Physicians resist states’ interference in practice of medicine

Increasingly common laws regulating conversations with patients and the delivery of services have some in organized medicine concerned that new mandates are going too far.

By Charles Fiegl amednews staff — Posted Aug. 27, 2012

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An organization representing internists has drafted principles designed to protect the physician-patient relationship when lawmakers draft measures regulating health care.

Some states have adopted statutes interfering with the care provided by doctors, the American College of Physicians said in its “Statement of Principles on the Role of Governments in Regulating the Patient-Physician Relationship.” Some laws and regulations require doctors to offer care that is not supported by evidence-based guidelines.

“Several states have passed or are in the process of passing laws that are going after the conversation between patients and physicians,” said ACP President David L. Bronson, MD. “That is protected territory.”

The statement of principles opposes laws overriding physician orders, mandating that patients be notified of or provided with certain health services, and limiting what topics doctors can discuss with patients. The document also recommends principles that elected officials should follow when deciding health policy. For instance, laws prohibiting physicians from discussing risk factors with patients should not be enacted, the ACP said.

“We hope this will become a document that they will think about and state societies will get behind it as well,” Dr. Bronson said.

The American Medical Association opposes government intrusion in the physician office and asks lawmakers to leave determinations about what qualifies as medically necessary treatment up to doctors and patients, said AMA President Jeremy A. Lazarus, MD.

“The ability of patients and physicians to have open and confidential conversations has always been the cornerstone of a successful health care system,” Dr. Lazarus said. “Lawmakers should not dictate the use of certain medical practices, nor should they threaten the open communication between physician and patient.”

Laws infringing upon the practice of medicine has increased during the past several years, doctors said. In 2009, the Connecticut Legislature enacted a law requiring physicians offering mammograms to notify women if they have high breast density and to inform them of additional screening opportunities. The law had created problems for doctors when insurance companies would not cover certain screenings based on a diagnosis of dense breasts, said Kathleen LaVorgna, MD, past president of the Connecticut State Medical Society.

“This leaves us in an awkward situation, and women are blaming us as physicians,” Dr. LaVorgna said. “The blame comes when legislators don’t fully understand the consequences.” The state Legislature later adopted a law requiring insurers to pay for the additional screenings, she added.

The physician community uses established best practices that follow evidence-based guidelines and that result from significant study, Dr. LaVorgna said. Doctors sympathize with lawmakers attempting to improve the health system for their constituents, but elected officials need to recognize the guidelines have been examined thoroughly, she said.

An April 4 study in The Journal of the American Medical Association titled “Detection of Breast Cancer with Addition of Annual Screening Ultrasound or a Single Screening MRI to Mammography in Women with Elevated Breast Cancer Risk” concluded that the additional screenings have led to higher detection rates of cancer but also an increase in false-positive findings.

“Despite its higher sensitivity, the addition of screening MRI rather than ultrasound to mammography in broader populations of women at intermediate risk with dense breasts may not be appropriate, particularly when the current high false-positive rates, cost, and reduced tolerability of MRI are considered,” the study states.

In several states, new laws have targeted abortion by regulating physician care. In Wisconsin, for instance, a recent law included language requiring three office visits with a patient — two visits before and one following — when a drug-induced abortion is prescribed.

The law’s supporters said the requirements were needed to ensure that an abortion is in fact voluntary. “The physician must determine if the woman’s consent is voluntary by speaking to her in person, out of the presence of anyone other than a person working for or with the physician,” according to the law. “If the physician has reason to suspect that the woman is in danger of being physically harmed by anyone who is coercing the woman to consent to an abortion against her will, the physician must inform the woman of services for victims or individuals at risk of domestic abuse and provide her with private access to a telephone.” The law was enacted April 6.

Doctors have taken issue with the Wisconsin statute because it mandates how physicians interact with patients, said Wisconsin Medical Society President Tosha Wetterneck, MD. For instance, the law requires that the patient be alone and that the physician be the person to give the patient the abortifacient medication in the clinic that day.

“There are a lot of things in the law that interfere with the physician-patient relationship,” Dr. Wetterneck said. “Things that must happen that are not adding to quality care.”

Physicians want to provide care based on evidence, quality and patient safety, while ensuring access to necessary services, she said. Interference in the physician-patient relationship will cause the patient to miss out on high-quality care.

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7 questions internists want lawmakers to ask themselves

The American College of Physicians offers elected officials a series of questions to ask when drafting legislation to reform or change the health care system. The ACP says answers to these questions will help lawmakers consider the appropriateness of a proposed law and its potential impact on the physician-patient relationship.

  • Is the content and information or care consistent with the best available medical evidence on clinical effectiveness and professional standards of care?
  • Is the proposed law or regulation necessary to achieve public health objectives and, if so, is there any other reasonable way to achieve the same objectives?
  • Could the presumed basis for a government role be better addressed through advisory clinical guidelines developed by professional societies?
  • Does the content and information or care allow for flexibility based on individual patient circumstances and on the most appropriate time, setting and means of delivering such information or care?
  • Is the proposed law or regulation required to achieve a public policy goal without preventing physicians from addressing the health care needs of individual patients?
  • Does the content and information to be provided facilitate shared decision-making between patients and their physicians based on the best medical evidence and the physician’s clinical judgment, or would it undermine shared decision-making?
  • Is there a process for appeal to accommodate for specific circumstances or changes in medical standards of care?

Source: “Statement of Principles on the Role of Governments in Regulating the Patient-Physician Relationship,” American College of Physicians, July (link)

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External links

“Detection of Breast Cancer with Addition of Annual Screening Ultrasound or a Single Screening MRI to Mammography in Women With Elevated Breast Cancer Risk,” The Journal of the American Medical Association, April 4 (link)

“Statement of Principles on the Role of Governments in Regulating the Patient-Physician Relationship,” American College of Physicians, July (link)

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