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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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42. Referrals & Fee-Splitting
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It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.
~ Florence Nightingale
Referral Ruse
The Consequences of Fee-Splitting and Improper Referrals in Medical Practice
Dr. Jane Smith had always prided herself on her patient-centered approach to medicine. She believed that her primary responsibility was to act in the best interests of her patients, and she had built a successful practice on this philosophy. So when a colleague approached her with a proposition to split fees for referrals to his specialty practice, she was taken aback.
Dr. Smith knew that fee-splitting was illegal, and that it violated the ethical principles of beneficence and nonmaleficence. But her colleague was persuasive, and he argued that it was a common practice in the industry. He promised that it would be mutually beneficial, and that they would both profit from the arrangement.
Despite her misgivings, Dr. Smith eventually agreed to the scheme. She started referring her patients to her colleague’s practice, and she received a percentage of the fees that he charged for his services. At first, everything seemed to be going smoothly. Her colleague’s practice was successful, and she was making a substantial amount of money from the arrangement.
But then, one of her patients died unexpectedly while undergoing a procedure at her colleague’s practice. The patient’s family was devastated, and they filed a lawsuit against both Dr. Smith and her colleague, accusing them of negligence and malpractice.
The investigation that followed revealed that the patient had been referred to the specialty practice without sufficient evidence-based reasoning or medical standards of care rationale. The patient’s medical records had not been transferred in compliance with HIPAA laws, and the contractual patient’s health care relationships had not been considered. It was also discovered that Dr. Smith and her colleague had engaged in fee-splitting, a clear violation of the Stark law.
Dr. Smith was horrified by the consequences of her actions. She had thought that she was helping her patients by referring them to a reputable specialist, but instead, she had put them at risk. She had violated her professional and ethical responsibilities, and she had damaged her reputation and her career.
The case was a wake-up call for Dr. Smith, and she vowed to never again compromise her principles for financial gain. She took responsibility for her actions, cooperated fully with the investigation, and worked to make amends with the patient’s family. She also took steps to educate herself and her colleagues on the importance of proper referrals and the dangers of fee-splitting.
In the end, Dr. Smith learned a valuable lesson about the true meaning of patient-centered care. She realized that her patients’ health and well-being should always come first, and that any action that compromised this principle was not only illegal and unethical, but also potentially deadly. She made a commitment to always act in the best interests of her patients, and to never again let greed or self-interest cloud her judgment.
Abstract
Conflicts of interest in medical practice affects patients, practitioners, and public policy. The medical practitioner’s main priority is to act in the best interest of the patient, as determined by the patient’s reasonable goals, values, and priorities. The practitioner is expected to refer the patient to other healthcare services with evidence-based reasoning and to comply with HIPAA laws. Conflicts of interest, such as self-referral and fee-splitting, are incompatible with patient autonomy and violate the principles of beneficence and nonmaleficence for the practitioner. Public policy also plays a role in ensuring justice by protecting individual rights, implementing fair procedures, and distributing social goods equitably. Federal law prohibits self-referral under the Stark law, and it is considered a violation of the principle of justice.
**
Think
[42:1] The medical practitioner’s prime directive is to maximize the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities. This will frequently mean that the practitioner will need to refer the patient to another for health care services such as diagnostic laboratory services, or to a specialist for a particular diagnosis or treatment.
[42:2] It is imperative when referring, that the:
- 1. patient understands the objective evidence-based reasons and the medical standards of care rationale for the referral,
- 2. referrals expertise are only to professionals who have the specific knowledge, skills, and medical licensing for which the patient is being referred,
- 3. medical record information necessary for the referral is transferred in keeping with HIPAA confidentiality and privacy laws,
- 4. contractual patient’s health care relationships are considered,
- 5. patient-practitioner relationship is not dependent upon accepting the recommended referral, and
- 6. Conflict of interest, such as self-referral and fee-splitting violations, are not committed.
[42:3] Conflict of interest: decisions or actions that have the potential or appearance of influencing the practitioner’s clinical judgment.
[42:4] Self-referral: referring a patient to any facility, practice, equipment, or products in which the practitioner has an economic interest in. Federal Stark law prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest.
