Dr David KL Quek,KMN
MBBS (Mal), MRCP (UK), FRCP (London), FAMM (Mal), FCCP (USA),
FNHAM (Mal), FASCC (ASEAN), FAPSC (Asia...
BioMedical-Ethics:
Elements of Spheres of Well-being

Organic
Wellbeing

Preserve
Life

Cure
Disease
(From Robert M. Veatc...
Preserve Life
Promote Health
Relieve Suffering
Cure Disease
The contribution of the
medical practitioner or the
physician ...
Nearly 40000 provisionally
& fully registered doctors
in MMC Register

MMC: 250 to 300
complaints/inquiries /year
Public perception of Doctors are changing…
Many doctors
still cling to the
perceived
stagnant
inviolability of
physician
a...
Doctors in society
Medical professionalism in a changing world

“What is medical professionalism and does
it matter to pat...
Medical Professionalism
 What‟s

a good doctor?

RCP (London) Report of a Working Party, December 2005
Medical Professionalism


In day-to-day practice, doctors are
committedto (or are exhorted to have):
•
•
•
•
•
•

i...
Medical Professionalism
These values, which underpin the
science and practice of medicine,
form the basis for a moral cont...
As Doctors, we do have a
Professional Mission!
“Physicians are the stewards for quality,
and they must aggressively develo...
OTHERWISE, MORE AND MORE OF PRACTICE ISSUES & MEDICOLEGAL CHALLENGES COULD OVERWHELM OUR HEALTH SERVICES!
Increases in
public‟s
expectations of
access and
outcomes of
clinical care,
including party
political
expectations!!!
Doct...
Principles of medical ethics
1. A physician shall be dedicated to providing competent medical
care, with compassion and re...
Principles of medical ethics
5. A physician shall continue to study, apply, and advance scientific
knowledge, maintain a c...
Adherence to such ethics…






Implies more rigorous application of discipline
Often these run counter to real-life P...
Adherence to such ethics…
Is physician autonomy(to do as one pleases
or opines), sacrosanct or absolute?
 Despite well-es...
Adherence to such ethics…






Clearly, there have been mounting concerns that
doctors—like everyone else in today‘s m...
Adherence to such ethics, implies…
Physician Autonomy & Self-regulation


In other words, there is greater expectation
 ...
SOCIETAL JUSTICE
FAIR PLAY
PATIENT SAFETY
COST-EFFICIENCY
DUE DILIGENCE ON
PRODUCT/SERVICES
OFFERED &
DELIVERED

REASONABL...
Monitoring
Performance…
Some scenarios as examples:
 Over-utilisation/testing/
unnecessary procedures/
therapies: Who che...
Ethical dilemmas:


So, is there a need for monitoring
healthcare services, for physicians,
facilities?



CLEARLY the a...
The lure of money and personal
lucre is a dizzying deflector and
obscurer of conscience,
integrity and professional
The uses of monitoring
information


Understanding the health
situation in your community
and how the health
services are...
The uses of monitoring
information


Ensuring that activities
and tasks are performed
in accordance with set
standards.

...
“DOCTOR KNOWS BEST” ATTITUDE AND PATERNALISTIC
APPROACH TO PATIENT CARE IS PASSÉ…
Pseudo-rationalisation to justify actions,
which may be driven by the lure of
personal profit, extra income and/or
profess...
Ethical dilemmas:
Real Practice Issues:
 Private practice institutions
reward volume of testing,
diagnostic procedures an...
Ethical dilemmas:
Real Practice Issues:
 Large GLCs encourage and actually rate
higher, sanction and approve physicians o...
Deaths Linked to Cardiac Stents Rise
as a Third Called Unneeded

When stents are used to restore blood flow in heart attac...
Rate of Stent-Related procedures:
Number of PCIs for every 1000 Medicare enrollees
Procedures per angiographies: Doctors use angiography scans to look
for blockages; they implant stents afterward about hal...
A Heart With 67 Stents,

N. Khouzam, RajvirDahiya, Richard
Schwartz,J Am CollCardiol. 2010;56(19):1605-1605. doi:10.1016/j...
Elective Coronary Stenting
not Harmless…




Cardiac stents were linked to at least 773 deaths in
incident reports to th...
Elective Coronary Stenting not Harmless…
Case in Point: Multiple Stents by a DrPatil
 Catheterization and stents at St. J...
The Lure of Lucre
High Median Income
 Interventional cardiologists earn a median
income of $562,855 a year, as compared t...
Elective Coronary Stenting not Harmless…
Michigan Deaths and Malfeasance

1. MehmoodPatel, a Lafayette, Louisiana, cardio...
Elective Coronary Stenting not Harmless…
Cleveland Raid
In Ohio, Simecek, a worker at the Ford dealership, grew suspicious...
Also, Elective Endoscopies not Harmless…
Hospital A in Selangor
 A gastroenterologist does some 20-25 scopes per working ...
Also, Elective Endoscopies not Harmless…
Hospital C in KL
 Senior gastroenterologist from Penang, charged in MMC
for havi...
Ethical dilemmas:
Real Practice Issues:
 Who monitors and ensures standards and
quality of care?
 Patient safety complia...
Ethical dilemmas:
Real Practice Issues:
 In-built venal interests vs. public good
 Moral hazards: self-referral for test...
Ethical dilemmas:
"Is it ethical for hospital management, peer specialist societies or
regulatory authorities (MOH, MMC) t...
WHAT SHOULD WE DO WITH
THIS “ETHICS” THING ABOUT
PERFORMANCE MONITORING?

