Financial Arrangements

As professionals dedicated to serving the sick, all physicians should do their fair share to provide services to uninsured and underinsured persons. Financial relationships between patients and physicians vary from fee–for–service to government contractual arrangements and prepaid insurance. Financial arrangements and expectations should be clearly established in advance.

Fees for physician services should accurately reflect the services provided. Physicians should be mindful that forgiving co–payment may constitute fraud. When physicians elect to offer professional courtesy to a colleague, physicians and patients should function without feelings of constraints on time or resources and without shortcut approaches. Colleague–patients who initiate questions in informal settings put the treating physician in a less–than–ideal position to provide optimal care. Both parties should avoid this inappropriate practice.

Financial Conflicts of Interest

The physician must seek to ensure that the medically appropriate level of care takes primacy over financial considerations imposed by the physician’s own practice, investments, or financial arrangements. Trust in the profession is undermined when there is even the appearance of impropriety.

Potential influences on clinical judgment cover a wide range and include financial incentives inherent in the practice environment (such as incentives to over utilize in the fee–for–service setting or underutilize in the managed care setting) , drug industry gifts, and business arrangements involving referrals. Physicians must be conscious of all potential influences and their actions should be guided by appropriate utilization, not by other factors. A fee paid to one physician by another for the referral of a patient, historically known as fee–splitting, is unethical. It is also unethical for a physician to receive a commission or a kickback from anyone, including a company that manufactures or sells medical instruments or medications that are used in the care of the physician’s patients. Physicians should not refer patients to an outside facility in which they have invested and at which they do not directly provide care. Physicians may, however, invest in or own health care facilities when capital funding and necessary services are provided that would otherwise not be made available. In such situations, in addition to disclosing these interests to patients, safeguards must be established against abuse, impropriety or the appearance of impropriety. The acceptance of individual gifts, hospitality, trips and subsidies of all types from the health care industry by an individual physician is strongly discouraged. The acceptance of even small gifts has been documented to affect clinical judgment and heightens the perception (as well as the reality) of a conflict of interest.