[42:5] Fee-splitting: occurs when a fee or commission is paid to a practitioner or by a practitioner for a referral with the express intention of ensuring referrals to the payee. Fee-splitting is also known as getting-a-cut or kickback and is regulated by state and federal law.
[42:6] Online group marketing websites like Groupon and online Telemedicine fee-for-service often use fee-splitting online technology for marketing and paying for services. Online financial structures have started to break down the universal moral analysis that all fee-splitting activities are unprofessional and unethical.
Assess
Patient: 1) Autonomy
[42:7] Autonomy, or self-rule, depends on the shared decision-making process between the patient and the medical practitioner, where the practitioner is trusted to provide accurate, evidence-based information and unbiased clinical judgments. This patient-practitioner relationship requires that the practitioner disclose all conflict of interest that may impact the practitioner’s clinical judgments. Without such conflict of interest avoidances and disclosures, the practitioner runs the risk of diminishing the patient’s trust in the practitioner’s clinical information and clinical judgments, along with the actual diminishing of the practitioner’s unbiased clinical judgments necessary for a patient’s informed consent.
[42:8] If patient autonomy can only exist within a patient-practitioner relationship, and if the patient cannot trust the practitioner because of conflict of interest, then it logically follows that the patient cannot be autonomous under those conditions. Conflict of interest are therefore incompatible with patient autonomy. Since medical decision-making such as referrals are to be autonomously chosen by the patient, and since self-referral and fee-splitting are types of conflict of interest, it follows that self-referral and fee-splitting are incompatible with autonomous medical decision-making.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[42:9] The medical practitioner’s prime directive is the professional maxim of maximizing the patient’s best interests, as determined by the patient’s reasonable goals, values, and priorities. This prime directive is accomplished using the two professional principles of beneficence (do good) and nonmaleficence (do no harm).
[42:10] Therefore, it is professionally necessary for the practitioner to avoid and disclose any conflict of interest that by definition increases the risk of compromising the practitioner’s ability to provide accurate, evidence-based information and unbiased clinical judgments, increasing the patient’s risk of harm, a violation of nonmaleficence (do no harm).
[42:11] The medical practitioner has a professional obligation to avoid any real and apparent conflict of interest based on the principle of beneficence (do good). Since self-referral and fee-splitting are types of conflict of interest, it follows that they also violate the principle of beneficence (do good) and nonmaleficence (do no harm).
[42:12] Professionally, the patient-practitioner relationship is to be patient-centered, not practitioner-centered. Mixing self-centered capitalistic motivation with altruistic patient-centered care is logically incompatible. Self-referring and fee-splitting are defined as incompatible with patient-centered health care and, therefore, a conflict of interest.
Public Policy: 4) Justice
[42:13] Justice (be fair) is instantiated through the process of legislation of public policy for:
- 1. protecting individual rights and liberties,
- 2. implementing fair procedures for equal opportunities, and
- 3. distributing social goods equitably throughout society.
[42:14] In parallel with the public policy purposes, conflict of interest are incompatible with the patient’s rights and liberties for:
- 1. unbiased information and judgments from the practitioner,
- 2. equal opportunity for a patient-practitioner relationship, and
- 3. living in an equitable society.
[42:15] Stark law is a federal law that prohibit practitioner self-referral, with any entity that the practitioner or family members have a financial interest in for “designated health services” payable by Medicare or Medicaid. It is recognized by patients, the medical profession, and by public policy that conflict of interest associated with practitioner self-referrals and fee-splitting are incompatible with justice (be fair).
[42:16] Telemedicine fee-for-service and the use of fee-splitting online technology for marketing and paying for services has started to challenge some aspects of these professional economic boundaries. Revisions and reconsiderations will need to be made as to what will be economically accepted in light of new online technologies that use a different model for marketing, providing services, and pay compared to traditional medical practice.
Conclude
Medical Boards
[42:17] Public policy, the medical professions, and moral analysis all argue for the importance of the practitioner to have honest and transparent discussions with patients about any activity that could be perceived as a patient-practitioner conflict of interest and the importance of taking steps to mitigate such occurrences. Self-referrals and fee-splitting are illegal, and internet group marketing practices have the potential to distract medicine from its patient-centered, patient-practitioner relationship, whose prime directive is to maximize the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities.
