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Conflicts of Interest and “Whack a Mole”

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Most of the talk about medical conflicts of interest have centered on how financial interests can influence the practice of medicine (or conduct of research), by subtly (or not so subtly) influencing decisions on what drugs to prescribe, what devices to implant, or which way a clinical trial leans. The underlying concerns relate to the quality, and in some cases the cost effectiveness, of the care provided. By now most people know what questions to ask, such as:

“Was a more expensive (but no more effective) drug provided because the physician was paid for “consulting” by its manufacturer?” or:

“Was the result of that clinical trial equivocal because a positive finding could threaten royalties from a similar drug in which the investigator has an interest?”

Now questions are being raised turning these concerns about conflicts of interest on their head. Some physicians are asking if incentive programs designed to improve quality and cost effectiveness, by promising increased revenue through “gainsharing” to physicians for attaining specific results, are creating conflicts of their own.

These COI concerns focus on a different aspect of the Medical-Industrial ecosystem: reimbursement for care provided. While the effects of money from industry have been well documented and discussed at length, the impact of various reimbursement systems have received much less attention.

In an opinion piece published on Medpage Today, Sanjeev Saksena, MD, Clinical Professor of Medicine at Rutgers-RWJ Medical School argues that incentive programs designed to improve quality while reducing inpatient lengths of stay may push patients out of the hospital before sufficient planning has been done to prepare for the longer term care needs of complex cases. Dr. Saksena states:

“Current short-term rewards for “efficient” patient care fail to recognize the reality of longer-term care for patients with increasing comorbidities…”

So, while it has long been understood that reimbursement systems based on fee-for-service contain inherent conflicts (more services = more revenue but not necessarily better quality), we now have to consider the possibility that within quality- and efficiency-based reimbursement models lurk different but no less concerning conflicts of interest that can adversely affect the quality of patient care delivered.

It is helpful to recognize the fact that conflicts of interest will never go away. Managing conflicts of interest is like a game of “Whack a Mole”, where you smack one plastic mole down only to have another pop up elsewhere. Indeed, solutions that are developed to address one type of conflict may have the unintended consequence of creating another. Compliance Officers and COI Managers need to anticipate and respond promptly when that happens.