Addressing conflicts of interest that matter

Mention conflict of interest in medicine and the knee jerk response is likely to be a diatribe about drug company gifts to doctors. This selective outrage is misdirected. Drug company gifts, though ubiquitous, are modest these days, and any potential conflicts of interest they create for doctors are trivial in comparison to other conflicts in day to day professional life, especially compensation incentives.

Physician compensation plans in the U.S. are varied and complex but almost all, with perhaps the notable exception of the V.A.’s, contain financial incentives that can influence practice patterns and clinical decisions. This NEJM Career Center article on compensation plans notes (italics mine) “’Compensation plans in the 1990s were very complicated, and included such things as participation in the group and patient satisfaction, which involved very complex formulas. Today, they [models] are moving back to a focus on productivity, efficiency, and the amount of dollars a physician brings in’”. Though these positive cost incentives are the norm today the negative incentives of capitation common in the managed care era still prevail in some regions according to the NEJM report. Both types of incentive can influence clinical practice away form what’s best for patients and away from the dictates of evidence based medicine.

The effects of compensation in clinical practice are more pervasive than those of drug company gifts because they go beyond drug prescribing. Pressure to see more patients in less time as well as incentives to overuse ancillaries and do more procedures all have potential to harm patients.

What is the evidence that compensation incentives influence doctors? Jason Shafrin, the blogger at Healthcare Economist, discusses his recent paper on physician compensation here (h/t to Kevin). The post contains a link to the actual draft of the paper, which reviews previous research linking compensation plans to physician behavior and presents new data showing that switching from capitation to fee-for-service compensation increases surgery rates by 155%! Now that represents a lot of surgery. Think of all the pens and lunches that could be funded by those extra fees!

What’s a doctor to do? There’s no pat answer in the real world. We’re not all alike, and not equally susceptible to perverse incentives. Most of us would strive to adhere to first principles. Patients come first. But there are some who take a more radical position. The folks at No Free Lunch apparently believe that the only way to deal with conflicts of interest is to avoid them altogether. By selectively addressing drug company gifts they are focusing on the easiest conflict to avoid. It costs virtually nothing. But any consistent application of the avoidance principle must also take into account the conflicts inherent in compensation incentives. Avoidance of such conflicts is possible, but often at great personal sacrifice. Those doctors who sign the No Free Lunch pledge to avoid conflicts of interest should consider this cost and be willing to disclose their compensation incentives.