Even so, the AMA vote is merely an ethical guideline with no force of law, and it has plenty of exemptions. Doctors can still refer patients to labs and other facilities they own if the patients clearly need such services. They can also refer patients to facilities where they themselves work-and order tests and treatments that are an extension of their own practices. According to AMA counsel Kirk Johnson, most doctors know whether their investments are in their patients’ best interests or solely for their own profit, and therefore unethical under the guidelines.
On the surface, the AMA ruling seems like yet another example of the medical establishment rushing to police itself before changes are forced upon the health-care system. Earlier this month, the Health Insurance Association of America made an abrupt about-face and embraced the idea of universal health insurance for all Americans. In October, the pharmaceutical industry, under fire for high prices, reported that average wholesale drug prices rose by only 5.4 percent in the past year, compared with 9.5 percent in 1989. In taking the tough stand against physician self-referrals, the AMA members clearly had public relations in mind. Said AMA trustee Dr. Nancy Dickey, “Now was not the time to take a position that even appeared to be self-serving.”
Some physicians aren’t taking the AMA’s word as gospel. “I have my own ethical guidelines, and they are very high,” says Dr. Robert E. Windsor, an Atlanta orthopedist who owns interests in three local MRI units. He says he refers patients to only one of them because it is of very high quality and charges less than other centers. He won’t sell out unless the Georgia licensing board cracks down on such investments. “But it looks like the writing is on the wall,” he says. “These joint ventures probably won’t last much longer.”
Some states have already taken steps against self-referrals. In Florida, where 40 percent of doctors owned stakes in medical businesses last year, the legislature has given doctors until 1995 to either sell their interests or stop referring patients to facilities they own. Some physicians say that trend won’t necessarily make for better medicine-that as more doctors sell their interests, more entrepreneurs and national chains will buy in, and that will leave even fewer controls on quality and prices.
Clearly, economics as well as ethics is driving the self-referral furor. The battle is likely to continue if the Clinton administration, as expected, clamps down on reimbursements for a wide range of medical services. That could make medical enterprises less profitable-and that in itself may help separate greed from need in doctors’ motives. Those who are interested chiefly in making profits may sell out, leaving those who really are more concerned for their patients’ needs.