,

HOW MUCH OF WHAT WE DO AS DOCTORS CAN STAND U...
The critical attitude in medicine:
the need for a new ethics
NEIL McINTYRE, KARL POPPER







“These standards of obje...
Always act in the best
interests of your patients
Primum Non Nocere, First Do No Harm…

 You are personally responsible f...
In the UK when you commence service in the health sector,
you‟re provided with some set of rules and conduct…

In Malaysia...
Act in best interests of patients, always
Primum Non Nocere, First Do No Harm…

 You must not do anything, or allow
someo...
Act in best interests of patients, always
Primum Non Nocere, First Do No Harm…

 You are responsible for the appropriaten...
Keep high standards of
personal conduct.
You must keep high standards
of personal conduct, as well as
professional conduct...
Keep professional knowledge
and skills up up to date.










You must make sure that your knowledge, skills and
pe...
Act within your limits, skills and
experience
You must keep within your scope of practice. This
means that you should only...
Communicate properly and
effectively
You must take all reasonable steps
to make sure that you can
communicate properly and...
Effective Care, Supervision and
Referral


People who receive care or services from you
are entitled to assume that you h...
Informed consent


You must explain to patients the care or services you
are planning to provide, any risks involved and ...
Informed consent


A person who is capable of giving their consent
has the right to refuse to receive care or
services. Y...
Keep accurate records


Making and keeping records is an essential
part of providing care or services and you
must keep r...
Keep accurate records


Whenever you review records, you should update
them and include a record of any arrangements
you ...
Limit your work or stop practising
if affected by ill-health…
You have a duty to take action if your
physical or mental he...
Honesty and integrity
vs. public trust
You must justify the trust that other
people place in you by acting with
honesty an...
Basic Human Instinct for
Free-Market enterprise?
“Every individual necessarily labours to render the
annual revenue of the...
Ethical behaviour and
practice can be nurtured…
Standards of Care
Assessment…


How can private hospitals/private sector
help to ensure that patient safety
measures as w...
Standards of Care Assessment…
MSQH and JCI are the technical accreditation benchmarks for
some sort of systems approach to...
Rating Doctors…
Some possible performance
measures to consider/monitor…
At PHKL, the MDAC has instituted a few preliminary
measures:
 Rea...
Some possible performance
measures to consider/monitor…
At PHKL, the MDAC has instituted some preliminary
measures: REVIEW...
US Mandatory Physician
Quality Reporting System
– linked to Payment to be
in place by 2015
Physician Quality Reporting System (PQRS)

We want to emphasize that if a group of physicians with 100 or more eligible
pr...
Process Measures for Eligible Professionals and Group Practices Who
Report Using Administrative Claims for the 2015 PQRS P...
Process Measures for Eligible Professionals and Group Practices Who
Report Using Administrative Claims for the 2015 PQRS P...
Outcome Measures for Eligible Professionals and Group Practices Who Report Using
Administrative Claims for the 2015PQRS Pa...
Cost Measures
Section 1848(p)(3) of the Act requires physicians to evaluate
costs, to the extent practicable, based on a c...
Relationship between Quality of Care
and Cost Composites & Value Modifier
Tavistock principles


Rights
 People have a right to health and health care.



Balance
 Care of individual patients ...
Tavistock principles


Cooperation
 Healthcare succeeds only if we cooperate with

those we serve, each other, and those...
Why have such principles?


The most fundamental problems in health
care are ethical:





Who will live?
Who will di...
“The practice of
medicine is an art,
not a trade;
a calling, not a
business;
a calling in which
your heart will be
exercis...
Discernment…
―But I AM ALWAYS WARY OF
DECISIONS MADE HASTILY.
―I am always wary of the first decision,
that is, the first ...
 Most if not all doctors are smart, highly
intelligent but individualistic people, with low
tolerance of perceived „stupi...
In many respects, our world has
changed, and increasingly physicians
will see more and more oversight
activities and regul...
Thank you!
The ethics of performance monitoring-private sector perspective
The ethics of performance monitoring-private sector perspective
The ethics of performance monitoring-private sector perspective
The ethics of performance monitoring-private sector perspective
The ethics of performance monitoring-private sector perspective
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The ethics of performance monitoring-private sector perspective

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Increasingly medical practice is coming under intense scrutiny as to what is appropriate and affordable care, including serious considerations of patient safety issues and protection. Medical professionalism must be consciously adhered to as we try and find the best health care for our patients at the best value and outcomes for our patients themselves, and also for society at large. In view of escalating health care costs, physician autonomy to practice as he or she likes or deems fit has now come under siege with more and more performance monitoring, not just for appropriateness, but also for outcomes, necessity and cost-effectiveness. Physician' vested interests must be tempered with evidence-based benefits or at least be associated with no increase in harm or incur affordability issues. Fraudulent physician malfeasance are now being uncovered via whistle-blowers, or through greater more meticulous audit of various validated performance measures, and those physicians found to have flouted these due to pecuniary self-interests, overuse of tests or procedures have been found guilty and sanctioned with heavy fines, return of reimbursements as well as imprisonment, and erasure from medical registries and the removal of license to practice.

