Professionalism in Health Care Systems

Payment models and financial incentives can create conflicts of interest among patients, health care organizations, and physicians. They can encourage undertreatment and overtreatment, as well as dictate goals that are not individualized for the particular patient.

Structures that influence where and by whom care is delivered—such as accountable care organizations, group practices, health maintenance organizations, and other entities that may emerge in the future—can affect patients’ choices, the patient-physician relationship, and physicians’ relationships with fellow health care professionals.

Formularies, clinical practice guidelines, decision support tools that rely on augmented intelligence, and other mechanisms intended to influence decision making, may impinge on physicians’ exercise of professional judgment and ability to advocate effectively for their patients, depending on how they are designed and implemented.

Physicians in leadership positions within health care organizations and the profession should:

1. Ensure that decisions to implement practices or tools for organizing the delivery of care are transparent and reflect input from key stakeholders, including physicians and patients.
2. Recognize that over reliance on financial incentives or other tools to influence clinical decision making may undermine physician professionalism.
3. Ensure that all such tools:
   1. are designed in keeping with sound principles and solid scientific evidence.
      1. Financial incentives should be based on appropriate comparison groups and cost data and adjusted to reflect complexity, case mix, and other factors that affect physician practice profiles.
      2. Practice guidelines, formularies, and similar tools should be based on best available evidence and developed in keeping with ethics guidance.
      3. Clinical prediction models, decision support tools, and similar tools such as those that rely on AI technology must rest on the highest-quality data and be independently validated in relevantly similar populations of patients and care settings.
   2. are implemented fairly and do not disadvantage identifiable populations of patients or physicians or exacerbate health care disparities;
   3. are implemented in conjunction with the infrastructure and resources needed to support high-value care and physician professionalism;
   4. mitigate possible conflicts between physicians’ financial interests and patient interests by minimizing the financial impact of patient care decisions and the overall financial risk for individual physicians.
4. Encourage, rather than discourage, physicians (and others) to:
   1. provide care for patients with difficult to manage medical conditions;
   2. practice at their full capacity, but not beyond.
5. Recognize physicians’ primary obligation to their patients by enabling physicians to respond to the unique needs of individual patients and providing avenues for meaningful appeal and advocacy on behalf of patients.
6. Ensure that the use of financial incentives and other tools is routinely monitored to:
   1. identify and address adverse consequences;
   2. identify and encourage dissemination of positive outcomes.

   All physicians should:

7. Hold physician-leaders accountable to meeting conditions for professionalism in health care systems. 
8. Advocate for changes in how the delivery of care is organized to promote access to high-quality care for all patients.