AMA Journal of Ethics^®

Case

Dr. Johnson is an enterprising internist in a single specialty group in a busy practice. While in medical school, he earned his master’s degree in business administration with a focus in health care management because he believed that good business acumen would be nothing but beneficial to him, his family, and his future patients. He was always interested in general internal medicine and takes pride in the treatment of his compliant patients.

Most of Dr. Johnson’s patients are adequately insured and have the range of chronic medical conditions that plague his community—hypertension, diabetes, heart disease, cancer.  In general, his patients do well, and he has the statistics to prove it. By all accounts, his statistics are better than any other in the community, when it comes to quality monitoring and improvement—lower hemoglobin A1c, tighter blood pressure control, cancer screening examinations and vaccines always up to date, and lipids always at goal. Dr. Johnson looks forward to the proposed changes in health care that will bring “pay-for-performance,” believing that the system will reward those physicians who maintain better control of their patients while, at the same time, benefiting their patients.

Dr. Johnson initiated a “protocol” in his office for scheduling new appointments. His community has a large health information exchange that allows physicians members unrestricted access to patient records from all hospitals in the area. Dr. Johnson has instructed his staff that, when a new patient called for a visit, they were to send him an e-mail with the patient’s identifying characteristics and inform the patient that a representative from the office would contact them. After the close of business each day, Dr. Johnson investigates each of the prospective new patients, of whom there are many. Dr. Johnson looks into each patient’s chart on the health information exchange to determine that individual’s comorbid conditions, payer status, history of medical compliance, and recent laboratory evaluations. In fact, Dr. Johnson uses this information to select the patients most likely to be compliant with his advice and most likely to improve his quality measures over the long term. Those with poor numbers are informed that, unfortunately, Dr. Johnson is not accepting new patients at this time.

Commentary

Computers and the Internet have evolved into indispensible tools that allow people to optimize daily tasks, whether it be researching information, communicating with others, or just making a simple purchase from an online vendor. The advent of novel web applications under the moniker of Web 2.0 has brought a new dimension to this platform by introducing the concept of sharing information in a more personable and interactive manner. In the health care field, this environment has empowered both patients and doctors to make more conscientious decisions about the access and delivery of health services, simultaneously giving way to new ethical considerations.

Trusted online resources have allowed patients to become informed participants in their health care. The public is now learning more about their conditions, finding specialists to treat them, and seeing how particular doctors are rated by their peers and patients. For physicians, hospitals, and other medical care organizations, electronic health care solutions show promise in improving the cost, quality, and access to care through the use of tools such as interoperable electronic medical records and virtual patient encounters. In our consumer-driven society most citizens have developed a sense of entitlement in the marketplace.

This phenomenon has manifested itself in the health care market as well [1] and, coupled with the power of the Internet, technology-savvy patients have become quintessential consumers. Web sites such as Healthgrades.com readily provide physician ratings based on patient reviews and performance measures, and ultimately can help a patient decide whether or not to obtain medical services from a particular health care professional [2]. This concept of patient as consumer in the capitalist economic system reopens the question at the heart of our nation’s health care debate today—do people have a right to health care?

Do the same market principles suggest that physicians have a similar right to choose their patients? Like any other small business owner, the physician employs a workforce to whom he or she pays salaries and benefits, has multiple costs comprising overhead, has business and educational financial obligations, and has to work in a high-pressure environment with the constant guillotine of litigation over his or her head. A pay-for-performance model would be the obvious choice upon which to balance physician reimbursement with delivering quality care to one’s patients. After all, choosing compliant patients to keep your statistics perfect and get paid accordingly is just business, right?

The first line of the American Medical Association’s Report of the Council on Ethical and Judicial Affairs reads, “Physicians are professionals and as such have obligations to use their skill and knowledge for the benefit of society.” Yet the council believes that, “both patients and physicians should be able to exercise freedom in choosing with whom to enter into a patient-physician relationship.” These two statements need not be mutually exclusive. Though the jury is still out in the United States, pay-for-performance has been a widely popular model in Europe, and patients excluded from pay-for-performance programs may actually be less likely to achieve treatment goals [3]. Novel health care encounter technologies such as virtual medicine also show promise in improving access to health care and improving outcomes. A study carried out by Chan and co-workers demonstrated that children with asthma who were given asthma education and monitoring via telehealth systems had improved quality of life scores, medication compliance, and disease control [4].

Health information exchange (HIE) systems are becoming an integral part in the future of health informatics and patient care. The goal is to provide universal, interoperable, and secure access of medical records to any physician directly involved in a patient’s care, across a variety of health care settings, to ensure cost effective and quality care. Unfortunately, this widespread access to sensitive information leaves open the potential for abuse. Under the guise of maintaining favorable health quality indices, Dr. Johnson is accessing the medical records of patients with whom he has no established relationship and consciously choosing not to treat the more complicated cases. He is ultimately denying care to those in need for the primary purpose of financial reward. These actions clearly cross the ethical boundaries that doctors are expected to uphold and may even constitute a violation of the HIPAA laws.

The aforementioned evidence would suggest that providing quality medical services to patients regardless of their level of compliance or payer status may in fact improve quality of health and be financially beneficial for the practitioner. Health care organizations that embrace collaborative, Internet-based health care information management will be rewarded with loyal “customers” because they will deliver a better product. Ultimately, the advantages delivered by the ethical use of the Internet enhance the health of patients and create a more rewarding doctor-patient relationship.