Medicine, Money and Morals: Physicians' Conflicts of Interest  by Marc A. Rodwin.  Oxford University Press, New York, 1993, $25.

Review by Del Meyer, MD

Marc A. Rodwin, JD, PhD, develops the problem of Physicians’ Conflicts Of Interests (COI), which he sees as being of epidemic proportion in medicine.  He gives us insight into the many areas in which it occurs.  He feels that COI in fee-for-service medicine are significant and intractable.  Coupled with insurance, they have spawned a great deal of overuse of medical services.  He quotes hospital kickbacks for each admission ($70 in one case, a $75,000 loan that could be paid off by patient referrals in another), from drug companies’ “research grants” and pharmaceutical gifts (average value of $727), from supply companies (one physician received nearly a quarter of a million dollars over a four-year period from two pacemaker manufacturers), and incentives provided by hospitals and other health care facilities.  He recognizes all these as subverting the commitment of the physician to the patient’s well being. 

Rodwin points out that COI is entering a novel and still more intractable stage.  Instead of fostering needless tests and services, now there are incentives such as salaries, capitation, and risk-sharing plans for physicians to decrease services.  The controlling influences are hospitals, government regulators and health maintenance organizations that want physicians to reduce the cost incurred in referrals, diagnostic tests and therapies. 

Whereas in the past the hospital’s favorite doctors were the ones who ordered the most reimbursable tests, under Medicare’s prospective payment reimbursement program, hospitals have a critical stake in doctors’ treating patients quickly and efficiently, thereby maximizing turnover and reducing length of stay. They are hiring and promoting physicians who meet this standard.  HMOs are profitable to the extent that employee-physicians see many patients and keep down treatment bills, and many use incentive payments to shape physicians’ behavior.  Indeed, since the federal government seems likely to rely upon HMO-type organizations in its projected national health care program, the pattern of rewarding doctors for not treating are likely to become more entrenched.  Managed care means that both the patient and the doctor are managed. 

Rodwin also focuses on some other conflicts involving physicians.  He singles out payments made by hospitals to doctors to purchase physicians’ medical practices (an actual Sacramento practice) and payments made by hospitals to doctors to recruit and bond physicians (also an actual Sacramento practice).  He feels when physicians receive payments from hospitals it increases their loyalty to the hospital, creates dependence, and may compromise loyalty to patients.  Institutional providers draw on these to promote their own financial interests.  For patients who depend on physicians to act in their interests, these practices corrode the bond with their doctors. 

It appears that the abuse of kickbacks, bogus research grants and disappearing loans is much greater than many of us would have suspected.  My only brush with this type of conflict occurred in a small restaurant near ARH, when an oxygen company offered me $50,000 per year to refer at least 85 percent of my oxygen patients to them.  I of course refused, just as I did not allow the pharmacist in my office building to put a direct telephone line in so I would call all prescriptions to him.  I’ve always felt it was unethical behavior and assumed it was against our professional code of ethics.  Rodwin would correct the abuse with health-care policy and law.  He favors more regulations.  He proposes auditing czars reviewing hospital financial records and COI review boards.  I would hope that our code of ethics would always be stricter than the law so that the law would not have to be used.  Unfortunately, too many physicians now follow the law rather than lead. 

Rodwin is a good resource, albeit somewhat difficult, circuitous and redundant at times.  Although I expected an indictment of physicians, it seems that Dr. Rodwin is most critical of the hospitals, HMOs, and government regulators, and, except in the obvious conflicts, almost vindicates most of us.  It might have been titled, “Health Care Conflicts of Interest,” to include not only doctors, but hospitals and insurance carriers.  It probably reflects the pervasive public notion that anything wrong with health care is the doctor’s fault.  The public considers us the most powerful, influential and controlling force in medicine.  We’d best accept that responsibility and act in our patients’ best interest, or we will be judged not only for what we didbut also for what we did not do.