[42:17] In summary, it is essential for medical practitioners to maintain honest and transparent communication with their patients regarding any potential conflicts of interest, such as self-referral and fee-splitting. These practices are not only incompatible with patient-centered care but also violate legal and ethical principles. As online technologies and telemedicine continue to evolve, it is imperative for public policy and medical professions to adapt and address these new challenges to ensure that the prime directive of maximizing patients’ best interests remains at the forefront of medical practice.
**
42. Review Questions
1. It is imperative when referring, that the:
2. Conflict of interest: decisions or actions that have the potential or appearance of influencing the practitioner’s clinical judgment.
3. Self-referral: referring a patient to any facility, practice, equipment, or products that the practitioner has an economic interest in.
4. Federal Stark law: prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest.
5. Fee-splitting: when a fee or commission is paid to a practitioner or by a practitioner for a referral with the express intention of ensuring referrals to the payee.
6. If patient autonomy can only exist within a patient-practitioner relationship, and if the patient cannot trust the practitioner because of conflict of interest, then it logically follows that the patient cannot be autonomous under those conditions.
7. Mixing self-centered capitalistic motivation with altruistic patient-centered care is the professional ideal of patient care.
8. Justice (be fair) is instantiated through the process of legislation of public policy for:
9. New online technologies, like telemedicine, use a different model for marketing, providing services, and pay as compared to traditional medical practice.
**
Wrong 😕
[42:2] It is imperative when referring, that the:
1. patient understands the objective evidence-based reasons and the medical standards of care rationale for the referral,
2. referrals expertise are only to professionals who have the specific knowledge, skills, and medical licensing for which the patient is being referred,
3. medical record information necessary for the referral is transferred in keeping with HIPAA confidentiality and privacy laws,
4. contractual patient’s health care relationships are considered,
5. patient-practitioner relationship is not dependent upon accepting the recommended referral, and
6. Conflict of interest, such as self-referral and fee-splitting violations, are not committed.
CORRECT! 🙂
[42:2] It is imperative when referring, that the:
1. patient understands the objective evidence-based reasons and the medical standards of care rationale for the referral,
2. referrals expertise are only to professionals who have the specific knowledge, skills, and medical licensing for which the patient is being referred,
3. medical record information necessary for the referral is transferred in keeping with HIPAA confidentiality and privacy laws,
4. contractual patient’s health care relationships are considered,
5. patient-practitioner relationship is not dependent upon accepting the recommended referral, and
6. Conflict of interest, such as self-referral and fee-splitting violations, are not committed.
CORRECT! 🙂
[42:3] Conflict of interest: decisions or actions that have the potential or appearance of influencing the practitioner’s clinical judgment.
Wrong 😕
[42:3] Conflict of interest: decisions or actions that have the potential or appearance of influencing the practitioner’s clinical judgment.
CORRECT! 🙂
[42:4] Self-referral: referring a patient to any facility, practice, equipment, or products that the practitioner has an economic interest in. Federal Stark law prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest.
Wrong 😕
[42:4] Self-referral: referring a patient to any facility, practice, equipment, or products that the practitioner has an economic interest in. Federal Stark law prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest.
CORRECT! 🙂
[42:4] Self-referral: referring a patient to any facility, practice, equipment, or products that the practitioner has an economic interest in. Federal Stark law prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest.
Wrong 😕
[42:4] Self-referral: referring a patient to any facility, practice, equipment, or products that the practitioner has an economic interest in. Federal Stark law prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest.
CORRECT! 🙂
[42:5] Fee-splitting: when a fee or commission is paid to a practitioner or by a practitioner for a referral with the express intention of ensuring referrals to the payee. Fee-splitting is also known as getting a cut or kick back and is regulated by state and federal law.
Wrong 😕
[42:5] Fee-splitting: when a fee or commission is paid to a practitioner or by a practitioner for a referral with the express intention of ensuring referrals to the payee. Fee-splitting is also known as getting a cut or kick back and is regulated by state and federal law.
