Patients usually make decisions about their health based on the advice of medical professionals. This is especially true in significant, high acuity cases – where there is both a lack of information and greater imbalance between the knowledge and skill levels of patient and physician.
For medical practitioners, the call to act in a patient’s best interests dates back to the Hippocratic oath. But what happens when this conflicts with other types of fiduciary responsibility?
This question has been brought to a head with the advent of healthcare payment structures designed to mitigate rising cost concerns, such as Managed Care Organizations (MCOs) and Accountable Care Organizations (ACOs). As participants in these structures, physicians are empowered to act as fiduciaries for risk-bearing institutions, such as employers, health plans and health systems.
Herein lies a potential conflict of interest. Perhaps a doctor must choose between optimal treatment for an individual patient and compliance with cost-containment pathways and protocols. One example could be that a patient needs an MRI scan, but the cheapest one is two hours away.
Medical professionals are increasingly savvy about financial realities, but at what point does this threaten their ability to put patients first? To examine the potential economic magnitude of this conflict, Accenture divided total U.S. healthcare spend into three qualitative levels, depending on the impact of the physician’s fiduciary duty.
The first level involves trivial costs. This encompasses most low-acuity and/or low-spend items such as health and wellness services (for example, gym membership or dietary programs), dietary supplements, cold and allergy medication, and optometry. This category accounts for just 3 percent of total U.S. healthcare spend.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
The middle level involves material, but not significant costs. Examples might include primary care, dental services, pediatric visits, ophthalmology and antibiotics. These types of products and services account for about one-third of total healthcare spend in the U.S.
The highest level entails the most significant cost — examples include cancer treatment, specialty medication, and most rare diseases. These are complex, high-stakes services and products that typically need to be tailored to each patient and account for nearly two-thirds of total healthcare spend.
It is within this highest level that the question of balancing fiduciary responsibility with patient care is especially acute. It is also likely that we will see the accountability dilemma continue to sharpen with the rising cost of new treatments (which impacts a fiduciary duty to risk-bearing institutions) and increasing asymmetry of information (which impacts a fiduciary duty to patients).
As health systems develop and become more complex, it is inevitable that these kinds of accountability dilemmas will arise. Nevertheless, how can a doctor honor their Hippocratic oath of putting the patient first, while at the same time adhering to cost management requirements inherent with the advent of MCOs and ACOs?
Greater direction is clearly needed from a health organization level in order to mitigate the practical implications of this potential conflict. As we see it, there are three ways this can be done most effectively.
First, new governance models are needed that allow for a medical professional to navigate their dual conflicting fiduciary duties. This tension needs to be explicitly understood and incorporated because it cannot be eliminated. “Either-or” models will ultimately fail to meet any parties’ interests.
Second, prices need to be made transparent to patients. Ensuring patients have a full understanding of the price of services involved in every option will reassure and empower them. Costs are a function of the price and use of services, and clinical judgment goes into the use of these services. The price of services can and should be provided to patients in the interest of minimizing perceived conflict.
The third piece is full disclosure. Full disclosure of compensation arrangements is a necessary part of a patient-first framework. This is no different than expectations already placed on providers and individual physicians with respect to drug or device promotion. Complex payment models increase the risk of fiduciary tension compared to a basic fee-for-service payment model and place a higher burden on disclosure.
The asymmetry of information between provider and patient has always demanded the highest level of responsibility from individual practitioners, as well as broader health organizations. Historically the industry has maintained strong levels of trust, but the changes to the health system described here have added significant competing pressures that could quickly degrade that.
We believe it is in the hands of the medical community to provide the leadership required to develop the necessary new governance models, transparent pricing and compensation disclosure that will help avoid not only dangerous conflicts of interest but also a complete breakdown of trust between caregivers and their patients.
Finney Gilbert is a senior manager with Accenture
Photo: Ieremy, Getty Images
