The AMA’s Code of Medical Ethics was created in 1847—before the outbreak of the American Civil War, the invention of the telegraph and the standardization of indoor plumbing. In its more than 160 years guiding physicians in the enduring values of ethics and medicine, the Code has seen a lot of changes, and updating it to reflect modern health care delivery and payment models is no easy task.
The original authors of the Code likely never dreamed what would be possible in medicine today, but the AMA’s current Council on Ethical and Judicial Affairs (CEJA) must consider new health care delivery organizations and new payment systems. At the same time, CEJA has to factor how to control health care costs while weighing the increased emphasis on improving patient safety and quality of care—a tricky balance.
CEJA outlined some ethical challenges in a report (AMA login required) to the AMA House of Delegates at the 2013 AMA Interim Meeting and made recommendations for how to accommodate the changing health care system in a code that will carry physicians through another century.
New models for financing and organizing health care delivery could set competing responsibilities for physicians, undermine trust in the patient-physician relationship or have unintended consequences for patients’ access to care and physicians’ professional satisfaction, the report said. Health care organizations are increasingly using incentives to improve care efficiency and control costs, which can exacerbate inequalities.
“For example, pay-for-performance programs can adversely affect care for vulnerable populations if they incentivize physicians to avoid patients for whom performance targets would be difficult to achieve,” the report said.
Further, cost-containing measures can create conflicting loyalties, asking physicians to serve both the interests of individual patients and the interests of health care organizations.
To accommodate new models, CEJA recommended that practices for financing and organizing care delivery:
- Are transparent
- Reflect input from key stakeholders, including physicians and patients
- Recognize that overreliance on financial incentives may undermine physician professionalism
- Encourage physicians to provide care for patients with difficult-to-manage medical conditions
- Enable physicians to respond to the unique needs of individual patients and provide avenues for advocacy on behalf of patients
The council also noted the most appropriate incentives for physicians are those that are based on a sense of shared purpose, protect and promote physicians’ sense of moral responsibility, and enable physicians to take ownership of the incentive.
“All physicians have an ethical responsibility to … advocate for changes in health care payment and delivery models to promote access to high-quality care for all patients,” the report said.
New guidance based on CEJA’s report will be issued as Opinion E-8.131, Professionalism in Health Care Systems, at AMA’s upcoming Annual Meeting.
CEJA is updating guidance on related topics in its project to modernize the Code. AMA members have the opportunity to read and comment on proposed changes to the Code, including changes to “CM 11 Opinions on Financing & Delivery of Health Care,” through June 30.
