Ethics of the new economic credentialing: Conflicted leadership roles
Article Outline
For many years Dr X has been the Chief of Surgical Services and the only credentialed vascular surgeon at St Antipathy, a mid-sized, greatly underfunded private hospital in a small city. He now serves as well on the hospital's board of directors. An opportunity has arisen for him to join several professional friends in founding a local physician-owned ambulatory surgery center (ASC). He planned to pursue this project while maintaining his positions at St Antipathy's, but when the hospital administration learned of his plans, the board of directors asked him and his partners to resign their hospital staff memberships. This would of course require surrender of his other hospital positions as well. He could do outpatient procedures like arteriovenous fistulas at the ASC but would require continuing access to inpatient services. The nearest other hospital suitably equipped for major inpatient vascular procedures is 50 miles away. What should he do?
Modern medicine is an altruistic business with a complex organizational structure, inviting a tangle of knotty financial conflicts. As long as the cost-plus payment system was in effect, these conflicts were considered trivial because the pool of resources was deep enough to accommodate everyone very nicely. Because every medical doctor, regardless of efficiency, turned a handsome profit for the hospital, conflicts were usually resolved in the physician's favor. As third party payers' business strategies squeezed hospitals and physicians by raising financial risks, economic conflicts began to be taken more seriously.
The authorization to practice medicine at a particular hospital is clearly understood as a privilege, not a right. Medical staff privileging stresses the physician's responsibilities and restrictions on their scope of practice. Almost every hospital's privileging documents specify the institution's authority to rescind hospital access for violations of the medical staff bylaws. Because physicians are considered to be the only legitimate judges of their colleagues' practices, the institutional responsibility guaranteeing the quality of care within its domain is assigned to peer review. Historically, at least in theory, the criteria for appointment and continuation as a medical staff member have exclusively been those used for determining whether a physician meets institutional quality standards in patient care.
The peer review system in credentialing works fairly well, when it is permitted to. Sometimes occult criteria with territorial financial undercurrents are permitted to influence and even determine where some otherwise qualified physicians practice. Physician's interests in limiting competition and hospital executive's recruitment through economic incentives have accompanied the process for some time, drawing little disdain. Whether that is a good or a bad thing in the life of a hospital can become a complicated question. Currently, fostered by concern about the fiscal well being of their institutions, hospital administrators are carefully scrutinizing the efficiency of the doctors who practice there. Nevertheless, the lay administration's overt role in deciding which physicians practice in its hospital has typically been secondary to the process of peer evaluation.
Both the hospital administration and medical leadership are interested in clinical quality and in economics when they consider their medical staffs. Historically, quality was exclusively the concern of the medical staff, and finance was left to the administration. This long-standing tradition faded when cost-plus reimbursement systems were replaced by diagnosis-related groups and other tactics designed to reduce hospital reimbursements. Inefficient medical practices like redundant laboratory tests and lengthy inpatient stays were once gold mines for hospitals, but they have become intolerable liabilities. Quality of care, once measured only by clinical outcome, began to be evaluated by financial variables like average hospital or intensive care unit days, operating room cost, total cost of hospitalization by diagnosis, or even the time it takes a particular surgeon to do a procedure. Rightly or wrongly, physicians have been made to feel unmistakable and ever-increasing pressure from cost-conscious hospital administrators to reduce expenses by closely monitoring resource utilization. Although re-credentialing decisions are properly reserved to the medical staff, most administrators quietly believe they can influence the reappointment of physicians who appear to lose money for the hospital. Only relatively recently has the practice of unilaterally revoking physician's privileges by hospital boards, termed economic credentialing, become a regular event.
The physician's milieu is necessarily a public trust, with the most restrictive moral obligations on personal-professional relationships of any human endeavor for which money is exchanged for service.1 There is a significant difference between the ethical standards required of a medical professional and those expected of an honest businessman.2 The virtues, values, goals, and their applications are distinct; the physician's interests are voluntarily subordinated to the patient's best interest. Fundamentally, decisions are made with the consideration of who will benefit most; fiduciary decisions assure that patients will be the beneficiaries. Commercial ethics, by contrast, promote the concept that each party is justified in acting to protect and advance self-interest.
Medicine nowadays commingles professional and commercial ethics. The activities required in managing an office, negotiating with third party payers, teaching trainees, and interacting with hospital administrations reflect both value systems, but the physician's primary responsibility is always to care for the sick, the injured, and the helpless. How should a conscientious physician determine which element of a given relationship should be governed by a professional medical ethic that sublimates self-interest, and which by the business ethic that places primary value on self-interest? Physicians do not have the same fiduciary obligations toward their office landlords, their hospital administrators, or their investment companies that they have toward their patients. Also these non-patients do not owe the same respect and deference to physicians during business dealings.
