This is what it looks like when a profession dies...

[drusso]

Perspective

Guiding Choice — Ethically Influencing Referrals in ACOs
Matthew DeCamp, M.D., Ph.D., and Lisa Soleymani Lehmann, M.D., Ph.D.

N Engl J Med 2015; 372:205-207January 15, 2015DOI: 10.1056/NEJMp1412083

http://www.nejm.org/doi/full/10.1056/NEJMp1412083


Drs. DeCamp and Lehmann, along with the editorialists at the NEJM, set a new low in intellectual dishonesty with publishing this "perspective." Their tortured analysis, justification, and endorsement of what amounts to nothing less than racketeering, kick-backs, and fee-splitting (albeit blurred by accounting magic and inter-institutional operating agreements) would make organized crime syndicates blush with shame.

Physicians have taken an oath to protect their patients--not the collectivist interests of a soul-less bureaucratic entity like an "ACO." Sadly, we see this happening around us at a dizzying pace: Employed MD's are expected to refer "within" as a condition of their employment, proof of their loyalty to the Company, and fidelity to the cause of....(fill in the blank "Triple Aim," "Mission statement," "Equity", etc).

Colleagues, remember this: There is no defensible ethical position, decision-aid, or incentive that puts your duty to serve the best interests of your patient above any other collectivist goal. Rage against the machine.

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[101N]

Back in the day there was MGM, Dream Works, 20th Century Fox, etc. Now there is Netflix, Amazon & Google. But the actors are still working.

The cheese always moves.

 

[hyperalgesia]

Perspective

Guiding Choice — Ethically Influencing Referrals in ACOs
Matthew DeCamp, M.D., Ph.D., and Lisa Soleymani Lehmann, M.D., Ph.D.

N Engl J Med 2015; 372:205-207January 15, 2015DOI: 10.1056/NEJMp1412083

http://www.nejm.org/doi/full/10.1056/NEJMp1412083


Drs. DeCamp and Lehmann, along with the editorialists at the NEJM, set a new low in intellectual dishonesty with publishing this "perspective." Their tortured analysis, justification, and endorsement of what amounts to nothing less than racketeering, kick-backs, and fee-splitting (albeit blurred by accounting magic and inter-institutional operating agreements) would make organized crime syndicates blush with shame.

Physicians have taken an oath to protect their patients--not the collectivist interests of a soul-less bureaucratic entity like an "ACO." Sadly, we see this happening around us at a dizzying pace: Employed MD's are expected to refer "within" as a condition of their employment, proof of their loyalty to the Company, and fidelity to the cause of....(fill in the blank "Triple Aim," "Mission statement," "Equity", etc).

Colleagues, remember this: There is no defensible ethical position, decision-aid, or incentive that puts your duty to serve the best interests of your patient above any other collectivist goal. Rage against the machine.

I completely agree. These bureaucrats should have written this for a finance journal as they sip on lattes with the other CFOs.

 

[drusso]

Back in the day there was MGM, Dream Works, 20th Century Fox, etc. Now there is Netflix, Amazon & Google. But the actors are still working.

The cheese always moves.

The actors under "contract" had terrible deals with the big studios. They were censored, subjected to "loyalty"oaths, economically exploited, deprived of royalties, etc.

What's happening now in Medicine is not a shift in a business model, nor a "disruptive" innovation in service delivery; it's an ideological battle between LEFT and RIGHT. Rather, it's a "culture war" over province of professional autonomy in an honorable, sacred, and ancient trade dating back to the dawn of civilization.

The hospitals, ACO's, and other large medicalized corporate entities cannot be expected to behave ethically nor morally because they are not "bound" to the covenants of this profession like natural people. Ultimately, healing is an (inter-)personal act between doctor and patient. Healthcare is not a widget.

 

[powermd]

"If information alone proves insufficient but physicians and patients retain control over referral decisions, additional incentives may be necessary to influence referrals. Nonfinancial incentives, such as organizational recognition of “high-value referrers,” may be a logical next step."

Public shaming and peer pressure.

"If that approach is ineffective, carefully applied financial incentives, such as bonuses linked to high-value referral practices, may be necessary."

Kickbacks!

"For the use of such incentives to be ethical, however, patients must be informed of their existence, both by the ACO and by the referring physician."

The same way Apple informs me of changes in the service agreement for my iPhone? Or how Chase informs me of changes in their billing or privacy policies? Or how AT&T gets me to sign away my right to any recourse other than binding arbitration using their choice of firms as a condition of using their services?

Will ACOs get to bury this information in legal speak that no patient will ever read or understand?

"Whatever incentives are used, patients' best interests should remain primary, and the incentives should not inappropriately influence medical decision making."

And if they do, oh well, we saved a ton of money!

The problem here, as drusso identified, is the professional ethic vs the commercial one. Professional ethics are easily adhered to by individuals because one is face to face with the other to whom he owes a fiduciary duty. Take away the face to face and add all kinds of financial incentives to serve the organization over the interests of the patient, and professional ethics no longer exist. Every patient becomes a cost center needing "management".