should assure patients that their ongoing care is not in jeopardy if they decide to refuse recommended referrals.

"The physician should be up front and tell the patient first that he or she may have an interest in a facility," said William A. Dolan, MD, an orthopedic surgeon in Rochester, N.Y., and a member of the AMA Board of Trustees. "The patient can then trust the physician -- that he or she is doing the best thing for the patient."

The AMA says doctors should not refer patients to outside facilities in which they have financial interests but where they do not directly provide care. Doctors should not buy into or invest in health facilities, equipment or products, or enter into group practice contracts, if doing so is contingent upon making referrals or if the agreement means barring referrals to competitors.

The income doctors receive from the arrangements should not be contingent on the volume of referrals, states the AMA Council on Ethical and Judicial Affairs opinion adopted by the House of Delegates.

Regular reviews should be done to monitor referral patterns. Doctors should base referrals on "objective, medically relevant criteria" and enter financial arrangements primarily to improve patients' access to high-quality care.

The policy replaces three older CEJA opinions on managing physician conflicts of interest in health facility ownership, medical imaging leasing and home health care arrangements.

While innovative business arrangements can improve both quality and access to health care, the CEJA opinion says, they "can also be ethically challenging when they create opportunities for self-referral in which patients' medical interests can be in tension with physicians' financial interests."

The CEJA report says these self-referral arrangements "can undermine a robust commitment to professionalism in medicine as well as trust in the profession."

ADDITIONAL INFORMATION

Meeting notes: Medical ethics

Issue: The AMA's Code of Medical Ethics has not been comprehensively reviewed in more than 30 years.
Action: The AMA Council on Ethical and Judicial Affairs will undertake a three-year project to reorganize the code to make it easier to use and to consolidate opinions and identify gaps in policy.

Issue: Drug- and device-maker funding of graduate and continuing medical education can pose conflicts of interest for physicians and unconsciously bias the content of educational activities.
Action: CEJA and the AMA Council on Medical Education are working together to issue recommendations at the 2009 Annual Meeting on how best to manage these conflicts. An open call for comments will be posted to the AMA Web site.

Issue: Some hospitals, required to provide uncompensated long-term care for immigrant patients have had the patients deported to home countries, where appropriate care is often lacking.
Proposed action: The AMA should adopt policy opposing the deportation of patients. [ Referred for study ]

Issue: The AMA has no ethical policy explicitly outlining physicians' duty to provide the right care to the right patient at the right time through continuous quality improvement.
Proposed action: A CEJA report spelled out physicians' ethical obligation to provide high quality care. Some delegates objected that the proposed policy placed untenable demands on doctors in underserved areas. [ Referred for study ]

Issue: Health care organizations are increasingly using "secret-shopper" patients to report on physician and hospital performance in areas ranging from customer service and patient-centeredness to hand hygiene and decor.
Proposed action: A CEJA report stated that secret-shopper patients could be used as one way to assess and improve quality. But, the council said, these pseudo patients should not deprive real patients from getting care and should be used only with the approval of physicians. Delegates overwhelmingly objected that secret-shopper patient programs are inherently deceptive and misallocate scarce health care resources.[ Not adopted ]