Wrong 😕
[42:8] If patient autonomy can only exist within a patient-practitioner relationship, and if the patient cannot trust the practitioner because of conflict of interest, then it logically follows that the patient cannot be autonomous under those conditions. Conflict of interest are therefore incompatible with patient autonomy. Since medical decision-making such as referrals are to be autonomously chosen by the patient, and since self-referral and fee-splitting are types of conflict of interest, it follows that self-referral and fee-splitting are incompatible with autonomous medical decision-making.
CORRECT! 🙂
[42:8] If patient autonomy can only exist within a patient-practitioner relationship, and if the patient cannot trust the practitioner because of conflict of interest, then it logically follows that the patient cannot be autonomous under those conditions. Conflict of interest are therefore incompatible with patient autonomy. Since medical decision-making such as referrals are to be autonomously chosen by the patient, and since self-referral and fee-splitting are types of conflict of interest, it follows that self-referral and fee-splitting are incompatible with autonomous medical decision-making.
Wrong 😕
[42:12] Professionally, the patient-practitioner relationship is to be patient-centered, not practitioner-centered. Mixing self-centered capitalistic motivation with altruistic patient-centered care is logically incompatible. Self-referring and fee-splitting are defined as incompatible with patient-centered health care and, therefore, a conflict of interest.
CORRECT! 🙂
[42:12] Professionally, the patient-practitioner relationship is to be patient-centered, not practitioner-centered. Mixing self-centered capitalistic motivation with altruistic patient-centered care is logically incompatible. Self-referring and fee-splitting are defined as incompatible with patient-centered health care and, therefore, a conflict of interest.
Wrong 😕
[42:13] Justice (be fair) is instantiated through the process of legislation of public policy for:
1. protecting individual rights and liberties,
2. implementing fair procedures for equal opportunities, and
3. distributing social goods equitably throughout society.
CORRECT! 🙂
[42:13] Justice (be fair) is instantiated through the process of legislation of public policy for:
1. protecting individual rights and liberties,
2. implementing fair procedures for equal opportunities, and
3. distributing social goods equitably throughout society.
Wrong 😕
[42:16] Telemedicine fee-for-service and the use of fee-splitting online technology for marketing and paying for services has started to challenge some aspects of these professional economic boundaries. Revisions and reconsiderations will need to be made as to what will be economically accepted in light of new online technologies that use a different model for marketing, providing services, and pay compared to traditional medical practice.
CORRECT! 🙂
[42:16] Telemedicine fee-for-service and the use of fee-splitting online technology for marketing and paying for services has started to challenge some aspects of these professional economic boundaries. Revisions and reconsiderations will need to be made as to what will be economically accepted in light of new online technologies that use a different model for marketing, providing services, and pay compared to traditional medical practice.
42. Clinical Vignettes
1. Ms. Jane Bailey is a 45-year-old accountant who presents to her primary care practitioner with chronic back pain. After a thorough physical examination, her practitioner refers her to a local physical therapy clinic for further evaluation and treatment. Upon completion of her therapy, Ms. Bailey is surprised to receive an invoice indicating that her practitioner's office will be splitting the fee for her treatment with the physical therapy clinic. Which of the following is the umbrella issue raised by the fee-splitting arrangement between Ms. Bailey's practitioner's office and the physical therapy clinic?
2. Ms. Olivia Garcia is a 45-year-old self-employed artist who presents to Dr. Blake Walton's clinic with shoulder pain. Dr. Walton, performs a physical examination and diagnoses Ms. Garcia with a rotator cuff tear. Dr. Walton then informs Ms. Garcia that he has a close friend who is a surgeon specializing in rotator cuff repairs, and that he can refer her to this surgeon. Dr. Walton mentions that he would like to follow up with Ms. Garcia after the surgery. Ms. Garcia agrees to the referral and later receives a bill for the surgery that shows that Dr. Walton has billed her insurance for a consultation on the day of the surgery. Is it ethical for Dr. Walton to self-refer Ms. Garcia to his friend, a surgeon specializing in rotator cuff repairs, and bill for a consultation on the day of the surgery?
3. Mr. Vance Peck is a 45-year-old software engineer who has been experiencing back pain for several weeks. He visits his primary care practitioner, Dr. Berry Spencer, who believes that he may need to see a specialist for further evaluation. Dr. Spencer can refer Mr. Peck to a specialist within his own medical group, where he has a financial interest, or to an independent specialist. What should Dr. Spencer do?
