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Ethics case study

Are health plan incentives hurting generalist-specialist relationships?

From the June 2001 ACP-ASIM Observer, copyright © 2001 by the American College of Physicians-American Society of Internal Medicine.

This is the 27th in a series of case studies with commentaries by ACP–ASIM’s Ethics and Human Rights Committee and Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College’s “Ethics Manual” or other position statements.

Case history

Judy Judkins, MD, an invasive cardiologist, has been in private practice for 20 years. She belongs to a busy group of five cardiologists in Pottertown, an industrial city.

The city’s largest manufacturer, UniCorp, which employs 20% of Pottertown’s work force, recently switched health insurance plans to reduce its health care costs. It now uses CareUSA, a capitated plan.

CareUSA tries to contain costs by making its physicians financially responsible for minimizing unnecessary referrals, tests and treatments. The HMO with­holds 15% of primary care physicians’ pay and returns it only if physicians meet expenditure targets for tests, treatments and referrals. Like most physicians in the area, Dr. Judkins’ group signs on with CareUSA because the plan has such a large patient base.

A 58-year-old UniCorp employee, Guy Montag, presents with chest pain and anterior ST-segment elevations at Good Samaritan Hospital. He is treated with aspirin and TPA and admitted to the coronary care unit under Dr. Judkins’ care.

CareUSA certifies the admission and tells Dr. Judkins that Mr. Montag’s primary care internist, Dr. Kenobe, will contact her. Dr. Kenobe visits later that day and informs Dr. Judkins that he will assume care as the attending of record, but that Dr. Judkins can consult.

Dr. Judkins is a bit annoyed, as she is accustomed to being the attending of record for patients she cares for in the coronary unit. She has not worked with Dr. Kenobe before, however, so she doesn’t voice her frustrations.

Mr. Montag’s post-MI course is relatively uncomplicated, and he is discharged on atenolol and aspirin after a negative low-level stress test. As part of the patient’s post-discharge plans, Dr. Judkins plans to retest his lipids to assess the need for cholesterol-lowering agents. She also plans to perform a symptom-limited full stress test in two weeks to assess Mr. Montag’s preparedness for a phase II cardiac rehabilitation program.

Dr. Judkins writes an order for an appointment to perform the follow-up stress test in her office and to supervise the phase II rehabilitation program. Later that morning, however, she receives a call from Dr. Kenobe. He thanks her for her concern but says that he will perform the stress test in his office. He also explains that he will supervise the rehabilitation program and will contact Dr. Judkins if any problems arise.

Dr. Judkins begins to wonder whether the managed care environment and CareUSA’s financial incentives are having an adverse impact on Mr. Montag’s care, as well as on her relationships with primary care physicians in general. She wonders whether what she sees happening is ethical.

Commentary

Physicians’ primary ethical responsibility is to decide on the proper care for their individual patients. However, this care does not take place in a vacuum. (1) Beyond face-to-face encounters with individual patients, physicians also have moral responsibilities toward other patients, ethical duties to insurers and responsibilities to society as a whole.

Medicine today is no longer an individual enterprise. Generalists and specialists must cooperate now more than ever to optimize patient care. Ethical and contractual obligations to the HMO add another layer of moral responsibility and may complicate relationships between specialists and generalists. Dr. Judkins’ interaction with Dr. Kenobe highlights many of these issues.

Competence and ethical obligations. Physicians have an ethical duty not only to provide the care for which they have been trained, but also to avoid offering care that they have not been adequately trained to administer. The Hippocratic oath states that one should “forswear the use of the knife in deference to those who are skilled in its use.” Many ethicists interpret this as a pledge that physicians should not exceed their competence.

If Dr. Kenobe can competently supervise exercise tolerance testing and cardiac rehabilitation, there is nothing wrong with his providing that care. An ethical problem exists only if he exceeds the boundaries of his competence to increase his income under CareUSA’s capitation system.

Some ethicists worry that managed care is forcing generalists to act as marginal specialists and specialists to behave like marginal generalists. (2) Some general internists complain that they are being asked to stretch the care they deliver beyond their competency. (3) Dr. Judkins’ moral disquiet about Dr. Kenobe’s decision to provide all Mr. Montag’s post-MI care reflects her concerns that he is acting as a “marginal specialist.”

A controversial body of literature has suggested that patients who receive post-MI care from a cardiologist receive “more appropriate” care than those cared for by generalists. (4-7) Critics, however, have argued that differences in outcomes are sometimes due to the treating physician’s caseload and experience, factors that can operate independently of the physician’s specialty. (8) Others have suggested that the most appropriate care takes place in settings where generalists and specialists collaborate closely. (9,10)

It is often said that generalists tend to underutilize treatments and procedures and specialists tend to overutilize them. (5) The practices of individual specialists and generalists vary widely, however, and physicians should avoid stereotyping. What matters most is the competence of the care rendered, not the type of physician who provides the care.

The critical ethical point is that the patient’s care, whether provided by a generalist or a specialist or both, should be medically appropriate. Mr. Montag received appropriate therapy and the plans for his future care were appropriate.