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The ethics of performance monitoring-private sector perspective

  1. 1. Dr David KL Quek,KMN MBBS (Mal), MRCP (UK), FRCP (London), FAMM (Mal), FCCP (USA), FNHAM (Mal), FASCC (ASEAN), FAPSC (Asia Pacific) FACC (USA), FAFPM (Hon) Senior Consultant Cardiologist Chair, Medical & Dental Advisory Committee Pantai Hospital Kuala Lumpur Malaysia 10th MOH-AMM Scientific Meeting (16th Scientific Meeting of the National Institutes of Health and National Ethics Seminar) Symposium 2 ~ Ethics; 30 September 2013 (0915-1030h)
  2. 2. BioMedical-Ethics: Elements of Spheres of Well-being Organic Wellbeing Preserve Life Cure Disease (From Robert M. Veatch, Basics of Bioethics, Upper Saddle River, NJ: Prentice-Hall, 2003, p. 52.) Promote Health Relieve Suffering
  3. 3. Preserve Life Promote Health Relieve Suffering Cure Disease The contribution of the medical practitioner or the physician in influencing health and well-being is rather circumscribed, and not as large as we sometimes think! Organic Well-being
  4. 4. Nearly 40000 provisionally & fully registered doctors in MMC Register MMC: 250 to 300 complaints/inquiries /year
  5. 5. Public perception of Doctors are changing… Many doctors still cling to the perceived stagnant inviolability of physician autonomy to practice as he or she believes is right…
  6. 6. Doctors in society Medical professionalism in a changing world “What is medical professionalism and does it matter to patients? Although evidence is lacking that more robust professionalism will inevitably lead to better health outcomes, patients certainly understand the meaning of poor professionalism and associate it with poor medical care. The public is well aware that an absence of professionalism is harmful to their interests.” RCP (London) Report of a Working Party, December 2005
  7. 7. Medical Professionalism  What‟s a good doctor? RCP (London) Report of a Working Party, December 2005
  8. 8. Medical Professionalism  In day-to-day practice, doctors are committedto (or are exhorted to have): • • • • • • integrity compassion altruism continuous improvement excellence working in partnership with members of the wider healthcare team. RCP (London) Report of a Working Party, December 2005
  9. 9. Medical Professionalism These values, which underpin the science and practice of medicine, form the basis for a moral contract between the medical profession and society.  Each party has a duty to work to strengthen the system of healthcare on which our collective human dignity depends.  RCP (London) Report of a Working Party, December 2005
  10. 10. As Doctors, we do have a Professional Mission! “Physicians are the stewards for quality, and they must aggressively develop an agenda for improvement …we are at a critical cusp of time in which we have a last chance to retain our professional role, and to do so we must become protectors of quality. “Activism must persist and grow if we are to promote the professional/quality link at the level of patient care. This responsibility reaches to every physician.” Troyen Brennan, Physicians‘ professional responsibility to improve the quality of care. Acad Med 2002;77:973–80.
  11. 11. OTHERWISE, MORE AND MORE OF PRACTICE ISSUES & MEDICOLEGAL CHALLENGES COULD OVERWHELM OUR HEALTH SERVICES!
  12. 12. Increases in public‟s expectations of access and outcomes of clinical care, including party political expectations!!! Doctors in society. Medical professionalism in a changing world. RCP (London) Report of a Working Party, December 2005
  13. 13. Principles of medical ethics 1. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights. 2. A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities. 3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient. 4. A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law. AMA: Adopted June 1957; revised June 1980; revised June 2001.
  14. 14. Principles of medical ethics 5. A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated. 6. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care. 7. A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. 8. A physician shall, while caring for a patient, regard responsibility to the patient as paramount. 9. A physician shall support access to medical care for all people. AMA: Adopted June 1957; revised June 1980; revised June 2001.
  15. 15. Adherence to such ethics…     Implies more rigorous application of discipline Often these run counter to real-life Physician Practice, Autonomy & Self-regulation… The private sector is a different ‗animal‘ altogether, because services are not delimited by constraints of public resources (accessible tests, amenities, costlier drugs, perhaps lack of certain subspecialty doctors) or the lure of easier access for some demanded services, based on market forces… over-utilisation of services occurs! So under such circumstances, does self-regulation work?
  16. 16. Adherence to such ethics… Is physician autonomy(to do as one pleases or opines), sacrosanct or absolute?  Despite well-established and oftentimes selfevident professional ethics (mandated upon medical practitioners), how many of us doctors are conscious of our supposed aspirational ethos within which a medical doctor should practice: that he or she knows inherently what is ‘good’, proper and fair, i.e. what is professionally beneficent and ethical!? 
  17. 17. Adherence to such ethics…    Clearly, there have been mounting concerns that doctors—like everyone else in today‘s market-driven economy—are increasingly business-like and venal! Increasingly therefore, many oversight authorities including regulatory boards and councils are veering towards a more consistent and perhaps better enunciated “virtue based ethos of medical professionalism” that exhibits “transparency and sincerity with regard to achieving uniform quality and safety of health care.” There is a need to temper our inbuilt human „moral hazard‟ of self-interest vs. public good!
