AMA House of Delegates
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Melissa J. Garretson, MD, a delegate for the American Academy of Pediatrics and a pediatrician in a Texas emergency department, talked about the pressure she faces to meet her employer's performance goals. "Over the past few years, it's gotten uglier and uglier, " she said. Photo by Luci Pemoni / AP Images for American Medical News

AMA meeting: Delegates adopt physician employment principles

As the number of doctors in independent practice declines, the Association's policy aims to ensure that patient welfare stays ahead of employer imperatives.

By — Posted Nov. 26, 2012

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The autonomy of the rising number of employed physicians ought to be respected, and patient care should come before the financial interests of employers, according to principles on physician employment adopted in November at the American Medical Association Interim Meeting.

The principles, contained in an AMA Board of Trustees report the House of Delegates adopted, cover potential flash points in physician-employer relationships such as conflicts of interest, contracting, payment agreements, peer reviews, performance evaluations and medical staff-hospital relations.

“The principles for physician employment provide a broad framework to help guide physicians and their employers as they collaborate to provide safe, high-quality and cost-effective patient care,” said AMA board member Joseph P. Annis, MD, an anesthesiologist from Austin, Texas. “The guidelines reinforce that patients' welfare must take priority in any situation where the interests of physicians and employers conflict.”

For example, if an employer requires or pressures physicians to send referrals within the health care organization, that practice ought to be disclosed to patients, the AMA policy states. Another principle at stake is physicians' freedom to advocate for their patients or act on matters of professional judgment, which the house said employers should not restrict.

Also, employers should make clear to doctors the factors on which their compensations are based and how their performances will be evaluated. Employed physicians should have the same rights to participate in medical staff self-governance as doctors in independent practices, the policy states.

The house's move comes as the proportion of physicians with an ownership stake is falling. In 2000, 57% of the nation's 682,470 practicing physicians owned at least a part of their medical practices. In 2013, that figure is expected to be 36%, according to an analysis of data from the AMA and MGMA-ACMPE done by the consulting firm Accenture. The report, published Oct. 31, said physicians cite business expenses, health plan hassles, electronic health record requirements and high patient volumes as reasons why they are thinking about leaving independent practice.

Young physicians eye employment

The house in November 2011 adopted policy stating that the AMA “will strive to become the lead association for physicians who maintain employment or contractual relationships with hospitals, health systems and other entities.”

As a member benefit, the AMA offers information and advice to doctors on matters pertaining to their relationships with hospitals, health systems and other entities on issues such as breaches of contract, medical staff bylaws, sham peer reviews, economic credentialing and the denial of due process. The Association has model contracts available for physicians negotiating employment terms with hospitals or group practices. The recently formed Integrated Physicians Practice Section, which will represent physicians employed at integrated health systems, will join the house at the June 2013 Annual Meeting in Chicago.


Dr. Ehrenfeld

The principles initially were proposed by the Organized Medical Staff Section and referred to the board for study at the Annual Meeting in June. The newly adopted principles coming out of the board report set out general guidance on physician employment, said Lee Perrin, MD, a Boston anesthesiologist and OMSS alternate delegate.

The principles are especially important to younger physicians, who are opting for employment in greater numbers, said Jesse M. Ehrenfeld, MD, an alternate delegate for the American Society of Anesthesiologists.

“Young physicians like me are more likely to be employed by hospitals or large, integrated health practices compared to older physicians, and therefore the principles delineated in this report are of great importance to our demographic,” said Dr. Ehrenfeld, who spoke on behalf of the Young Physicians Section. “This report is timely in subject and scope. As more young physicians become salaried employees, they will benefit from this important guidance.”

Thirty-two percent of final-year residents say hospital employment is their first choice of practice settings, according to an Oct. 5, 2011, survey conducted by physician recruiting firm Merritt Hawkins. In 2001, only 3% of final-year residents listed hospital employment as the most appealing practice option.

The policy was adopted on a voice vote. The house directed the AMA to disseminate the principles among graduating residents and fellows and advocate for adoption of the guidelines by trade groups representing hospitals and medical groups.

More to come on physician employment

Meanwhile, the AMA Council on Ethical and Judicial Affairs appears likely to study some of the ethical dilemmas facing employed physicians. At an open forum, the council invited delegates to discuss their personal experiences with physician employment.

Several delegates reported feeling pressure from their employers to meet financial goals and improve on measures of patient satisfaction. Among them was Melissa J. Garretson, MD, a delegate for the American Academy of Pediatrics from Stephenville, Texas, who is employed as a pediatrician in an emergency department.

“Over the past few years, it's gotten uglier and uglier, and harder to do what's right for patients in the ER when all that anyone cares about is patient complaints,” Dr. Garretson said. When she went to a committee meeting regarding renewal of her credentials, administrators asked why she had double the complaint rate of her colleagues. Their patient complaint rate was 0.01%, while Dr. Garretson's was 0.02%, she said. Refusing patient requests for inappropriate care can result in complaints that have no merit, she explained.

The AMA ethics council typically studies topics addressed at open forums and presents related reports for the house's consideration within 12 to 18 months.

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5 principles to address physician employment conflicts of interest

The American Medical Association adopted a set principles for physician employment, five of which address conflicts of interest. The policy seeks to help doctors manage the “divided loyalty” they may face as employed physicians.

  • A doctor's paramount responsibility is to his or her patients. Additionally, given that an employed physician occupies a position of significant trust, he or she owes a duty of loyalty to his or her employer. This divided loyalty can create conflicts of interest, such as financial incentives to over- or undertreat patients, which employed physicians should strive to recognize and address.
  • Employed physicians should be free to exercise their personal and professional judgment in voting, speaking and advocating on any matter regarding patient care interests, the profession, health care in the community and the independent exercise of medical judgment. Employed doctors should not be deemed in breach of their employment agreements, nor be retaliated against by their employers, for asserting these interests.
  • In any situation where the economic or other interests of the employer are in conflict with patient welfare, patient welfare must take priority.
  • Doctors should always make treatment and referral decisions based on the best interests of their patients. Employers and the physicians they employ must ensure that agreements or understandings (explicit or implicit) restricting, discouraging or encouraging particular treatment or referral options are disclosed to patients.
  • Assuming a position such as medical director that may remove a doctor from direct patient-physician relationships does not override professional ethical obligations. … Physicians who hold administrative leadership positions should use whatever administrative and governance mechanisms exist within the organization to foster policies that enhance the quality of patient care and the patient care experience.

Source: AMA Principles for Physician Employment adopted by the House of Delegates, November (link)

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External links

American Medical Association model agreements for physician employment at a hospital or a group practice (link)

AMA Principles for Physician Employment adopted by the House of Delegates, November (link)

“Patient Satisfaction, Prescription Drug Abuse, and Potential Unintended Consequences,” The Journal of the American Medical Association, April 4 (link)

“Clinical Transformation: New Business Models for a New Era in Healthcare,” Accenture, Oct. 31 (link)

“2011 Survey of Final-Year Medical Residents,” Merritt Hawkins, Oct. 5, 2011 (link)

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