4. Mr. Christopher Rodriguez, a 45-year-old construction worker, presents to Dr. Davis with symptoms of persistent lower back pain. Dr. Kline Davis suspects that Mr. Rodriguez may have a spinal condition and recommends further testing, including an MRI. Dr. Davis provides Mr. Rodriguez with a list of imaging centers in the area that provide these tests and explains that he has no financial interest in any of these centers. Mr. Rodriguez selects an imaging center from the list and obtains the necessary tests. However, after the tests, Mr. Rodriguez receives a bill with a higher amount than expected, as the imaging center charged an additional fee to Dr. Davis for referring the patient to their center. The ethical question is, was Dr. Davis' referral ethical and professional?
5. Ms. Hillary Lopez, a 35-year-old restaurant worker, presents to Dr. Alexander Brown with symptoms of chronic lower back pain. Dr. Brown examines Ms. Lopez and recommends an MRI of the lower back to determine the cause of the pain. Dr. Brown informs Ms. Lopez that he owns a partial interest in an imaging center in the area that provides MRI services but recommends that Ms. Lopez obtain the MRI at a different facility without any financial interest. Dr. Brown explains that it is important to avoid any potential conflict of interest and to ensure that the referral is based solely on medical necessity. Ms. Lopez obtains the MRI at a different imaging center and returns to Dr. Brown for further treatment. Which of the following is the appropriate action for Dr. Brown to take when referring Ms. Lopez for an MRI?
CORRECT! 🙂
Explanation: Fee-splitting, or the division of fees between healthcare providers in exchange for referrals, is considered a conflict of interest [42:5]. Conflicts of interests are unethical because they end up violating the principles of beneficence and nonmaleficence, as it compromises the medical practitioner's ability to provide unbiased clinical judgments, potentially harming the patient [42:10]. Additionally, it is incompatible with patient autonomy, as it diminishes the patient's trust in the practitioner's clinical information and judgments [42:8]. Federal law prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest [42:4]. Fee-splitting is regulated by state and federal law and is considered incompatible with a just and equitable society [42:15].
Wrong 😕
Explanation: Fee-splitting, or the division of fees between healthcare providers in exchange for referrals, is considered a conflict of interest [42:5]. Conflicts of interests are unethical because they end up violating the principles of beneficence and nonmaleficence, as it compromises the medical practitioner's ability to provide unbiased clinical judgments, potentially harming the patient [42:10]. Additionally, it is incompatible with patient autonomy, as it diminishes the patient's trust in the practitioner's clinical information and judgments [42:8]. Federal law prohibits self-referral arrangements for Medicare or Medicaid patients to designated health services (DHS), such as a clinical laboratory where the practitioner has a financial interest [42:4]. Fee-splitting is regulated by state and federal law and is considered incompatible with a just and equitable society [42:15].
CORRECT! 🙂
Explanation: Self-referral violates the principles of beneficence and nonmaleficence as it has the potential to influence the practitioner's clinical judgment, leading to harm to the patient [42:3-4]. Additionally, self-referral is incompatible with patient autonomy as it compromises the patient's ability to make informed decisions about their healthcare [42:8]. Therefore, it is not ethical for Dr. Walton to self-refer Ms. Garcia to his friend, a surgeon specializing in rotator cuff repairs. The fact that Dr. Walton billed Ms. Garcia's insurance for a consultation on the day of the surgery further raises concerns about his intentions [42:4]. The other options are incorrect because disclosing the self-referral to Ms. Garcia does not make the arrangement ethical, the belief that Dr. Walton's friend is the best surgeon for Ms. Garcia is not sufficient justification for engaging in self-referral, just because some action may not be illegal that does not mean that that action is professional or ethical. Ms. Garcia may not me a Medicare or Medicaid patient and therefore not fall under the Feral Stark law which prohibits self-referrals, but it probably should be state law.