  18. 18. Adherence to such ethics, implies… Physician Autonomy & Self-regulation  In other words, there is greater expectation  that the medical professional delivers as he or she should as per     his professional duties and expertise or training, with integrity and trustworthiness that these health encounters and care outcomes are comparable with the ―best‖ expected or estimated standards, quality and safety that diagnostic or therapeutic harms or malfeasance are kept at an informed minimum, and that these services are transacted/purchased as per need and prudence, at reasonable costs not just for the individual patient, but also for society at large! That there should be an ideal balance between prudent „parsimonious‟ care over unnecessary or even fraudulent overutilisation of services, especially when these are for personal gain!
  19. 19. SOCIETAL JUSTICE FAIR PLAY PATIENT SAFETY COST-EFFICIENCY DUE DILIGENCE ON PRODUCT/SERVICES OFFERED & DELIVERED REASONABLE INDIVIDUAL / SOCIETAL EXPECTATION OF STANDARDS, SAFETY, QUALITY, OF TRULY NECESSARY TREATMENT RENDERED OUTCOMES AND COST OF EVERY HEALTH CARE ENCOUNTER SHOULD BE TOLERABLY GOOD & FAIR
  20. 20. Monitoring Performance… Some scenarios as examples:  Over-utilisation/testing/ unnecessary procedures/ therapies: Who checks this type of physician/practice?  Poor therapeutic results: high morbidity-mortality outcomes: Bad outcomes?  Callous indifferent attitude: Beyond skills/training expertise: who should set the limits?  Fraudulent practices, dishonest reporting, involuntary manslaughter for wrongful death due to gross negligence or incompetence…
  21. 21. Ethical dilemmas:  So, is there a need for monitoring healthcare services, for physicians, facilities?  CLEARLY the answer in this modern age is a resounding YES!  Modern Parlance: Performance Management  Performance Monitoring for physicians?  Even more so, as public doubts, distrust and patient empowerment demands greater accountability, shared responsibility in mutual decision making,  Even if disagreeable patient choice—Patient autonomy trumps paternalistic care/unilateral decision making Who‟s watching? Who‟s listening?
  22. 22. The lure of money and personal lucre is a dizzying deflector and obscurer of conscience, integrity and professional
  23. 23. The uses of monitoring information  Understanding the health situation in your community and how the health services are performing.  Determining whether the resources in the health services are being well used.  Ensuring that all activities are carried out properly by the right people and at the right time.
  24. 24. The uses of monitoring information  Ensuring that activities and tasks are performed in accordance with set standards.  Identifying health problems facing the community and starting to find solutions.  Ensuring community groups and local individuals participate appropriately in health activities.
  25. 25. “DOCTOR KNOWS BEST” ATTITUDE AND PATERNALISTIC APPROACH TO PATIENT CARE IS PASSÉ…
  26. 26. Pseudo-rationalisation to justify actions, which may be driven by the lure of personal profit, extra income and/or professional reputation, standing or arrogance… are ethically unsound…
  27. 27. Ethical dilemmas: Real Practice Issues:  Private practice institutions reward volume of testing, diagnostic procedures and therapies  Physicians are rewarded with incentives, bonuses for higher volumes of services rendered!  Fee-for-service also rewards physicians for their work… the more tests, procedures, surgeries, carried out and drugs used, the higher the income or earnings Moral Hazard: Conflicts of Duty Patient benefit vs. Self-interest, Personal gain
  28. 28. Ethical dilemmas: Real Practice Issues:  Large GLCs encourage and actually rate higher, sanction and approve physicians or surgeons who carry out more and earn more for the hospitals… more tests, more drugs, more disposables, more surgeries = GREATER TURNOVER & RETURN OF INVESTMENTS!  Recent IHH IPO example: pink forms…  In fact, sometimes ironically, more complications and use of ICU/CCU beget greater institutional profits!  But bad/poor outcomes lead to higher medico-legal costs which may override all profits! Moral Hazard: Conflicts of Duty Patient benefit vs. Self-interest, Personal gain
  29. 29. Deaths Linked to Cardiac Stents Rise as a Third Called Unneeded When stents are used to restore blood flow in heart attack patients, few dispute they are beneficial. These and other acute life-or-death cases account for about half of the 700,000 Americans who get stents annually.
  30. 30. Rate of Stent-Related procedures: Number of PCIs for every 1000 Medicare enrollees
  31. 31. Procedures per angiographies: Doctors use angiography scans to look for blockages; they implant stents afterward about half the time. A higher ratio of PCIs per 1,000 scans may show locales where doctors are more inclined to use stents.
  32. 32. A Heart With 67 Stents, N. Khouzam, RajvirDahiya, Richard Schwartz,J Am CollCardiol. 2010;56(19):1605-1605. doi:10.1016/j.jacc.2010.02.077
  33. 33. Elective Coronary Stenting not Harmless…   Cardiac stents were linked to at least 773 deaths in incident reports to the U.S. Food and Drug Administration last year, according to a review by Bloomberg News. That was 71 percent higher than the number found in the FDA‘s public files for 2008. The 4,135 non-fatal stent injuries reported to the FDA last year – including perforated arteries, blood clots and other incidents – were 33 percent higher than 2008 levels. 2011 study in the Journal of the American Medical Association that found only half of elective stent procedures nationally were appropriate under usage guidelines written by societies of heart specialists. The study found 12 percent were inappropriate, and 38 percent fell into the uncertain category of the guidelines.  Kickbacks: At least five hospitals have reached settlements with the Justice Department over allegations that they paid illegal kickbacks to doctors for patient referrals to their cath labs. St. Joseph Medical Center in Towson, Maryland, paid the government $22 million without admitting liability.
