Paid not to refer

I recently had a surprising experience with a patient that led me to reflect on how physicians' financial incentives might influence trust between doctors and patients. The experience made me wonder whether I should routinely discuss my financial incentives with my patients, and if so, how to do this while maintaining their trust. Susan, a 45-year-old patient I had known for years, developed left arm pain after bicycling on rough terrain. Her physical examination was normal and based on the history, I thought her pain was most likely caused by nerve impingement in her neck, but without neurological deficits. Without thinking too much about it, I recommended non-steroidal anti-inflammatories and suggested that she avoid exercise that might exacerbate the problem. One week later Susan returned because the pain was worse and now involved her neck as well as her arm. Her examination was unchanged. Together we decided that she would see a chiropractor for possible manipulation. I did not hear from Susan for a while, so I assumed the case was closed and forgot about it. Two months later, she returned. Her arm pain was still bothering her, keeping her awake at night. She was frustrated that so long after her initial injury, she was still having this problem. In addition, the chiropractor thought that her left triceps reflex was absent. Based on the persistence of her pain and her absent reflex, I referred Susan to a neurosurgeon who recommended surgery. I was relieved that we had finally gotten to the bottom of the problem. Susan, however, was not exactly comforted by this turn of events. She was upset that I had not referred her to the neurosurgeon earlier. She said that she had suffered over the last few months and that she would probably go ahead with the surgery. She did not express any anger directly to me, but her frustration was evident. I avoided asking her about her feelings. After the surgery, I called Susan to see how she was doing but she didn't call back. It seemed unlikely that I would see her again. I wondered if I had managed her case inappropriately and whether I should have referred her sooner. I was upset that I was probably going to lose a long-term relationship with a patient and that she was disappointed in my care. Of course, I didn't really know how she felt because I hadn't been brave enough to ask. To my surprise, Susan came to see me several months later for an unrelated problem. I was nervous when I saw her name on my schedule. Should I bring up the issue of her arm pain and what turned out to be a misdiagnosis, or would that only introduce more doubt into our relationship? I decided to apologize. I told her that I was sorry that she had suffered so long with the pain and that I wondered whether I should have referred her sooner. Susan accepted my apology and told me that it had been a horrible summer. Then she looked at me cautiously, paused, and asked, “Does my insurance company pay you to not refer me? I've read in the newspaper about financial incentives for doctors to decrease the cost of care.” I was shocked. I had never dreamed that her mistrust in me was related to concerns about how I was compensated. The issue hadn't entered into my decision-making process, and I was astounded that she thought it had. Instead, I had assumed that she was upset because she doubted my clinical competence in managing her care and the doubt had been gnawing away at me too. I explained this to her and she told me she appreciated both the information and the frank and open discussion. I was enormously relieved that we had cleared the air. If we hadn't talked, I would never have known what misconception lay behind her mistrust. I realized how difficult it was for me, and probably for her, to discuss the issue of financial incentives directly. Yet, the interaction left me with many more questions. For instance, who should disclose financial incentives? Regulatory agencies and some states have mandated that health plans disclose physicians's financial arrangements to those who request the information or to new enrollees.1–3 The Supreme Court recently reviewed a case pertaining to financial incentives for withholding medical services and commented on obligations of plans to disclose.4 It seems appropriate that these kinds of concerns be communicated by health plans rather than by physicians. After all, my job with patients is supposed to be focused on medical concerns, not money. Yet, this encounter made me realize that disclosure of financial incentives might also be up to me, not just the health plan. Even though enrolling patients might be told in the fine print on a contract about financial incentives, their real concerns may well surface in the consultation room with me, when they are sick and need a referral or service. As I thought about this encounter, I became increasingly troubled. I wondered how often other patients worried silently about the possibility that financial arrangements were influencing my decision making. Did they wonder if my pocketbook came before their health needs? How could I know about these unspoken worries without initiating the discussion myself? While this patient had been brave enough to ask me about my motives, I was certain that most patients would not. I suspected that this worry was an invisible force in the consultation room more often than I knew. Should I bring it up? Before initiating any discussions about financial arrangements, I realize that I must be certain that I am truly acting in my patient's best interest. Guidelines from both the American Medical Association and the medical literature provide parameters for physicians to assess the arrangements of particular health plans to ensure that they are ethically sound.5–7 Ultimately, I know that if I feel embarrassed about discussing my financial arrangements with patients, then I should not try to convince them that these incentives are appropriate. If I don't feel certain that I am on ethically firm ground, then my responsibility is to challenge the policy or leave the health plan. In Susan's case, I feel sure that my decision about a neurosurgical referral was based on medical issues and my best medical judgment about what she needed. Although it seems clear now that discussing financial arrangements with patients could be helpful, I am unsure about how this should be done. Some of the arrangements are so confusing to me that I wonder how I can explain them in a clear and useful way to patients. When should I initiate the conversations? Should it be with all new patients establishing a relationship with me as a primary care provider? This might be a reasonable time, yet we have other medical issues to discuss in the first visit in order for me to get to know the patient and his or her health needs. If I wait until the patient needs a referral due to illness, I worry that a conversation about finances will come at a time when patients feel vulnerable and worried about acute medical needs. This may be the worst time to bring up this sensitive topic. Also, it takes time to discuss financial arrangements thoroughly and I am already intensely pressured for time in office visits. In addition, I have never been trained in how to discuss the issue of financial incentives. Communication skills training programs can prepare physicians to discuss other difficult topics such as end-of-life care, sexual preference and domestic violence.8–11 Perhaps similar targeted training programs on discussing financial arrangements might be useful preparation. Such programs could be integrated into communication skills training for residents and into continuing medical education programs. I remember that I needed instruction on how to talk to patients about other sensitive issues, such as do not resuscitate orders, sexual preferences, and domestic violence. I have attended workshops on these topics that have helped me to practice putting ideas into words. Role playing with standardized patients allowed me to practice these discussions, make mistakes, and try again. Perhaps workshops on discussing financial arrangements would help physicians navigate this difficult area better. Ultimately, I wonder whether or not having these types of conversations will increase trust between my patients and me. On one hand, open discussions may enhance trust by revealing unspoken worries and indicating the willingness of both individuals to discuss challenging issues. On the other hand, a recent study indicates that patients who do not know how their doctors are paid are more likely to trust them than patients who know something about physicians' financial arrangements with payers.12 Research is needed to explore the consequences of policies involving disclosure of financial incentives. For example, studies might explore how patients can be effectively informed without decreasing trust. Can existing communication skills be applied to this situation? Currently, a large national study of patient preferences for disclosure is being conducted by the National Opinion Research Center. In the end, my humble apology to Susan proved useful to me, in a way very different from what I could have imagined. The trust between us had been damaged and if one of us hadn't been brave enough to discuss an uncomfortable topic, the relationship could have been lost. I now feel strongly that as physicians, we need to develop ways to handle these challenging situations. As managed care policies and regulations evolve, they have consequences for us in our daily routines as practicing doctors. We need to recognize the unspoken effects of these policies and find words to discuss them with our patients.