Professionalism, Physician Payment and

Conflicts of Interest

Sharon Levine, M.D.

Associate Executive Director

Kaiser Permanente

October 20-21, 2008

Beijing, China

2

Professionalism

For more than a decade, renewed interest in professionalism in medicine in the US In the face of growing threats to the respect,

esteem and historically venerated status of the profession

Less trusted by the public Much more expensive Transparency of “error-prone-ness”, opaqueness of

performance data on quality and cost Immersed in the market place Misappropriation of the term “professionalism”

Confusion with economic self-interest Use as a “shield” to avoid scrutiny

3

Three Realms of Professionalism

Hippocratic framework – ethical basis of western medicine for 2500 years

societal

institutional

individual

4

What Professionalism Is

Maintain standards of excellenceMastery of body of knowledgeMaintenance of technical skill and competenceContinued self-improvement

Maintain standards of behaviorEthical serviceAltruism Duty to serve, to teach, to advocateDuty to participate in betterment of the profession: protect

patients from failures of professionalismDuty to avoid conflicts of interest

Maintain the public trust Fiduciary duty to preserve heath and resourcesStewardship and distributive justice

5

What Professionalism is Not

Unlimited autonomy to do what I want, clinically and financially

Freedom from regulation: Licensing by state

Specialty board certification, recertification

Credentialing

Privileging – hospital staff participation

Freedom from scrutiny: peer review

6

Professionalism in Context

Role of the profession and definition of “professionalism” is not determined by the profession in isolation, but by negotiation of the “social contract” with the society we serve

Relatively little change from the time of Hippocrates to mid 19th century regarding delivery of care and financing - barter, self-pay negotiated by doctor and patient

Emergence of insurance in the 20th century

Public and private arrangements for pooling the risk of many, and the resources of many to provide the care that each needs

7

Changing Context & Social Contract

In any insurance scheme

Primary ethical obligation to the needs of the patient

Obligations of the physician expand to include others in the “risk pool”

Stewardship of resources, and patient advocacy within a framework of distributive justice

Failure of the profession to embrace and acknowledge these obligations risks the loss of the public trust.

8

What makes this difficult?

Variable levels of acceptance of the implications of insurance by U.S. consumers Contributing to a pool of resources from which all our care

must come (social solidarity) vs unlimited ability of an individual to call on those resources independent of the value of the service, the needs of others

Tension intensified by rapid increase in cost of care: drugs/technology/medical interventions

Rapid pace of introduction of “innovative” products to market

Rate of uptake and use of new technologies far faster than rate of development of “evidence of benefit”

Direct-to-consumer advertising

Limited ability to distinguish “ new” from “improved”

9

Payment of Physicians and Professionalism

No payment scheme is free of potential for unintended consequences

Payment scheme should favor the interests of patients (altruism)

Modes of Payment

Fee-for-service: Pay for activity – do more, earn more Inherently inflationary

Capitation to individual; physicians: Do less, earn more Concerns about withholding care

Salary: Payment independent of production, productivity No incentive to do more or less than is appropriate

10

Payment of Physicians and Professionalism

Conflicts of Interest that threaten altruism

Industry influence over physician education: medical students, residents, practicing physicians

Industry inducements to promote new, expensive drugs, devices, technology

Honoraria Speaker fee on behalf of industry Consulting fees Free samples of expensive drugs

Industry sponsorship and control of clinical trials, research

Physicians’ augmenting income through mark up of drugs dispensed in their offices

11

Changing Context & Social Contract

Many very public examples of commercial interests subverting science and research: Whom can the physician trust?

Widespread practice of gifts and payments to physicians from manufacturers of drugs, devices, equipment Whose interests are being served?

Whom does the patient trust?

12

60 Years of Professionalism in Kaiser Permanente

An “outsider” model of organizing care delivery (multispecialty group practice)

An “outsider” model of payment: prepayment to the group, salaries for physicians – ethical compensation – viewed with suspicion by the fee-for-service practice community

Development of a robust model for professionalism

congruent with the mission of the organization, and

attractive to the best physicians: balancing clinical autonomy with collective stewardship, and the needs of

each patient with the needs of the population

13

Professionalism in Kaiser Permanente

Strong institutional and individual ethic for professionalism – mutually reinforcing

societal

institutional

individual

14

60 Years of Professionalism in Kaiser Permanente

Rigor and discipline about what decisions get made in each realm – institutional level: needs of the population; individual level: needs of the patient

Success depends upon broad participation by clinicians in decisions in the institutional realm

Dual responsibility for the needs of the individual in the office , and the needs of the population contributing resources for the care of each patient

Commitment to clinical practice based on the best available evidence, reinforced by unblinded sharing of performance data on quality, appropriateness

Absolute prohibition on acceptance of gifts of any size from industry; strict control of use of “free samples”; no “outside income” from sale of goods/services to patients allowed