  34. 34. Elective Coronary Stenting not Harmless… Case in Point: Multiple Stents by a DrPatil  Catheterization and stents at St. Joseph in London (after a DrPatilbegan practicing there), climbed from 210 to 929 from 2000 - 2009  Stenting income from Medicare alone >1/6 of the hospital‟s 2009 operating income  When Patil left in 2010, catheterization procedures fell 34 percent from their 2009 high; the decline would have cost the hospital about $15 million. RM, one of Patil‘s patients, had her arteries catheterized 18 times and received 8 cardiac stents over four years, according to a lawsuit she and 361 other patients have brought against Patil, St. Joseph and other doctors who practiced there. The defendants deny the negligence and fraud allegations against them. Short of Breath  RM said she suffers from chest pain and shortness of breath, and has been told by her new doctor that she may need more stents and surgery to keep her coronary arteries from closing. She said she gets so tired she needs to sit and rest after walking down the stairs. Penalties   St. Joseph-London repaid Medicare $256,800 for unnecessary procedures. Patil lost his privileges to practice in December 2010.  Under his plea bargain, Patil agreed to serve 30 to 37 months in federal prison.  He forfeited his Kentucky medical license for five years. In 2012, he told a family court judge his monthly income was $53,300.
  35. 35. The Lure of Lucre High Median Income  Interventional cardiologists earn a median income of $562,855 a year, as compared to $207,117 for family doctors, according to Medical Group Management Association, which surveys physician practices.  Interventionalistsranked 13th among 118 specialties tracked by MGMA.  Recent data „leaked‟ from hospital sources estimate that some top earning physicians/surgeons in Malaysia gross in excess of RM 4-5 million (USD 1.2-1.5 million) per year… i.e. 300k to 400k/mo
  36. 36. Elective Coronary Stenting not Harmless… Michigan Deaths and Malfeasance  1. MehmoodPatel, a Lafayette, Louisiana, cardiologist was jailed last year on 51 counts of charging for needless stents, made over $16 million in one three-year span. Prosecutors said he was ―driven by the desire to be the busiest cardiologist in town‖.  He unsuccessfully argued/appealed that he used his best medical judgment in every case and lost.  Patel is serving a 10-year sentence in a federal penitentiary. 2. JashuPatel, an interventionalist in Jackson, Michigan, billed $2.7 million for procedures in 2007, according to a U.S. Justice Department case against him settled in July. (He is no relation to Mehmood Patel). Needless Stents The suit alleged Patel implanted needless stents in at least two patients, including one that led to a blood clot that killed an unnamed woman who had reported no symptoms of reduced cardiac blood supply. A stress test showed normal blood flow, and notes in her file said she didn‘t want interventions, said Julie Kovach, a cardiologist who worked with Patel and brought the case to the government‘s attention. ―It was appalling,‖ Kovach said in an interview. ―Patel coerced her into getting a stent she didn‘t need, which killed her.‖ False Claims  ―He‘s their cash cow,‖ said Kovach, now co-director of a clinic at the Detroit Medical Center. ―They‘re not about to turn him in.‖  Patel and the hospital, Allegiance Health, agreed to pay the U.S. a total of $4 million to settle the federal charges. Kovach was awarded $760,000 as a whistle-blower under the U.S. False Claims Act. Allegiance disagreed with the allegations and settled the claims to avoid ―lengthy litigation.‖ 
  37. 37. Elective Coronary Stenting not Harmless… Cleveland Raid In Ohio, Simecek, a worker at the Ford dealership, grew suspicious after his sixth stent from cardiologist Harry Persaud at the Cleveland Clinic‘s Fairview Hospital in 2011. Simecek said he went for a second opinion and was told he didn‟t need any of the stents. Now he said he has to take blood thinners the rest of his life.  Persaudis under criminal investigation for health care fraud, mail fraud and money laundering, according to federal court filings. Last October, Federal Bureau of Investigation agents raided his office and removed financial records and patient files for procedures at 3 Cleveland-area hospitals. The government has seized $343,634 from his and his wife‟s bank accounts, alleging the funds represent the proceeds of fraud related to a ―significant number‖ of unnecessary stent procedures. Multiple, Elongated Full-Metal Jacket  The Cleveland Clinic found ―problems related to the use of stents in some patients‖ at Fairview and reported them to the government, according to spokeswoman Eileen Sheil. She would not say how many patients were affected. Persaud resigned from the hospital staff last year.  At least 64 of Persaud‘s patients at St. John Medical Center in suburban Westlake received letters from the hospital saying they may have received an unnecessary stent between 2010 and 2012, according to spokesman Patrick Garmone, who said Persaud no longer practices there.  Persaud denied wrongdoing in court filings and said his stent procedures were proper. Neil Freund, his attorney in lawsuits filed by patients alleging unwarranted stents, said ―it is our intent to defend these cases.‖ He had no comment on the federal investigation.   Another case: “Excessive” stent work… included 31 stents stretching for 14 inches inside the arteries of a Patient B.
  38. 38. Also, Elective Endoscopies not Harmless… Hospital A in Selangor  A gastroenterologist does some 20-25 scopes per working day, averaging some 450 - 500 OGDS and Colonoscopies per month, income ~ RM400,000; drives a Ferrari and Bentley  Some peers complain ‗quietly‘ that he scopes just about anyone that walks into his clinic before he even sees or examines them… YES physician envy and oversight is coming…  Management has been relatively quiet, as he is the highest performing physician in terms of use of facility and other disposables and OR times. MDAC not able to act based on lack of formal complaints or incidents… Hospital B in Selangor  A physician-gastroenterologist walks around his wards, then points out to his inpatients for urgent OGDS/colonoscopies to ‗top up‘ his weekly performance; and was heard to exclaim (by nurses) that his ‗quota‘ for the month of scopes has notyet been reached, which usually is around 60-70 per week; estimated income averages RM300,000+ per month… http://www.cms.gov/PhysicianSelfReferral/95_advisory_opinions.asp#TopOfPage.
