AMA House of Delegates

AMA meeting: AMA exhorts doctors to offer charity care, help the uninsured

■ Physicians also should become involved in the political process and help cut financial obstacles to care, says new ethics policy.

By Kevin B. O’Reilly — Posted June 29, 2009

Chicago -- As the debate on how to reform the health system and cover the country's approximately 47 million uninsured patients heats up on Capitol Hill, the American Medical Association House of Delegates adopted policy saying physicians have an ethical obligation to care for patients, regardless of their ability to pay.

So long as it is fiscally sustainable for physicians, the policy says, doctors should accept uninsured patients and maintain relationships with patients who lose health coverage. Doctors should help patients access public programs and charitable sources. They should take part in the political process to cut financial obstacles to health care access, delegates said.

Regina M. Benjamin, MD, outgoing chair of the AMA Council on Ethical and Judicial Affairs, said the Association's ethical stance on access to care dovetails with its lobbying efforts to cover the uninsured.

"This policy fits right into this entire debate at the base of what we do as physicians, which is to put the patients' needs first," said Dr. Benjamin, an Alabama family physician who last October was awarded a $500,000 MacArthur Foundation "genius grant." She founded a clinic in 1990 caring for patients in the medically underserved, remote area in and around Bayou La Betre, Ala.

"Right now, if a patient doesn't have access, they can't get our care," Dr. Benjamin said. "We need to use whatever resources we have, be it our voices or our advocacy -- and health reform is just part of that."

Charity care getting squeezed out?

Regina M. Benjamin, MD, walks the talk. The family doctor is founder and CEO of a clinic bringing "health care with dignity" to people in an underserved area of Alabama.

The new policy comes when declining physician income appears to be affecting the amount of charity care doctors provide. A March 2008 Milbank Quarterly report found doctors' pay fell 7% from 1996 to 2005, when adjusted for inflation. In the same period, the proportion of doctors offering charity care dropped 10% to about two-thirds of physicians. A 2005 Health Affairs study found that among those who are insured, 61% skip care due to out-of-pocket costs.

Some delegates argued that the CEJA report's injunction that physicians provide charity care "when possible" would make medical practice fiscally unsustainable.

"What does 'when possible' mean?" asked Joy A. Maxey, MD, a pediatrician in the Georgia delegation. "In Georgia, you could be Andrew Carnegie and you can't run a practice based on all Medicaid patients."

Ob-gyn Stanley F. Brunn, MD, a member of the New York delegation, said in reference committee discussion that the proposal "overstepped the bounds" and amounted to "mandates that are unfunded."

CEJA member H.R. Greene, MD, said the report was not intended to put physician practices at fiscal risk.

"It's an overwhelmingly obvious good that physicians maintain their financial integrity," said Dr. Greene, an Elida, Ohio, medical oncologist. "We are not saying that the responsibility of ensuring health care access is solely that of physicians.

"What we are exhorting physicians to do is to do the best you can as individuals to help with this problem and advocate with other stakeholders to resolve this issue. We are not telling physicians to go broke."

ADDITIONAL INFORMATION

Meeting notes: Medical ethics

Issue: Breaches of electronic medical records security can compromise privacy and harm patients physically and emotionally. When such breaches occur, what responsibilities do physicians have toward their patients?
Proposed action: An ethical policy recommending that physicians promptly inform patients of any breach and the potential for harm, describe how the breach happened and what steps patients can take to minimize any adverse results. [Adopted]

Issue: Physician assistants and nurse practitioners are increasingly taking on ownership roles in practices such as retail health clinics. This gives rise to the ethically problematic situation where a doctor is hired to supervise the work of a midlevel practitioner who also owns the practice and is the physician's employer.
Proposed action: An ethical policy that acknowledges the conflicts inherent in such an arrangement. The opinion says physicians have a duty to always exercise their independent professional judgment in patients' best interest, even if it puts them at odds with their employers. [Adopted]

Issue: Some hospital patients with racial or other prejudices are hostile to the physicians assigned to care for them or refuse their treatment, but hospitals do not have uniform guidelines to address these situations.
Proposed action: Direct the AMA to work with other organizations to encourage hospitals and health systems to adopt policies allowing patients to change doctors and have mechanisms to address abusive patient behavior and ensure continuity of care for a patient who declines care from the attending physician. [Adopted]

Issue: So-called chimeric embryos -- created when human genetic material is introduced into a nonhuman embryo or transferred into an enucleated nonhuman egg, creating a hybrid -- are being explored as an alternative to stem cell research techniques that destroy human embryos.
Proposed action: The Council on Ethical and Judicial Affairs said there is a lack of policy or scientific and ethical consensus on chimeras, and the issue affects few physicians. The council proposed examining the issue as part of its review of opinions relating to medical genetics in the AMA Code of Medical Ethics. [Adopted]

Issue: Working with patients to plan in advance for end-of-life care situations is a legally complicated and ethically fraught area for doctors.
Proposed action: Direct the AMA to develop an educational session on advance care planning at an upcoming Annual or Interim Meeting and ask CEJA to update its ethical guidance on end-of-life issues. [Adopted]