The Association of American Medical Colleges has released the third report in a three-part series on how physicians should practice medicine, how they should behave, and with whom they should and shouldn't interact.
“In the Interest of Patients: Recommendations for Physician Financial Relationships and Clinical Decision Making” goes beyond the previous two AAMC reports, which were concerned with conflicts of interest (COI) in medical education and research, and tackles "individual or institutional financial interests in the patient care setting."
A book could be written in response to this report, but for the sake of your sanity, this will be a hyper-condensed commentary and only focus on two points. First, the rationale used by the AAMC to justify this endeavor. Second, an issue addressed in the report that easily trumps the rest of its topics but is inadequately addressed: The influence of reimbursement structure (i.e., insurers) on clinician behavior.
Point #1: The Timeless Rationale
Keeping with COI literature tradition, the report begins by extolling the benefits of collaboration, then quickly moves into the myriad reasons it should never occur. Apparently, it’s the preponderance of psychological literature that supports nullifying physician-industry interactions:
"The psychological research shows that ... when individuals stand to gain by reaching a conclusion they tend to unconsciously and unintentionally weigh the evidence in a biased fashion ... furthermore, the process of weighing evidence can happen beneath the individual's level of awareness. This research explains how even well-intentioned individuals can succumb to conflicts of interest and why the effects of conflicts of interest are so insidious and difficult to combat."
There you have it ... you didn't mean to do it, you couldn't control yourself. Sound familiar ... it looks strikingly similar to recent quote in the NY Times regarding industry funding of CME (previous blog coverage is HERE). And once again, the same tired JAMA articles are cited to support these claims (Dana & Loewenstein 2003; Wazana 2000). You get the picture; their argument for them to regulator you is solid.
Point #2: Reimbursement and COI
With all the focus on how pharmaceutical companies and device manufacturers are influencing, swaying, biasing, and bribing physicians to use their products, is seems that the elephant in the room feels a little neglected -- the insurance companies, of course. However, the AAMC took the bold leap to at least mention the possibility that reimbursement structure might influence practice decisions (they actually should get credit for this).
As they put it “the fundamental impact of payment mechanisms have on clinical decision processes must be recognized. Although the evidence is neither extensive nor conclusive, it is clearly suggestive of ethical challenges” and “associations have been reported between compensation mechanisms and resource utilization [which happens to be the whole purpose of pay-for-performance] that may imply some erosion of medical professionalism.”
They may be on to something here. When payment (reimbursement or withhold) is determined by whether a particular therapy or treatment strategy is utilized, and is devoid of patient-level considerations, it seems like the insurer is teetering close to the precipice of bias, influence, or whatever you like to call it.
Luckily, the AMA has decided to take issue with some insurer practices and is mounting a well orchestrated effort to let the public and policymakers know that there is a lot of room for improvement in insurance land. Take a read through the Insurer Code of Conduct (HERE) they recently released. It may be small step, but it’s a step in the right direction.