  39. 39. Also, Elective Endoscopies not Harmless… Hospital C in KL  Senior gastroenterologist from Penang, charged in MMC for having perforated a gut due to negligence and unethical behaviour for unconvincing indication, and not giving adequate informed consent about possible adverse outcomes and risks of complications. Reprimanded as he could not satisfactorily convince the MMC of his standard of care, proper documentation and his standard operating protocols; slip-shod work ethic etc.  What‟s fair physician income and remuneration?  Who decides whom to treat or perform some of these self-referred procedures and surgeries?  Stark Law obviously breached but not applicable here; no oversight… Should there be? http://www.cms.gov/PhysicianSelfReferral/95_advisory_opinions.asp#TopOfPage.
  40. 40. Ethical dilemmas: Real Practice Issues:  Who monitors and ensures standards and quality of care?  Patient safety compliance?  Competence: Missed/delayed treatment  Incompetence & Poor skills/performance  Dubious indications for tests /therapies  Adverse outcomes/Complications of therapy/lack of informed consent  Chronic disease management and outcome  Pay for performance or goal-directed outcomes?
  41. 41. Ethical dilemmas: Real Practice Issues:  In-built venal interests vs. public good  Moral hazards: self-referral for testing, skewed diagnostic &therapeutic choices…  Too Much Rx: Over testing, overtreatment, EBM?  Defensive medical practice… fear of medico-legal litigation  Harms associated with such decisions  Outdated Knowledge base: Inadequate attention to CME/CPD  Peer review and oversight  Appropriateness of Care: Fair deal for patients, for payers  Prudent or Parsimonious Care for all patients, society
  42. 42. Ethical dilemmas: "Is it ethical for hospital management, peer specialist societies or regulatory authorities (MOH, MMC) to evaluate the performance of a medical practitioner using clinical outcomes or electronic performance monitoring data gathered on that individual?“  Is it time to consider such approaches to improve patient outcomes & safety?   Ultimately will such monitoring help to  reduce system failures,  weed out or curtail poor performance,  stem fraud, and/or  help reduce overall healthcare costs escalation?  Or does this impinge on the rights and physician autonomy and practice of the medical professional?
  43. 43. WHAT SHOULD WE DO WITH THIS “ETHICS” THING ABOUT PERFORMANCE MONITORING? , HOW MUCH OF WHAT WE DO AS DOCTORS CAN STAND UP TO CLOSE SCRUTINY AND AUDIT TO QUALIFY AS GOOD, BEST OR EVEN APPROPRIATE PRACTICES? ARE OUR OUTCOMES UP TO THE MARK?
  44. 44. The critical attitude in medicine: the need for a new ethics NEIL McINTYRE, KARL POPPER    “These standards of objective truth and criticism may teach him (the individual man) to try again and to think again; to challenge his own conclusions, and to use his imagination in trying to find whether and where his own conclusions are at fault. They may teach him to apply the method of trial and error in every field, and especially in science; and thus they may teach him how to learn from his mistakes, and how to search for them. These standards may help him to discover how little he knows and how much there is he does not know. They may help him to grow in knowledge, and also to realise that he is growing. They may help him to become aware of the fact that he owes his growth to other people's criticism and that reasonableness is readiness to listen to criticism.” KARL POPPER, 1978
  45. 45. Always act in the best interests of your patients Primum Non Nocere, First Do No Harm…  You are personally responsible for making sure that you promote and protect the best interests of your service users/patients.  You must respect and take account of these factors when providing care or a service, and must not abuse the relationship you have with a patient.  You must not allow your views about a patient‘s sex, age, colour, race, disability, sexuality, social or economic status, lifestyle, culture, religion or beliefs to affect the way you deal with them or the professional advice you give.  You must treat patientswith respect and dignity.  If you are providing care, you must work in partnership with your patients and involve them in their care as appropriate.
  46. 46. In the UK when you commence service in the health sector, you‟re provided with some set of rules and conduct… In Malaysia too, we have our Code of Professional Conduct via the MMC
  47. 47. Act in best interests of patients, always Primum Non Nocere, First Do No Harm…  You must not do anything, or allow someone else to do anything, that you have good reason to believe will put the health, safety or wellbeing of a service user in danger. This includes both your own actions and those of other people.  You should take appropriate action to protect the rights of children and vulnerable adults if you believe they are at risk, including following national and local policies.  You are responsible for your professional conduct, any care or advice you provide, and any failure to act.
  48. 48. Act in best interests of patients, always Primum Non Nocere, First Do No Harm…  You are responsible for the appropriateness of your decision to delegate a task.  You must be able to justify your decisions if asked to.  You must protect patients if you believe that any situation puts them in danger. This includes the conduct, performance or health of a colleague.  The safety of patients must come before any personal or professional loyalties at all times. As soon as you become aware of a situation that puts a service user in danger, you should discuss the matter with a senior colleague or another appropriate person.