Generalist-specialist communication. While communication between generalists and specialists is an area of concern in all practice environments, the managed care setting (with the possible exception of the staff model HMO) poses unique barriers to effective communication between generalists and specialists. (11)

Because health plans’ physician panels change frequently, generalists often find it difficult to maintain close working relationships with specialists. (12) Drs. Judkins and Kenobe, for instance, have never worked together before and don’t know each other’s style of practice.

As generalists are forced to refer patients to specialists they do not know, they often find it difficult to call for advice that might forestall a referral. Generalists also find it difficult to interpret advice from specialists who are strangers to them.

Collaboration between generalists and specialists improves when physicians understand each other’s style. (“That Judy Judkins is conservative. She caths only when it’s absolutely necessary.”) Dr. Judkins, for instance, might be less worried if she knew that Dr. Kenobe is highly skilled at supervising exercise tolerance testing and that he would seek appropriate assistance if anything were to go awry.

One solution might be to institute a policy that encourages physicians to talk to each other by telephone each time a consultation is requested. Such a policy would facilitate personal contact.

Patient-physician communication. Physicians have a duty to communicate not only with other physicians, but also with patients. (1) Because respect for patient autonomy demands that patients be involved in decision-making, Dr. Kenobe should discuss options with Mr. Montag.

Another major issue is whether Dr. Kenobe should disclose CareUSA’s financial incentives designed to discourage him from referring patients to specialty physicians. While some managed care plans may explicitly or subtly disapprove of such disclosures, many physicians believe they have an ethical duty to disclose financial incentives. (13)

Generalists may want to use “curbside consults” to informally bring specialists into the patient’s care, but such consults should be avoided. Because taking a history requires direct interaction, there may be cases in which specialists can render proper advice only by talking directly to the patient.

Perhaps all cases do not require patients to see a specialist in person. A phone call from the specialist to the patient might suffice in some instances. In this case, for instance, Dr. Judkins might simply ask Dr. Kenobe for an opportunity to speak to Mr. Montag directly over the phone.

Cost-containment. Both Drs. Judkins and Kenobe have a duty to patients and to society to avoid unnecessary and expensive tests and treatments. They might, for instance, consider whether exercise testing is necessary before proceeding with cardiac rehabilitation. (14)

Physicians have a duty to be good stewards of society’s health care resources, but they also must be sure that cost-containment measures do not adversely affect patient care. (1) While Mr. Montag does not appear to have been adversely affected by Dr. Kenobe’s decision not to refer to a cardiologist, there were evident tensions between Dr. Kenobe and Dr. Judkins that could lead to adverse effects in the future.

Both physicians should make special efforts to communicate with each other effectively in the future. They should also commit to working toward health care reform that not only controls health care costs but also facilitates generalist-specialist communication and optimizes patient care.

Acknowledgment:The Ethics and Human Rights Committee would like to thank Daniel P. Sulmasy, ACP–ASIM Member, author of the case history and commentary.

References

1. American College of Physicians-American Society of Internal Medicine Ethics Manual 4th ed. Ann Intern Med. 1998;128:576-94.

2. Pellegrino ED. Managed care at the bedside: how do we look in the moral mirror? Kennedy Institute of Ethics Journal. 1997;7:321-30.

3. St Peter RF, Reed MC, Kemper P, Blumenthal D. Changes in the scope of care provided by primary care physicians. N Engl J Med. 1999;341:1980-5.

4. Ayanian JZ, Hauptman P, Guadagnoli E, et al. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994; 331:1136-42.

5. Donohoe MT. Comparing generalist and specialty care: discrepancies, deficiencies, and excesses. Arch Intern Med. 1998;158:1596-1608.

6. Ayanian JZ, Guadagnoli E, McNeil BJ, Cleary PD. Treatment and outcomes of acute myo­cardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med. 1997; 157:2570-6.

7. Casale PN, Jones JL, Wolf FE, Pei Y, Eby LM. Patients treated by cardiologists have lower in-hospital mortality for acute myocardial infarction. J Am Coll Cardiol. 1998;32:885-9.

8. Nash IS, Corrato RR, Dlutowski MJ, Nash DB. Generalist versus specialist care for acute myo­cardial infarction. Am J Cardiol. 1999;83:650-4.

9. Wilson DJ, Soumerai SB, McLaughlin TJ, Gurwitz JH, et al. Consultation between cardiologists and generalists in the management of acute myocardial infarction: implications for quality of care. Arch Intern Med. 1998;158:1778-83.

10. Ayanian JZ. Generalists and specialists caring for patients with heart disease: United we stand, divided we fall. Am J Med. 2000;108:259-61.

11. Roulidis ZC, Schulman KA. Physician communication in managed care organizations: opinions of primary care physicians. J Fam Pract. 1994;39:446-51.

12. Flock SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract. 1997;45:129-35.

13. Sulmasy DP, Bloch MG, Mitchell JM, Hadley J. Physicians’ ethical beliefs about cost-control arrangements. Arch Intern Med. 2000; 160:649-57.

14. McConnell TR, Klinger TA, Gardner JK, Laubach CA, Herman CE, Hauck CA. Cardiac rehabilitation without exercise tests for post-myocardial infarction and post-bypass surgery patients. J Cardiopulm Rehab. 1998;18:458-63.

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