Unethical business practices in U.S. health care alarm physician leaders

Physician Executive, March-April, 2005 by David O. Weber

JO   I was just thinking ... do you know what's paying for these three
     days in Marrakesh? (Ben chuckles.)
JO   ... And the purse I bought in Paris? Bill Edwards' tonsils....
BEN  All the way home we'll be riding on Herbie Taylor's ulcers.
JO   And Allida Markle's asthma....
BEN  Now, if we could only get four cases of the seven-year itch, we
     could retire. Or, if Mrs. Yarros really has triplets, we could at
     least redecorate the house.
JO   (Laughs) Oh, Ben, what would they say if they heard us?
--Dr. Ben McKenna (James Stewart) and his wife Jo (Debbie Reynolds), in
Alfred Hitchcock's The Man Who Knew Too Much, 1956

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No profession is more fundamentally rooted in an ethic than medicine. In the 21st century, almost every young American physician graduates from medical school by reciting some version of an oath of ethical behavior first sworn to by doctors in the fifth century B.C.

To be sure, the original formulation by the Greek physician Hippocrates is a bit outdated--starting with its invocation of obscure Greek gods and, among many anachronisms, equating treatment with "dietetic measures" and relegating surgery to barbers.

Many medical schools have adopted updated versions of the oath, in which not only the language and concepts are modernized but also considerations such as avoiding overtreatment and factoring the patient's economic well-being into the therapeutic relationship are explicitly included in the pledge.

Ethical guidelines are central to medical practice because of what one respondent to ACPE's recent poll of physician leaders summarized as the "inherent conflict of interest" between the physician's role as trusted healer and the physician's role as breadwinner--earning a living from the medical knowledge and ministrations applied.

That's precisely the push-pull affirmed so chirpily by the fictional Dr. McKenna and his wife in Hitchcock's mid-20th century thriller. It was a time when virtually all medicine was fee-for-service and a conscientious Indiana physician like Ben McKenna regarded his patient-neighbors as extended family, made house calls at all hours and shepherded his flock through the vicissitudes of life from birth to asthma, ulcers, seven-year-itch and the final, fatal accident or illness.

But even back then Ben and Jo could chuckle a guiltily over the dichotomy between his profession as selfless art and his practice as self-serving business.

"In managing their patients," noted that same ACPE survey respondent, "[doctors] can 'churn' for optimal financial success. [These days] the business of medicine has just added a few more layers of opportunity."

Second-hand smoke

How have physicians--along with other health care providers--responded to the universal seep of commercial imperatives into the modern practice of medicine? To what extent have the insistent demands of profit and loss, of cost/benefit ratio and market opportunity, of quarterly earnings and reimbursement renegotiations encouraged behaviors in the health care sector that cross traditional ethical boundaries?

That was the issue the American College of Physician Executives addressed in a poll of physician executives that examined ethical business practices and behaviors.

"As a physician leader," the ethical behavior survey inquired, "how concerned are you about unethical business practices affecting U.S. health care today?"

Almost 1,500 ACPE members participated in the poll--or about 21 percent participation in the survey that was sent to 7,000 ACPE members.

More than half of the respondents--54.6 percent--described themselves as "very concerned" about unethical business practices in health care. Another 36 percent were "moderately" concerned. Only nine of 1,479 respondents dismissed the matter altogether.

Several survey participants were careful to couch their answers in context.

"In all categories above where I have indicated low concern," wrote one, "I have done so because I do not think that the vast majority of physicians would alter their behavior because of the potential conflict of interest. If they did alter their behavior to the detriment of patients, then I would be very concerned. In general, physicians compartmentalize these issues well and have the best interest of patients as their first priority. When that does not occur for any reason, I am deeply concerned."

Summarized another, "The second-hand-smoke-like effects of unethical business practices can cause ethical cancers to develop throughout health care, and diminish the ethical reputation/standing of all physicians."

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Top concerns

Asked to select among a list of "potentially unethical" business practices ascribed to the health care sector and to indicate the degree to which it concerns them, the physician leaders chose "refusing to accept call on patients who don't have insurance" as most troubling. Fully 59 percent said they are "very concerned" and another 21 percent called themselves "moderately concerned" about this growing phenomenon.