AMA council adopts self-referral standards

September 25, 1991

The American Medical Association's Council on Ethical and JudicialAffairs has revised its standards governing physician self-referral.The revamped standards published this month broke little new ground.Both the AMA and the American College of Physicians

The American Medical Association's Council on Ethical and JudicialAffairs has revised its standards governing physician self-referral.The revamped standards published this month broke little new ground.Both the AMA and the American College of Physicians have previouslyissued similar recommendations to guide physicians who refer patientsto medical businesses where they have an ownership interest.

The council statement that accompanied the recommendationssent mixed signals about the propriety of self-referral. The statementcharacterized physician investment in health-care facilities asa tradition that has indisputably benefited patients. Yet, thecouncil admitted that many physicians do not know how do dealwith the conflicts that arise from self-referral.

"If patients' interests can be represented more fairly,we must find a way to represent them," said Dr. Oscar Clarke,council chairman.

Self-referral has been the target of several recent federaland state initiatives. In July, the Department of Health and HumanServices announced safe harbor regulations aimed at eliminatingabusive self-referral practices.

A state-sponsored study in Florida published in August foundmany types of physician-owned businesses, including imaging services,are more profitable and lead to more utilization than independentbusinesses.

Several industry observers had predicted the AMA would usethe ethics policy change to politically distance itself from thecontroversial issue. The forecasts appear to be off target.

The AMA policy recommends against physician involvement indeals where dividends are tied to referral volume. As with theMedicare anti-kickback safe harbor regulations, the AMA requiresthat the general community have an opportunity to invest in themedical businesses on the same terms as physicians. Investmentthat require referral should be avoided, the policy said.

Two standards repeat previous AMA ethical policy. Patientsare to be informed about the physician's ownership interest whenreferred to the service and they are to be given an opportunityto use an alternative facility.

The council recommended establishing an internal utilizationreview program at facilities where physician investors refer patients.It cautioned physicians against exploiting their patients to induceunnecessary business. And it advised physicians to find an alternativesite for care when the patient's interests conflict with the physician'sfinancial interests.