Tuesday, February 14, 2006

USA Today Calls For Managed Care to Enforce Conflict of Interest Rules on Physicians

USA Today has weighed in about stricter standards for physicians' relationships with pharmaceutical and device companies, leaning heavily (as did the New York Times previously) on the recent article in JAMA by Brennan et al.
Unlike the Times, USA Today ladeled blame about evenly on physicians and industry. And the editorial's position on which of the specific rules advocated in the JAMA article should be adopted, I must say, mirrors mine.
But, in my humble opinion, USA Today stumbled badly on the issue of enforcement. The editorial endorsed enforcement by academic medical centers, without raising any questions about whether their leadership is more ethical, or less conflicted than physicians. Furthermore, it also suggested that "managed-care groups can help enforce rules for their participating doctors."
I am willing to believe that newspaper editorialists may be ignorant about how leaders of academic medical centers may have their own conflicts of interest, and in a few particularly bad cases, how they may have been involved in criminal activity (e.g., again, the recent cases of Roger Williams Medical Center, and the University of Medicine and Dentistry of New Jersey, whose previous leadership lead both organizations to submit to federal deferred prosecution agreements.)
But can newspaper editorialists really be ignorant of the conflicts of interest posed by managed care? I guess I should again quote what I wrote in "A Cautionary Tale,"[1]
Physicians, especially primary care physicians, are often exposed to incentives that conflict with professional values. 'Market driven health care creates conflicts that threaten medical professionalism.'[2] Managed care organizations, in particular, provided strong incentives to do less for patients, but at the risk of making physicians into 'double agents,' whose financial incentives are no longer clearly aligned with providing services, but may turn on holding services to some minimum level.'[3] Most primary care physicians feel pressure from managed care to limit referrals and see more patients,[4] and thus are concerned about conflicts of interest and failure to regard the patient’s interests as paramount.[5] Managed care organizations may employ a 'strategy of giving with one hand while taking away with the other, of offering consumers comprehensive benefits while restricting access through utilization review, [which] obfuscates the workings of the system, undermines trust between patients and physicians, and has infuriated everyone involved.'[6]
Putting managed care in charge of enforcing conflict of interest rules for physicians makes even less sense to me than letting leaders of academic medical centers enforce the rules. Instead, again, I suggest that there should be broad rules about conflicts of interest for all people who make decisions that affect health care, with the details of implementation and enforcement adjusted for the context, e.g., adjusted for practicing physicians, academic physicians, academic medical center leaders, managed care managers, etc.

1. Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14 (2003) 123–130.
2. Kassirer JP. Managed care and the morality of the marketplace. N Engl J Med 1995; 333: 50-52.
3. Shortell SM et al. Physicians as double agents: maintaining trust in an era of multiple accountabilities. JAMA 1998; 280: 1102-1108.
4. Grumbach K et al. Primary care physicians’ experience of financial incentives in managed-care systems. N Engl J Med 1998; 339: 1516-1521.
5. Feldman DS et al. Effects of managed care on physician-patient relationships, quality of care, and the ethical practice of medicine. Arch Intern Med 1998; 158: 1626-1632.
6. Robinson JC. The end of managed care. JAMA 2001; 285: 2622-2628.

1 comment:

james gaulte said...

The managed care folks overseeing conflicts of interest? Talk about the fox watching the chickens.Much about the operational reality of managed care is a conflict of interest.