  49. 49. Keep high standards of personal conduct. You must keep high standards of personal conduct, as well as professional conduct.  You should be aware that poor conduct outside of your professional life may still affect someone‘s confidence in you and your profession. 
  50. 50. Keep professional knowledge and skills up up to date.      You must make sure that your knowledge, skills and performance are of a good quality, up to date, and relevant to your scope of practice. You must be capable of meeting the standards of proficiency that apply to your scope of practice. We recognise that your scope of practice may change over time. We acknowledge that our registrants work in a range of different settings, including direct practice, management, education or research. You need to make sure that whatever your area of practice, you are capable of practising safely and effectively. Our standards for continuing professional development link your learning and development to your continued registration. You also need to meet these standards.
  51. 51. Act within your limits, skills and experience You must keep within your scope of practice. This means that you should only practise in the areas in which you have appropriate education, training and experience.  We recognise that your scope of practice may change over time.  When accepting a patient, you have a duty of care. Inclduing the duty to refer to others for care or services if it becomes clear that the task is beyond your own scope of practice.  If you refer a patient to another practitioner, you must make sure that the referral is appropriate and that, so far as possible, the patient understands why you are making the referral. 
  52. 52. Communicate properly and effectively You must take all reasonable steps to make sure that you can communicate properly and effectively with patients.  Youmust communicate appropriately, cooperate, and share your knowledge and expertise with other practitioners, for the benefit of patients. 
  53. 53. Effective Care, Supervision and Referral  People who receive care or services from you are entitled to assume that you have the appropriate knowledge and skills to provide them safely and effectively.  Whenever you give tasks to another person to carry out on your behalf, you must be sure that they have the knowledge, skills and experience to carry out the tasks safely and effectively.  You must not ask them to do work which is outside their scope of practice.
  54. 54. Informed consent  You must explain to patients the care or services you are planning to provide, any risks involved and any other possible options.  You must make sure that you get their informed consent to any treatment you do carry out.  You must make a record of the person's decisions and pass this on to others involved in their care.  In some situations, such as emergencies or where a person lacks decision-making capacity, it may not be possible for you to explain what you propose, get consent or pass on information. However, you should still try to do all of these things as far as you can.
  55. 55. Informed consent  A person who is capable of giving their consent has the right to refuse to receive care or services. You must respect this right.  Youmust also make sure that they are fully aware of the risks of refusing care or services, particularly if you think that there is a significant or immediate risk to their life.  You must keep to your employers‘ procedures on consent and be aware of any guidance issued by the appropriate authority in the country you practise in.
  56. 56. Keep accurate records  Making and keeping records is an essential part of providing care or services and you must keep records for everyone you treat or for whom you provide care or services.  You must complete all records promptly. If you are using paper-based records, they must be clearly written and easy to read, and you should write, sign and date all entries.  You have a duty to make sure, as far as possible, that records completed by students under your supervision are clearly written, accurate and appropriate.
  57. 57. Keep accurate records  Whenever you review records, you should update them and include a record of any arrangements you have made for the continuing care of the service user.  You must protect information in records from being lost, damaged, accessed by someone without appropriate authority, or tampered with.  If you update a record, you must not delete information that was previously there, or make that information difficult to read. Instead, you must mark it in some way (for example, by drawing a line through the old information).
  58. 58. Limit your work or stop practising if affected by ill-health… You have a duty to take action if your physical or mental health could be harming your fitness to practise.  You should get advice from a consultant in occupational health or another suitably qualified medical practitioner and act on it.  This advice should consider whether, and in what ways, you should change your practice, including stopping practising if this is necessary. 
  59. 59. Honesty and integrity vs. public trust You must justify the trust that other people place in you by acting with honesty and integrity at all times.  You must not get involved in any behaviour or activity which is likely to damage the public‘s confidence in you or your profession. 
  60. 60. Basic Human Instinct for Free-Market enterprise? “Every individual necessarily labours to render the annual revenue of the society as great as he can. He generally, indeed, neither intends to promote the publick interest, nor knows how much he is promoting it… He intends only his own gain, and he is in this, as in many other cases, led by the invisible hand to promote an end which was no part of his intention.” ~Adam Smith, in The Wealth of Nations “Purity of heart, if one could attain it, would be to see clearly and to act with grace and self-command from this point of view.” ~John Rawls, in A Theory of Justice
  61. 61. Ethical behaviour and practice can be nurtured…
