4 ethical dilemmas facing physicians

Today’s physicians are subject to numerous competing pressures, rooted in both time and money, perhaps to an extent they’ve never experienced before. Medical Economics consulted doctors and healthcare experts to explore the push-pull of four ethical, financial, and logistical dilemmas that doctors must navigate in 2014--and beyond.

Read: Top 10 challenges facing physicians in 2014

Consider the trends. Patients newly insured through the Affordable Care Act (ACA), some with long-ignored medical needs, will be flooding the system, with slightly more than eight million people signed up by late April, according to federal officials. Medicaid eligibility also expanded in 26 states. Meanwhile, the U.S. health system is rapidly evolving. Hospitals are consolidating and building networks, many doctors are moving away from independent practice, and everyone from federal officials to the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign are targeting ever-rising treatment costs.

Add to that mix the perpetual edginess about malpractice lawsuits and patients who walk into the exam room with an iPad stocked with medical studies and their own game plan, says Terry McGeeney MD, a visiting scholar at the Brookings Institution and chief medical officer for VillageMD, a Chicago-based practice acquisition and management company that works with primary care practices. Doctors somehow have to keep their practice solvent amid shifting economic incentives, he says.

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“Even though a lot of physicians are living in fee-for-service and RVU (relative value unit) worlds, the reality is that there’s an end date on all of those things,” he says. “Physician compensation is going to be moving more toward total cost of care, quality, following protocols for whatever the process or disease might be. But we’re caught in this sort of transition time right now.”

Even before the influx of newly-insured patients, doctors felt as though they were practicing a form of triage to best meet patients’ medical needs. A primary care doctor would have to work nearly 22 hours each day to meet all of the guidelines for preventive care and chronic disease management for a typical patient panel of 2,500, according to an analysis published in 2009.

“People who already feel like they are doing a ton of work, are going to say, 'I can’t do anything more. There’s nothing more to squeeze out of me,’ ” says Marc Tunzi, MD, a family practitioner at Natividad Medical Center in Salinas, California. “You want me to do more work, but then you want me to be empathetic. So I need to deal with my own wellness. I need to get some exercise. There’s only 24 hours in the day.”

Medical Economics explored four ethical dilemmas that many doctors face on a regular basis.

Next: Dilemma No. 1

Ordering marginal or unneccesary tests

Slightly more than half of physicians, 53%, say they would order an unnecessary test if the patient was “quite insistent,” according to findings from an ABIM Foundation survey of 600 physicians conducted earlier this year. Malpractice concerns were cited as a major reason by 52% of those surveyed, along with other related rationales, such as “just to be safe” (36%) and “want more information to reassure myself” (30%).

Numerous studies have spotlighted unnecessary medical costs. One frequently-cited Institute of Medicine report, published in 2012, estimated that overuse of medical services beyond evidence-established levels reached $210 billion annually.

One significant gap in the ACA is that, while it places some pressure on doctors to hold down costs, it doesn’t take any steps t address tort reform, McGeeney says. Take the common complaint of nagging back pain, he says, which guidelines say don’t immediately require costly imaging tests for most patients right away, but rather a physical exam, anti-inflammatory medicine and rest.

“The patients, on the other hand, will have Googled it and are just convinced that they have a ruptured disc or a spine tumor,” he says. “And they will come in armed with articles justifying an MRI immediately.”

It’s time consuming to argue, and there is always that nagging worry at the back of the doctor’s mind that the patient’s worst fear will become a reality, thus risking a lawsuit, McGeeney says. “It’s easier to just order the test. And they very often do.”

But these conversations don’t have to be time-consuming, if the doctor has built a trusting relationship, says Dave Carlyle, MD, a family practitioner in Ames, Iowa, who works in a large multi-specialty practice. Carlyle says that he sees 25 to 40 patients a day and definitely has some “worried well” among their ranks. “Everybody is just worried about the cancer behind the door-worried that you are missing something.”

Still, the Iowa physician says that he can frequently convince his patients, many of whom he’s seen for a decade or longer, to hold off on costly and unnecessary tests for a few weeks and return if the medical problem hasn’t resolved. “I think that liability goes up when you don’t have a strong relationship with your patients,” he says.

Next: Dilemma No. 2

Pressures to refer patients within physician’s health system

Nearly two-thirds of physicians, 60%, still practice in independent physician-owned practices, according to the most recent American Medical Association survey data from 2013. But employment is picking up, spurred in part by hospitals wanting to create larger affiliated networks. By 2012, 29% of doctors either worked directly for a hospital or in a practice that was at least partially owned by a hospital, the survey found.

Read: How to survive in independent practice

 So when, if at all, does a physician’s loyalties to the patient and the hospital system employer diverge? Despite the emergence of accountable care organizations and other shared savings arrangements, the reality is that most doctors are still paid based on their production, McGeeney says. “With hospital-employed physicians, where there are imaging centers that are owned and specialists that need to be kept busy, I think there is certainly at least some indirect encouragement to utilize those services when they’re available.”

Being part of these integrated networks can have some advantages,  McGeeney says, by facilitating referrals and lab results and sharing costly information technology. But there’s also a broader marketshare goal that can exert pressure not just on employed physicians, but also affiliated physicians to some extent, he says. “These networks are very often created to, for lack of a better term, put more butts in the beds, and to prevent leakage out of the system.”

