Conflict of interest in an unaligned world

The issue of conflict of interest was raised last week when I was assisting a new peer review committee for a public hospital where the physicians are predominantly in private practice. Committee members questioned how peer review can be accomplished when physicians are partners or competitors and when some physicians are employees and others independent. Ironically, the issue also came up the previous week when I was working with a large physician practice group that was attempting to establish an internal peer review process. In that instance, everyone was a partner and yet there still was a concern about conflicts of interest.

Let's start with the definition of conflict of interest and then explore how it makes peer review difficult. A conflict of interest occurs when an individual or organization is involved in multiple interests, one of which could possibly corrupt the motivation for an act in the other.  In peer review, this means that the evaluating physician’s judgment might be affected by some conflict with the physician under review. Peer review conflicts are typically economic or personal.  For purposes of this column, I’ll focus on the economic issues.

Economic conflicts range from direct competition or economic interdependence such as referral sources or partnership. Competition tends to raise the potential for over scoring (being too harsh) while economic interdependence can lead to underscoring (being too nice).  However, if partners are not getting along, an economic conflict can turn into a personal one and reverse the impact.

A potential economic conflict does not preclude participation in peer review.  The ethical obligation for the individual with a conflict of interest is disclosure. It is the obligation of the deliberative body to determine whether the conflict is substantial enough to disqualify the individual.  This decision is best made on a case-by-case basis. I have observed peer review performed fairly by partners and competitors who can place the relationship aside to objectively evaluate the issues of a case.  I have also seen instances when individuals could not do so and needed to be recused from the process.

In this world of complex medical economic relationships the question arises as to whether conflicts of interest can ever be completely eliminated.  The answer is clearly no. Human beings will always have the potential for multiple interests affecting their judgment. The better question is what models of medical organization can reduce conflicts of interest.

The likelihood of direct economic competition within a specialty can be reduced with a medical staff with a single group practice, like an academic medical center, or a complete physician employment model. However, inter-specialty competition may still exist in such models especially related to overlapping clinical privileges.

But what model can reduce economic conflicts within an organization that has a typical medical staff that includes independent and employed or contracted physicians?

The model that seems most promising is one where physicians have an aligned economic relationship with each other regardless of the type of practice. The concept of an accountable care organization (ACO) creates such an alignment. The economic shared success of an ACO is designed to provide the basis for mutual accountability that can reduce the need to defend a partner or attack a competitor.  It will be interesting to see if physicians who find themselves in an ACO can take advantage of this opportunity for conflict-free peer review.

Robert J. Marder, MD, CMSL, is vice president of The Greeley Company, a division of HCPro, Inc. in Danvers, Mass.