Wrong 😕
Explanation: Self-referral violates the principles of beneficence and nonmaleficence as it has the potential to influence the practitioner's clinical judgment, leading to harm to the patient [42:3-4]. Additionally, self-referral is incompatible with patient autonomy as it compromises the patient's ability to make informed decisions about their healthcare [42:8]. Therefore, it is not ethical for Dr. Walton to self-refer Ms. Garcia to his friend, a surgeon specializing in rotator cuff repairs. The fact that Dr. Walton billed Ms. Garcia's insurance for a consultation on the day of the surgery further raises concerns about his intentions [42:4]. The other options are incorrect because disclosing the self-referral to Ms. Garcia does not make the arrangement ethical, the belief that Dr. Walton's friend is the best surgeon for Ms. Garcia is not sufficient justification for engaging in self-referral, just because some action may not be illegal that does not mean that that action is professional or ethical. Ms. Garcia may not me a Medicare or Medicaid patient and therefore not fall under the Feral Stark law which prohibits self-referrals, but it probably should be state law.
Wrong 😕
Explanation: Dr. Spencer should refer Mr. Peck to an independent specialist to avoid any potential conflict of interest associated with self-referral and fee-splitting [42:4-5]. Self-referral, which involves referring a patient to any facility, practice, equipment, or products in which the practitioner has a financial interest, is prohibited under the Federal Stark law for any Medicare or Medicaid patients to any designated health services (DHS)[42:4]. Fee-splitting, which occurs when a fee or commission is paid to a practitioner or by a practitioner for a referral with the express intention of ensuring referrals to the payee, is regulated by state and federal law [42:5]. By referring Mr. Peck to an independent specialist, Dr. Spencer can uphold his professional obligations to act in Mr. Peck's best interests and avoid any potential harm resulting from a conflict of interest [42:9-10]. The options of referring to a specialist in his medical group would be a conflict of interest, discussing the referral option with Mr. Peck would be unethical because even if Mr Peck did choose the Dr. Spencer’s medical group, that choice may not be fully autonomous, and lastly, it would be medical negligence to not refer Mr. Peck to a specialist, that could result in harm, and medical malpractice.
CORRECT! 🙂
Explanation: Dr. Spencer should refer Mr. Peck to an independent specialist to avoid any potential conflict of interest associated with self-referral and fee-splitting [42:4-5]. Self-referral, which involves referring a patient to any facility, practice, equipment, or products in which the practitioner has a financial interest, is prohibited under the Federal Stark law for any Medicare or Medicaid patients to any designated health services (DHS)[42:4]. Fee-splitting, which occurs when a fee or commission is paid to a practitioner or by a practitioner for a referral with the express intention of ensuring referrals to the payee, is regulated by state and federal law [42:5]. By referring Mr. Peck to an independent specialist, Dr. Spencer can uphold his professional obligations to act in Mr. Peck's best interests and avoid any potential harm resulting from a conflict of interest [42:9-10]. The options of referring to a specialist in his medical group would be a conflict of interest, discussing the referral option with Mr. Peck would be unethical because even if Mr Peck did choose the Dr. Spencer’s medical group, that choice may not be fully autonomous, and lastly, it would be medical negligence to not refer Mr. Peck to a specialist, that could result in harm, and medical malpractice.
Wrong 😕
Explanation: The medical practitioner's prime directive is to maximize the patient's best interests as determined by the patient's reasonable goals, values, and priorities. This includes referring patients to other healthcare services with evidence-based reasoning and avoiding conflicts of interest such as fee-splitting [42:2, 42:4, 42:9]. Dr. Davis failed to disclose any financial interest in the imaging centers, which is considered a violation of the principle of transparency and patient trust. By accepting the fee from the imaging center, Dr. Davis violated the principles of beneficence and nonmaleficence, as this financial interest may have influenced his clinical judgment in the referral [42:10, 42:11]. The patient's autonomy may also be violated, as the patient was not fully informed of any potential conflicts of interest or financial incentives that may have influenced the referral decision [42:7, 42:8]. The other options do not address the ethical issue of fee-splitting and lack of transparency in the referral.
CORRECT! 🙂
Explanation: The medical practitioner's prime directive is to maximize the patient's best interests as determined by the patient's reasonable goals, values, and priorities. This includes referring patients to other healthcare services with evidence-based reasoning and avoiding conflicts of interest such as fee-splitting [42:2, 42:4, 42:9]. Dr. Davis failed to disclose any financial interest in the imaging centers, which is considered a violation of the principle of transparency and patient trust. By accepting the fee from the imaging center, Dr. Davis violated the principles of beneficence and nonmaleficence, as this financial interest may have influenced his clinical judgment in the referral [42:10, 42:11]. The patient's autonomy may also be violated, as the patient was not fully informed of any potential conflicts of interest or financial incentives that may have influenced the referral decision [42:7, 42:8]. The other options do not address the ethical issue of fee-splitting and lack of transparency in the referral.
