Business Challenges to Our Professionalism

Chapter 87 Business Challenges to Our Professionalism



Robert E. Booth, Jr., MD


Professionalism is the defining aspect of an occupation that implies mastery of a complex body of knowledge and skills. It also presumes a commitment to competence, integrity, morality, and altruism over self-interest as well as a contract with society to guarantee these qualities.1


Many physicians chose a career in medicine presuming they will enjoy relative autonomy in their actions and decisions on behalf of their patients. Today this privilege is in danger of being eroded by external pressures—largely economic and legal—that threaten our professionalism. The patient-physician relationship has deteriorated, the trust of the public has been undermined, academic and educational vehicles have been compromised, and our professional societies have become but a passive voice in the policing of our own profession.


The greatest and most immediate of these economic pressures threatening our professionalism is the relentlessly declining reimbursement for medical care mandated by the external agencies that now control the business of medicine. Medicare, for instance, has been on a decremental reimbursement scheme since 1991, paying less each year for procedures that are better, faster, and more enduring. This is frequently a discouragement to those who continue to strive to provide that care.


For surgeons attempting to define their style of practice and maintain their professionalism, multiple external economic challenges remain. How to negotiate with an HMO, for instance, is a challenge. HMOs are interested in negotiating with physicians who have an established, large-volume practice. Beginning your practice, you may be at the mercy of an HMO, whose reimbursements are traditionally a fraction of Medicare. Dropping out of mandated reimbursement schemes is one strategy; however, this seems inherently anti-Hippocratic to most altruistic physicians. Nonetheless, some physicians believe that this strategy may be their only option for fiscal survival.


The Stark law prohibits physicians from making referrals for a “designated health service,” payable by Medicare or Medicaid, to an entity with which the physician has a financial relationship. This law prevents a physician, for example, from referring a patient for an x-ray to a facility in which he has any financial interest. This law is evidence of growing public mistrust of physicians.


Another challenge born of economic bankruptcy is the “pay-for-performance” concept of medical reimbursement based on outcomes. Outcomes are important; however, the instruments for outcome determination are still in their infancy and currently have more to do with patient satisfaction than true medical improvement. Since medical economics is currently a “null sum” game, it is difficult to believe that increased pay will be afforded to those who do a better job. The publication of physician outcomes in newspapers and magazines, as has occurred in the state of Pennsylvania, can have damaging and unintended consequences. Surgeons may consciously avoid risky or complicated procedures that they might otherwise have performed for fear of tarnishing their outcome score and their resulting income stream. This is another example of how a well-intentioned policy, driven by economics, has unintended consequences.


The relationship with the medical industry is yet another interface between professionalism and economics. Physicians who design new instruments or devices and are appropriately rewarded for their intellectual property and innovation have recently come under greater scrutiny for “conflict of interest.” With the steady decline of national research funding, much of the technological advancement in our profession comes from the medical industry, and the intersection of industry and medicine will continue to be important to medical innovation.


One final concern is the rise of medical advertising. Advertising by physicians, which used to be taboo, is now increasingly popular. The most aggressive medical practices produce educational seminars and infomercials, and use billboards, newspaper ads, TV and radio spots, and direct mailings to advertise their services. Claims and inducements are cleverly worded to emphasize only the positive, and in many instances constitute an embarrassment to the professionalism that once distinguished us.


The greatest challenge to both physicians and society remains the current malpractice environment. Its economic roots lie in the promise of obscene rewards for patients and their attorneys for the misfortunes and maloccurrences that will forever plague interactions between biology and technology. Currently, only 38 states have adopted tort reform. Without it the excessive financial awards and the consequences they engender will persist. Concerned and altruistic physicians must unite to resist the economic and political challenges that threaten our profession and our professionalism.



Reference



1 Cruess R. Teaching professionalism. CORR. 2006;449:177-185.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Business Challenges to Our Professionalism

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