March 1998

Uphold Professional Integrity in face of Businessmen Control

(Keywords:- HMO, capitation, incorporation, professional autonomy)

          Those were the days when life was simple. When a patient visited a  doctor and sought advice on health related problems; a doctor-patient relationship was established. The patient poured out his/her problems. The doctors analysed them, discussed them with the patient, suggested advice and administered treatment. The patient got well, he/she paid the doctor a fee -- a reward for service. It was a doctor-patient relationship. Yes, money did change hands, but it was a professional service, never a business relationship.

          Today as we move into expensive high tech medicine, as our ever increasing aging population require chronic extended care, medicine or health care is being seen, in particular by the business sector, as a ludicrous undertaking. Patients are seen by them as ¡§clients¡¨ or ¡§customers¡¨ with the ¡§$ sign¡¨ written all over their faces. The crunch comes when business people buy up medical practices and transform them overnight into business venture. The time honoured doctor-patient relation disappears; cost effectiveness becomes the order of the day. After all, in business there is one and only  one thing -- ¡§maximize profit¡¨. In the extreme case when businessmen control professional practice, professionals could be forced to forgo standards for that extra few bucks that will go into the wallets of the directors. The businessmen take the money and the doctors bear the responsibilities.

Professional Autonomy and Patient Benefit at stake

          In a recent discussion with corporate managers of a big Health Management Organisation (HMO) from the United States, I was told that in their organisation they never use non-ionic dye as a radiographic contrast. When asked how they would deal with medical litigation should sensitivity reactions arise leading to complications and loss of life, the reply was simple: ¡§we will settle it out of court, it is cheaper than to use non-ionic dye.¡¨ Patients¡¦ safety, even life, only plays second fiddle to financial gain!

          Let us look at it from another angle. When a patient visits a doctor and gets treated and is charged, say, $100; if service is quantifiable, the patient gets $100 of service from the service provider. On the other hand, if a patient joins a businessmen run HMO and pays, again, $100 per visit; that $100 ends up in a ¡§three ways split¡¨. For simplicity sake, assuming an equal share split, at least one-third will go to the share holders, one-third to the management and at most one-third goes to the service provider if he is luck! In short, the patient only gets $30 worth of service.

          But what about the integrity of the doctor, one might ask? The answer is straight forward. If a doctor is rewarded with only one-third of what he used to get by seeing one patient, it will be a natural tendency for him to see more to attain his usual income -- he could be less careful, he might cut corners -- through no fault of the service provider.

          Worse, once a business orientated HMO managed to lure a sizable number of ¡§customers¡¨, the corporate manager will have an enormous bargaining power. He will play Peter against Paul. He will offer his ¡§clients¡¨ to Peter for a very low consultation fees and if Peter refuses, he will offer it to Paul for even less. Standards of practice will no doubt be poured down the drain.

Pros and Cons of Possible Solutions

          What can be done?

          One suggestion is that such incorporation of medical practices may have to come under the ambit of the Medical Clinics Ordinance, which stipulates that such practices shall not be profit taking. Have these incorporations, therefore, contravened this Ordinance? Regrettably, so far legal advices sought have produced conflicting results. Furthermore, even if we were on firm ground and could ¡§throw the book¡¨ at these business incorporations, are we also affecting possibly many of our own colleagues who might have incorporated their practices for some time already?

          Another solution is to seek for the enactment of a ¡§Medical Practitioners¡¦ Incorporation Ordinance¡¨.

          Colleagues will have realised that the move to facilitate incorporating doctors¡¦ practices for taxation matters has been going on for quite some time. The fact remains that currently it is perfectly legal to incorporate doctors¡¦ practices, save that once a practice is incorporated, it may fall into the control of the Medical Clinics Ordinance which stipulates that such practice shall not be profit-taking. The action taken so far has been to attempt to bring in  amendments to the Medical Clinics Ordinance.

          The situation now is blatantly different. If we want to eliminate non-professionals to control medical practice, if we do not want medical practice to turn into a pure business venture, then we will need a specific Medical Practitioners¡¦ Incorporation Ordinance, hopefully to specify that the majority of directors are medical doctors (as in the current case of the dental profession) or almost exclusively medical doctors (in line with the accountant corporations). Colleagues will probably understand that to have such a bill introduced by Government will take prolonged lobbying. Furthermore, it will not be easy to go through any legislature as such a bill could be seen by many as protecting the profession¡¦s self interest.

          Perhaps the quickest way to dismantle businessmen organised HMOs is to compete with and defeat them through another type of HMO where all the directors are medical practitioners -- service providers for the organisation. Such an HMO, if participated by a sizable number of the profession, will no doubt provide a better service through a wider network and perhaps a more economical service. For with the health care providers being the directors of the organisation, there is no question of a ¡§three ways fees split¡¨. Instead, every dollar the patient spends goes to the health care service minus a small amount needed to run the administration of the system.

Act before too Late!

          Yet, for any of these options to be successful, the full cooperation of the medical profession is vital. At the end of the day, we have only ourselves to defend the situation.

          Without knowing the intricacy and what they stand to lose, the public would welcome HMO run by businessmen. To them it is another option and perhaps a way to cut health care prices. Even the Government might subtly offer these ¡§managed care system¡¨ her moral approval. After all, any method to curb, if not cut down, public health care spending, irrespective of standards, will be a possible good alternative to our policy makers.

          The pressure that is put to bear on the medical profession is tremendous. Our livelihood could be at stake. Our autonomy in practising medicine will surely be eroded, and the standard of care to the patients stand to be compromised!

          We must act now!

(HKMA News)

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