When making these sorts of in-house referrals, the doctor should be open that he or she is referring within the same system that employs them, says Michael Gusmano, PhD, a research scholar specializing in health policy at The Hastings Center, a nonprofit bioethics institute in Garrison, New York. “I absolutely think that there ought to be full disclosure of those kinds of financial relationships,” he says.

“I think in many instances it can be presented in fairly positive terms, and it often is,” Gusmano adds. The doctor can explain the teamwork approach of an integrated system, with its focus on improving quality and care coordination, among other measures, he says.

Lara Otaigbe, MD, who was an employed family medicine physician in Hattiesburg, Mississippi until recently, said she “tried to support her colleagues on this side of town,” as she describes it. “We’ve had a wonderful working relationship for a long time.”

But there were times when it made sense for a patient to be treated through the community’s other hospital if there was a particular specialty needed, or if the patient had a prior relationship with a doctor there.

“I really have not been to my knowledge been dinged for doing that,” she says. “I have a big respect for pre-existing relationships,” she says.

Next: Dilemma No. 3

Do physicians have an ethical responsibility to treat Medicaid and ACA patients?

taigbe, who launched a solo practice in Hattiesburg, is committed to taking all patients, regardless of their type of insurance. “I feel like we are all a brain injury or an accident away from Medicaid,” she says.

She also describes herself as one of relatively few local doctors that accepts patients insured through the ACA health exchanges. In January, she met with a newly-insured patient, a 41-year-old woman with an orange-sized lump in her breast. “She claimed that it just came up,” Otaigbe recalls. “You feel a mass like that and you think, 'This is not good.’”

The woman’s mammogram came back positive. Eventually Otaigbe, who couldn’t find a surgeon nearby who was accepting ACA patients, referred the woman to one in Jackson, 90 minutes away.

Even prior to this year, just 45.7% of doctors accepted new Medicaid patients, according to a 2013 survey conducted by healthcare recruiter Merritt Hawkins. Medicaid reimbursement varies from state to state and every doctor must figure out what works for them financially, based on their practice and overhead, Carlyle says. “I don’t begrudge somebody who says, `I can see 30% on Medicaid, but I can’t see 40%, because it doesn’t work out for me to keep the doors open,’” he says.

Otaigbe plans to subsidize her altruism with a medical cosmetics practice that she’s acquired. It will include botox injections, skin tightening and other procedures for which patients pay out of pocket. Still, she acknowledges that her “all comers” business strategy might be a bit risky. “Maybe you should interview me again in three years after I’ve been out on my own, and I’m 90%  Medicaid,” she says, with a short laugh.

For doctors, the treatment of patients on the ACA health exchanges also carries some risk, as those plans with the cheapest premiums also tend to carry high deductibles, says Gusmano, with the Hastings Center. “I can imagine some [physician] practices being concerned about that because people might not have the cash,” he says.

In the end, Tunzi argues,  doctors “need to find it in ourselves to do a smidgen more,” to meet the increasing demand. A doctor might accept a few newly insured Medicaid patients, or keep treating several patients whose coverage has shifted to one of the ACA health exchanges, he says. Perhaps they might implement some additional efficiency measures, such as adding group visits, to accommodate those additional patients, he says.

“I think if physicians are not seeing and doing their part in solving this problem, that if I were John Q. Public, I would look around and say, `What’s wrong with these guys?’ They make a pretty good living. Why aren’t they participating in solving this problem?’”

Next: Dilemma No. 4

Should doctors give patients what they want?

While malpractice concerns led the list of reasons that doctors reported ordering unnecessary tests or procedures, there also was evidence that the patient could be persuasive, according to the findings of the ABIM Foundation survey. Among the related explanations: patients insisting on a test (28%); wanting to keep patients happy (23%) and feeling patients should make the final decision (13%).

Sometimes these patient pressures can be headed off by taking a few minutes to delve into their underlying concerns, says David Shute, MD, an internist in Portland and a consultant to the “Choosing Wisely” campaign. “Asking a patient why a test or procedure is important is a very powerful and helpful step,” he says.

In the process, the doctor gains some insight into the patient’s mindset, and hopefully by the sheer act of listening, eases anxiety, he says. Then the physician can briefly lay out the medical evidence, and explain why the test or medication is not needed at that point. Shute says his patients tend to respond when he outlines the risk of false positives, and how they can lead to additional tests and procedures.

But Shute also acknowledges that he has acceded to persistent patients. One common scenario is when a patient suffers from a sinus infection and has imminent travel plans, or a big event to attend, such as a wedding. “Even though it’s not evidence-based care necessarily, they want to do everything they can to be able to participate and be present,” he says. “It’s not good medicine to treat emotional issues or anxieties with tests or procedures. But that is a reason we do it.”

Time and money also may play a role, according to the survey’s findings, albeit to a lesser extent. Insufficient time with patients was listed as a major reason by 13%; 5% referenced the fee-for-service system. To some extent, time and money are interrelated, even for primary care doctors, McGeeney points out.

“If the physician is paid on RVUs by volume, the more patients they see, the more they make,” he says. “A lot of times physicians don’t want to break stride as it were, or take their hand off the door knob. They are going to be more productive if they just order the test.”