  62. 62. Standards of Care Assessment…  How can private hospitals/private sector help to ensure that patient safety measures as well as physician performance are up to the mark comparable to peers, standards in the country or around the world?
  63. 63. Standards of Care Assessment… MSQH and JCI are the technical accreditation benchmarks for some sort of systems approach to ensure safety and performance: e.g. PSG (Patient-safety goals)  From the viewpoint of hospital management and peer groups, patient safety measures and monitoring can be instituted… 
  64. 64. Rating Doctors…
  65. 65. Some possible performance measures to consider/monitor… At PHKL, the MDAC has instituted a few preliminary measures:  Readmission rate within one week post-discharge  Deaths within 24-h of admission or surgery or procedure  Mortality assessment of all deaths, monthly audit, including causes, co-morbidities, costs of admission during last hospitalization  Review:  Hospital bills which run up beyond unexpected flagged targets, e.g. >RM100k  All hospitalizations extending beyond one week, for independent review  All surgeries that require > 2 re-surgical intervention
  66. 66. Some possible performance measures to consider/monitor… At PHKL, the MDAC has instituted some preliminary measures: REVIEW:  All unexpected outcomes where there is even an ‗implicit‘ potential patient or relative discomfort or complaint  Inter-hospital data mining as to relative incident and mortality rates of certain procedures and surgeries, e.g. CABG, PCI, Infection rates, with review of practice of physician outliers  Review physicians/surgeons who have been involved with repeated or recurrent incident reports  We‘ve not looked at physician income and procedure numbers or volumes… but we track intra-disciplinary physician charges and overall cost per procedure/therapy to detect outliers and possible deviant practices
  67. 67. US Mandatory Physician Quality Reporting System – linked to Payment to be in place by 2015
  68. 68. Physician Quality Reporting System (PQRS) We want to emphasize that if a group of physicians with 100 or more eligible professionals does not self-nominate/register to participate in the PQRS GPRO (Group practice reporting option web-interface or CMS-qualified registry) or elect the PQRS Administrative Claims option for groups for PY 2013, its Value Modifier in CY 2015 will be -1.0 percent.
  69. 69. Process Measures for Eligible Professionals and Group Practices Who Report Using Administrative Claims for the 2015 PQRS Payment Adjustment
  70. 70. Process Measures for Eligible Professionals and Group Practices Who Report Using Administrative Claims for the 2015 PQRS Payment Adjustment
  71. 71. Outcome Measures for Eligible Professionals and Group Practices Who Report Using Administrative Claims for the 2015PQRS Payment Adjustment
  72. 72. Cost Measures Section 1848(p)(3) of the Act requires physicians to evaluate costs, to the extent practicable, based on a composite of appropriate measures of costs. We adopted five per capita cost measures in the quality-tiering election for the Value Modifier:  Total per capita cost       Per capita cost for beneficiaries with four specific chronic conditions: Chronic obstructive pulmonary disease (COPD), Heart failure, Coronary artery disease (CAD), and Diabetes.
  73. 73. Relationship between Quality of Care and Cost Composites & Value Modifier
  74. 74. Tavistock principles  Rights  People have a right to health and health care.  Balance  Care of individual patients is central, but the health of populations is also our concern.  Comprehensiveness  In addition to treating illness, we have an obligation to ease suffering, minimise disability, prevent disease, and promote health.
  75. 75. Tavistock principles  Cooperation  Healthcare succeeds only if we cooperate with those we serve, each other, and those in other sectors.  Improvement  Improving healthcare is a serious and continuing responsibility.  Safety  Do no harm.  Openness  Being open, honest, and trustworthy is vital in healthcare.
  76. 76. Why have such principles?  The most fundamental problems in health care are ethical:     Who will live? Who will die? Who will decide and how? How will we allocate resources? There are ethical codes for individual professions but not for everybody in health care (owners, health care workers, patients)  We should have more explicit ethical codes for all, including healthcare owners and shareholders, even if GLCs! 
  77. 77. “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Sir William Osler 1849-1919 Sir William Osler, Aequanimitas: With other addresses to medical students... 2nd ed. (Philadelphia: Blakiston's Son, 1920) p.386
  78. 78. Discernment… ―But I AM ALWAYS WARY OF DECISIONS MADE HASTILY. ―I am always wary of the first decision, that is, the first thing that comes to my mind if I have to make a decision. This is usually the wrong thing. ―I have to wait and assess, looking deep into myself, taking the necessary time. ―The wisdom of discernment redeems the necessary ambiguity of life and helps us find the most appropriate means, which do not always coincide with what looks great and strong.‖ Pope Francis, 2013
  79. 79.  Most if not all doctors are smart, highly intelligent but individualistic people, with low tolerance of perceived „stupidity‟ or differing opinions unless from a respected „authority‟.  Most are dogmatic prima donnas, who strongly believe in personal and professional autonomy; some are inherently altruistic…  But times have changed, and medical regulatory authorities are invoked increasingly to constrain even discourage such selfinterested activities and market-driven ethos!
  80. 80. In many respects, our world has changed, and increasingly physicians will see more and more oversight activities and regulations including punitive sanctions to circumscribe some of our less than flattering actions and decisions… our society and our patients demand that we place their interests and benefits first and foremost, and not the other way round! Individual vs. Societal wants and Needs… We need to strike a prudent balance!
  81. 81. Thank you!

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