Professional courtesy among physicians has changed

Issue: December 2011

ByDouglas W. Jackson, MD

Douglas W. Jackson

I look forward to writing a Commentary in each December issue inspired by the end of the calendar year and the special holiday spirit it brings. For me, this is the time of year for reflections, as well as spending quality time with loved ones. In keeping with this tradition, I want to discuss professional courtesy and respect, particularly in our relationships with colleagues. During the years, it has been a privilege for me to interact, know and work with other orthopedic surgeons. These ongoing relationships and interactions have engendered in me more respect and a desire to show courtesy to my colleagues.

When I started practicing in the 1970s, professional courtesy was a long-standing tradition. It was a way to convey not only our respect for our common commitments, training and goals, but also discourage physicians from professionally treating or diagnosing his or her own family members. At the same time, professional courtesy created good will and often resulted in patient referrals. Most physicians considered it to be a complement when our colleagues trusted us to treat their own family.

History of professional courtesy

There are references dating back to Hippocrates, which suggest that physicians took care of other physicians’ families without charge. However, particularly in the last 40 years, we have experienced changes that have impacted not only our ability to offer professional courtesy, but also other discounts for gratis medical care. Our independence in the practice for “free care” has been impacted and eroded by legal and third-party issues.

Governmental agencies have interposed some insidious and avert regulations and mandates about the permissible scope for a physician to reduce their charges for medical care. Penalties have been established for violations that include insurance claims being challenged, deselecting physicians from an insurance plan, and threats of fines and legal charges. Physicians have lost much of their discretion in giving discounted treatments and have become aware of the potential consequences of non-compliance. Private insurers and the federal government have pushed the concept of “one price for all,” and physicians cannot reduce the cost of care for anyone in your practice. This includes no exceptions for professional courtesy.

Co-pays and discounts

This challenged area was when physicians reduced the cost of care for individual patients by waiving copays. Third-party payers believe that by making patients share part of the treatment cost discourages casual trips to the physician. If co-pays are successful in diminishing the amount of care a patient seeks, then that is less money the health plan will have to pay to physicians and hospitals. Currently, most private insurers and Medicare require physicians to make reasonable efforts to collect co-pays from their patients.

Co-pays make the practice of medicine a unique business. Most businesses — at one time or another — offer discounts and reductions in their normal charges. This discount is usually for a specific amount of money or a percentage of the charge. A physician may be challenged by the payer if he or she tries to give discounts. An investigation will determine if the discount applies to the total bill and not just the patient’s co-pay, and in some instances, the payers will insist that patients pay their full co-pay for services. Discounts can be used against us to challenge exactly what the physician’s customary charges are for an individual physician and procedure. Many private insurance plans and some federal programs have a clause in contracts that entitles the plan to pay the lowest charge the physician bills to anyone. Any discounts have the potential to bring about a reduction to the discounted price in the physician’s allowable reimbursement schedule.

No-charge services

Private insurers and the government do not object to a physician waiving the entire charge for care and supplies. However, no charge visits are prohibited if they are part of a fraudulent scheme. The physician must document the service and evaluation so patients do not get around pre-existing illness exclusions and waiting periods between illnesses as defined by different insurance policies. There are further restrictions on no-charge services applied toward large deductibles or any other manner that eliminates copays. Some new provisions apply to activities where no-charge services are used to generate ancillary business to the physician or generate referrals.

Currently, third-party payers basically have defined professional courtesy as no charge to anyone – patient or insurance – for medical care. There are no special exceptions in the law that allows professional courtesy to physicians. These rules should cause physicians to examine their professional courtesy policies to assure that they do not violate the contractual terms in their accepted insurance plans.

Hard times have impacted physicians’ families. As such, I have seen more requests for gratis treatment for adult children who have moved back to their physician parent’s home or do not have health insurance of their own. I have been asked to waive the large deductible of family members and bill the insurance company to help meet their deductible. Be careful of using gratis care in this manner as it can be a fraudulent act.

Disappearing professional courtesy

Professional courtesy, as it was previously defined and practiced, has essentially disappeared. What concerns me more than the loss of traditional professional courtesy is what I see as a loss in our professional collegiality, respect and courtesy in our relationships. It is only with our colleagues who we share unique common purposes and goals. While we have our individual differences, our colleagues deserve our respect and support unless they do something flagrantly against the ethics of medicine. If we do not have respect and courtesy among ourselves, then it will diminish the respect other people have for us.

I request that you go out of your way to wish a colleague well this holiday season. While we are unique in our career demands and goals, I believe we need to remember who we are now and how we continue to be more dependent upon each other to maintain an outstanding profession. The one thing we have in common is our unique ability to serve our patients and speak with our colleagues on issues that effect and benefit health care for all.

Douglas W. Jackson, MD, is Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email: OT@slackinc.com.