Wrong 😕
Explanation: Dr. Brown's recommendation for Ms. Lopez to obtain the MRI at a different imaging center without financial interest is the appropriate action [42:2]. It is essential to avoid any potential conflict of interest and ensure that the referral is based solely on medical necessity [42:2]. Fee-splitting is considered unethical and is regulated by state and federal law [42:5]. Dr. Brown should not offer Ms. Lopez a discount to obtain the MRI at the imaging center in which he has partial ownership as this can still be seen as a form of self-referral [42:4]. Additionally, asking Ms. Lopez to obtain the MRI at the imaging center in which he has partial ownership and splitting the fee with her violates the principle of nonmaleficence and beneficence, as it could potentially influence Dr. Brown's clinical judgment [42:9][42:10][42:11]. Therefore, it is important for Dr. Brown to refer Ms. Lopez to a different imaging center without any financial interest to maintain ethical practice.
CORRECT! 🙂
Explanation: Dr. Brown's recommendation for Ms. Lopez to obtain the MRI at a different imaging center without financial interest is the appropriate action [42:2]. It is essential to avoid any potential conflict of interest and ensure that the referral is based solely on medical necessity [42:2]. Fee-splitting is considered unethical and is regulated by state and federal law [42:5]. Dr. Brown should not offer Ms. Lopez a discount to obtain the MRI at the imaging center in which he has partial ownership as this can still be seen as a form of self-referral [42:4]. Additionally, asking Ms. Lopez to obtain the MRI at the imaging center in which he has partial ownership and splitting the fee with her violates the principle of nonmaleficence and beneficence, as it could potentially influence Dr. Brown's clinical judgment [42:9][42:10][42:11]. Therefore, it is important for Dr. Brown to refer Ms. Lopez to a different imaging center without any financial interest to maintain ethical practice.
**
42. Reflection Vignettes
1. Dr. Jane Smith is a 52-year-old practitioner that has a lucrative business referring patients who need cataract removal or corrective eye surgery to a local surgeon, and in return, the surgeon provides the practitioner with a 10% cut of the surgical procedure. Conflicts of interest in medical practice can have negative effects on patients, practitioners, and public policy. The medical practitioner's primary responsibility is to act in the best interest of the patient, with the objective of maximizing the patient's best interests as determined by the patient's reasonable goals, values, and priorities. Referring patients to other healthcare services should be based on evidence-based reasoning, comply with HIPAA laws, and avoid conflicts of interest such as self-referral and fee-splitting, which are incompatible with patient autonomy and violate the principles of beneficence and nonmaleficence for the practitioner. Self-referral is prohibited by federal law under the Stark law for Medicare or Medicaid patients to designated health services (DHS). Fee-splitting, also known as getting-a-cut or kickback, is regulated by state and federal law. Mixing self-centered capitalistic motivation with altruistic patient-centered care is logically incompatible, as it goes against the professional obligation to ensure a patient-centered healthcare relationship.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Dr. Sarah Robertson, a 45-year-old family practitioner in a rural community, has recently invested in a local clinical laboratory to provide convenient and quick lab results for her patients. In addition to the benefits for her patients, Dr. Robertson sees this as an opportunity for some extra income for her practice. However, it's important to note that state and federal laws regulate the financial relationships between physicians and clinical laboratories. The federal Anti-Kickback Statute prohibits the exchange of anything of value in return for patient referrals, while the Stark Law prohibits physician self-referral to entities in which they have a financial interest for designated health services payable by Medicare or Medicaid. In addition, some states have their own laws that further restrict physician ownership of clinical laboratories, such as California's prohibition on physician self-referral to clinical laboratories in which they have an ownership interest. It's important for Dr. Robertson to comply with all relevant laws and regulations to ensure that her investment in the clinical laboratory does not create any conflicts of interest or legal issues.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
