Professionalism, Physician Payment and Conflicts of Interest Sharon Levine, M.D. Associate Executive Director Kaiser Permanente October 20-21, 2008 Beijing, China

2 Professionalism n For more than a decade, renewed interest in professionalism in medicine in the US u In the face of growing threats to the respect, esteem and historically venerated status of the profession è Less trusted by the public è Much more expensive è Transparency of “error-prone-ness”, opaqueness of performance data on quality and cost è Immersed in the market place è 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 excellence  Mastery of body of knowledge  Maintenance of technical skill and competence  Continued self-improvement Maintain standards of behavior  Ethical service  Altruism  Duty to serve, to teach, to advocate  Duty to participate in betterment of the profession: protect patients from failures of professionalism  Duty to avoid conflicts of interest Maintain the public trust  Fiduciary duty to preserve heath and resources  Stewardship 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 n 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 n 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 n Emergence of insurance in the 20th century u 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 u In any insurance scheme è Primary ethical obligation to the needs of the patient è Obligations of the physician expand to include others in the “risk pool” è 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? n 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 n 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 n No payment scheme is free of potential for unintended consequences n Payment scheme should favor the interests of patients (altruism) n 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 n 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 n Rigor and discipline about what decisions get made in each realm – institutional level: needs of the population; individual level: needs of the patient n Success depends upon broad participation by clinicians in decisions in the institutional realm n 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 n Commitment to clinical practice based on the best available evidence, reinforced by unblinded sharing of performance data on quality, appropriateness n 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