In an effort to improve physician compliance with and interest in decreasing costs, intense financial conﬂicts of interest can be brought to bear on physicians by health care plans or health care systems. If a physician’s profile on costs or referral is too high, he or she might be excluded from the plan, thus decreasing his or her ability to earn a living or to provide care to certain patients with whom a relationship has developed. Conversely, a physician may receive a greater salary or bonus if the plan makes more money. The ability to earn a living and to see patients in the future is dependent on maintaining relationships with various plans and other physicians. These are compelling loyalties and conﬂicts that cannot be ignored (32–34).
These conﬂicts are substantially different from those of fee-for-service plans, although the ultimate effect on the patient can be the same. In fee-for-service plans, financial gain conﬂicts of interest have the potential to result in failure to refer a patient or to restrict referral to those cases in which the financial gain is derived by return referral of other patients (35). Patients who have poor insurance coverage may be referred differentially from those who have better coverage. Patients may be unaware of these underlying conﬂicts of interest, a situation that elevates conﬂict of interest to an ethical problem. A patient has a right to know what her plan covers, to whom she is being referred and why, and the credentials of those to whom she is referred. The reality is that health care providers make many decisions under the pressure of multiple conﬂicts of interest. Physicians can be caught between self-interest and professional integrity. The outcome for individuals’ and society’s relationship with health care providers is damaged by failure to recognize and specifically address conﬂicts of interest that impede decision making (36). Focusing clearly on the priority of the patient’s best interest and responsibly rejecting choices that compromise the patient’s needs are ethical requirements.
Institutions, third-party payers, and legislatures avoid accountability for revealing conﬂicts of interest to those to whom they offer services. The restrictions of health care plans are never placed in a position as equally prominent as the coverage. The coverage choices can be quite arbitrary, and there is rarely an easily accessible and usable system for challenging them. Whole health systems or options may or may not be covered, but their presence or absence is obscured in the information given to patients. The social and financial conﬂicts of interest of these payers can directly affect the setting and nature of the relationship between physician and patient. To deal with ambiguous and sometimes capricious decision making, revelation of the conﬂicts of interest and accountability for choices should be demanded by physicians and patients (37).
Legal Problems Abuses of the system (e.g., referral for financial gain) led to proposals and legislation, often referred to as Stark I and II, affecting physicians’ ability to send patients to local laboratories and facilities in which they have a potential for financial gain. There were clearly documented abuses, but the same legislation would negatively affect rural clinics and laboratories whose sole source of financial support is rural physicians. States vary on the statutory legislation regarding this issue. Regardless of the laws, it is ethically required that financial conﬂicts of interest are revealed to patients (38,39).
Another abuse of the physician–patient relationship caused by financial conﬂicts of interest is fraudulent Medicare and Medicaid billings. This activity resulted in the Fraud and Abuse Act of 1987 (42 U.S.C. at 1320a–7b), which prohibits any individual or entity making false claims or soliciting or receiving any remuneration in cash or any kind, directly or indirectly, overtly or covertly, to induce a referral. Indictments under these laws are felonies, with potential fines, jail sentences, and loss of the license to practice medicine. Physicians should be aware of the legal ramifications of their referral and billing practices (40–42).