The test to be applied is straightforward. The professional fiduciary role applies to all decisions that affect patient care of the medical “community” served, directly or indirectly. The ethical constructs of business apply to wholly financial decisions that do not affect the quality of patient care. As used herein, the word quality is understood in the clinical outcomes context of patient therapy rather than cost of outcome. Although modern doublespeak has conjoined cost and quality, and they often parallel each other, they are not identical. The cheapest therapy of a particular disease is for the patient to die early on.
Is our well-established, successful surgeon, serving in multiple leadership roles at St Antipathy, within his rights to form new business allegiances without reproach? Will his division of loyalties affect patient care? Ownership of a competing medical facility clearly conflicts with the leadership positions this surgeon holds at Antipathy. His seat on the board of directors is especially conflicted. The position's conferral of extraordinary influence on institutional decisions and special access to its most sensitive information is based on a trust that he will never favor a competitor, an assurance he can no longer make. This eliminates option B as an ethical response. Likewise, the position of Chief of Surgery reflects a trust endowed with substantial influence over the practices of the institution's largest profit centers. His duty to honor the integrity of the position with undivided loyalty eliminates the propriety of option D.
The struggle between the surgeon's right to retain medical staff privileges on the basis of his sound practice and compliance with medical staff rules and the hospital's right to decredential a practitioner solely on the basis of commercial competition is ethically more indistinct, therefore more complex and very context dependent. If our surgeon resigns his leadership positions and becomes a member of the general medical staff, he will no longer exercise special influence, receive privileged information, or affect hospital business policies. He will control his own practice by deciding where patients will have their operations. Selection of sites will be determined less by financial than by resource requirements, with the nature of the vascular procedure effectively dictating whether it is to be done on an inpatient or an outpatient basis. Lost revenue from the highly profitable outpatient surgery business might nevertheless seriously affect St Antipathy's ability to continue providing the community with some loss leader services like geriatrics, burn unit, or the emergency center.
Option E appears initially attractive, because it eliminates the ethical dilemmas associated with retaining the leadership roles in the hospital. This option remains problematic, however, when we consider the fiduciary obligation to patients and the community at large the surgeon shares with the hospital.3 As a hospital staff member, the physician is entitled to expect his hospital to conduct its business to the benefit of its patients. The physician must join the hospital in recognizing co-fiduciary obligations not only to his own patients but also to the entire patient population served by St Antipathy's. Our surgeon's transfer of his patients—and the transfers of his colleagues and co-owners—to his proposed outpatient program would threaten the legitimate economic self-interest of St Antipathy. Indeed, its financial stability could be undermined, denying it resources that it needs to serve all of its patients and perhaps even threatening the hospital's survival as an essential community resource. The surgeon's primary motivation in planning to invest in the surgery center is not fulfillment of fiduciary responsibility to his patients—he's already doing that at the hospital—but economic self-interest. Among those privileged to be physicians, financial self-interest should always be secondary to more ethically demanding patient responsibilities. Option E thus lacks ethical justification.
Option C does not violate the fiduciary obligation the surgeon shares with the hospital because it eliminates the hospital role that incurs this joint responsibility. By resigning all his hospital affiliations, however, our surgeon will jeopardize any patients who need emergency inpatient vascular surgery or emergency transfer to the hospital from the ASC.
Option A is the ethically justified alternative. By planning to invest in the surgery center to advance his self-interest at substantial risk to the hospital, our surgeon would deserve the imprecations of medical ethics but instead should subjugate his own interests to the needs of people whom he has accepted an obligation to serve. These sacrifices are routinely made by ethical physicians.
Assertions of individual autonomy and protection of economic self-interest should not be the fundamental responses of physicians to hospital restrictions and cost controls. Assumption of shared fiduciary responsibility, in the absence of which professional autonomy is stripped of its moral authority, should be.4 Insisting that hospital leadership accept the principles of professional co-fiduciary responsibility confirms the physician's equivalent obligations. The building of a competitive surgical facility in a small market would harm St Antipathy's patient population and should be abandoned.
Although this hypothetical construct is intended to illustrate the physician's institutional co-fiduciary responsibility and the need to consider the consequences of entrepreneurial activities on the community, other types of hospital infringements on the privileging process might be entirely unacceptable and will be discussed in a later article. In this case, however, the hospital's apparent harsh response to the threat of economic competition is in fact a legitimate defense of its clinical care programs.
References
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- . The physician as professional and the physician as honest businessman . Arch Otolaryngol Head Neck Surg . 1993;119:495–497
- . A basic concept in the clinical ethics of managed care (physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients) . J Med Philos . 1999;24:77–97
- . The ethics of clinical pathways and cost control . J Vasc Surg . 2003;37:1341–1342
PII: S0741-5214(04)01450-8
doi:10.1016/j.jvs.2004.11.002
© 2005 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
