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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

On Medicine and Money

US consumers have always had limited information about how physicians and other health care professionals practice medicine. Now, however, the April 9 release by the Centers for Medicare and Medicaid Services (CMS) of data on medical services and procedures provided to Medicare beneficiaries will help fill that gap “by offering insight into the Medicare portion of a physician’s practice,” said Health and Human Services Secretary Kathleen Sebelius in an accompanying statement. The newly released data, she added, will “afford researchers, policy makers and the public a new window into health care spending and physician practice patterns.”

Eli Adashi, MD, MS

All told, the newly released CMS data set provides information about more than 880 000 health care professionals who received $77 billion in Medicare payments in fiscal year 2012 for 6000 different types of services and procedures under the Medicare Part B Fee-For-Service program. Additional data releases may well follow before too long, with an eye towards enhancing transparency.

“Data transparency is a key aspect of the transformation of the health care delivery system,” said CMS Administrator Marilyn Tavenner. In addition to the new information about clinicians, CMS made hospital charge data available last May, thereby apprising consumers of the wide-ranging hospital costs for common inpatient and outpatient services.

Medicare Millionaires

As might have been anticipated, much of the media coverage of the release of the CMS data focused attention on health care professionals dubbed “Medicare millionaires” and their practice patterns. Tantalizing as such details might be, more profound issues were being sidestepped. In particular, little has been said with respect to the uncomfortable relationship between medicine and money.

This is an unfortunate state of affairs, because the ethical and moral challenges associated with the juxtaposition of medicine and money are highly deserving of our attention. A clear-eyed recognition of this age-old subject and of the all-too-common frailty of human nature were articulated as early as the 12th century by Moses Maimonides, the philosopher and physician, in the Prayer of Maimonides: “Do not allow thirst for profit, ambition for renown and admiration to interfere with my profession . . . .”

But there are no easy answers to this conunundrum.

Many see the pairing of money and medicine as a nonissue, and instead view it as capitalism at its best, with medicine being just another market in which competition reigns supreme. For proponents of this point of view, health care professionals might be seen as operatives in a retail business, wherein the volume of sales (of health services) carries the day, creating a vibrant health care market that sparks the scientific innovations upon which we have all come to depend. They see the business model of medicine as no different than that of any other field of pursuit, naturally rooted in foundational libertarian principles. Viewed in this light, the intersection of medicine and money is as American as apple pie. Exemplified by the time-honored “private practice” of medicine, this all-out embrace of the business principles of a market economy remains undiminished—if increasingly untenable.

No Fail-Safe Firewall

But there’s a potential flaw in this line of reasoning: the presumption of a fail-safe firewall between financial considerations and clinical decision making. Sadly, that may not always be the case.

Indeed, Congress has frequently seen fit to shield consumers from untoward practices. Examples of this include the Stark Law (which prohibits clinicians from “self-referring” a Medicare or Medicaid patient for services), the Emergency Medical Treatment & Labor Act (which ensures public access to emergency services regardless of ability to pay), and the Affordable Care Act (which expanded requirements for physician-owned hospitals).

Moreover, as recently as February 26, according to the annual Health Care Fraud and Abuse Control (HCFAC) Program report, the US government “recovered a record-breaking $4.3 billion in taxpayer dollars in Fiscal Year 2013 from individuals and companies who attempted to defraud federal health programs.” In that same year, 718 defendants were convicted of health care fraud–related crimes. Defendants who were charged and sentenced are facing an average of 52 months in prison. Regrettably, many of those involved were physicians, nurses, and other licensed medical professionals.

Clearly, opinions vary widely as to the ethical and moral wisdom of mixing medicine with money. Some would favor a lightly regulated, self-policing field, wherein unfettered entrepreneurship and Medicare millionaires are bound to thrive. According to this outlook, infractions perpetrated by a select few do not warrant the imposition of blanket, heavy-handed oversight.

But those who consider medicine and money to constitute a volatile mix may express preference for another model, such as a national health care system buttressed by a single governmental payer, in which value rather than volume of services determine provider compensation. Under this system, Medicare millionaires are unlikely to flourish.

Will the push for transparency into health care spending and how clinicians practice medicine foster change that addresses the intersection of medicine and money?

About the author: Eli Y. Adashi, MD, MS (Eli_Adashi@brown.edu) is a professor of medical science and a former dean of medicine and biological sciences at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. A member of the Institute of Medicine, the Association of American Physicians, and the American Association for the Advancement of Science, Dr Adashi has focused his writing on domestic and global health policy at the nexus of medicine, law, ethics, and social justice. A former Franklin fellow, Dr Adashi served as a senior advisor on Global Women’s Health to the Secretary of State office of Global Women’s Issues during the first term of the Obama Administration.