Hidden conflicts of interest in primary care
Why your primary care doctor may be pressuring you to undergo cancer screenings
When considering financial conflicts of interest in medicine, primary care doctors are typically not the first offenders that come to mind. Many times we think of surgeons who make a living from doing procedures. But what about primary care doctors? Surprisingly, they too face pressure to recommend certain interventions, creating a conflict of interest.
It’s easy to imagine why a surgeon may be biased toward recommending procedures. The more procedures they do, the more money they make. Thus they have a financial incentive to do more procedures. A notorious example is of cardiologists screening for peripheral arterial disease, or blockages in the arteries of the leg. Depending on the results, they then recommend a procedure to remove the blockage. This practice is of uncertain benefit to the patients that are screened, but it makes the cardiologists a lot of money.
Primary care doctors also face great pressure to recommend certain interventions. For example, Centers for Medicare and Medicaid Services (CMS) heavily incentivizes making sure patients are up to date on age appropriate cancer screening, i.e. colorectal cancer and breast cancer screening.
Insurance companies are graded based on how many eligible patients have fulfilled this recommendation, and there are financial incentives tied to this metric. The financial implications of maximizing this metric must be huge, because it’s all I ever hear about from upper management in the various practices I’ve spent time in. Entire departments and staff are hired whose sole responsibilities are to ensure patients fulfill their cancer screenings. Doctors are offered a bonus many times.
The obsession with improving these numbers is bordering on harassment in my opinion, both against the doctors and the patients. Patients receive, at minimum, annual letters reminding them to get screened. Front desk staff are trained to comb through charts and call patients to remind them. I’ve even seen cash incentives being offered to patients for completing their screenings.
As if that’s not enough, insurance company representatives frequently conduct audits to make sure doctors are keeping up. I am constantly reminded about these “care gaps”, so I can sell patients on the intervention. I use the word “selling” intentionally. Surprisingly, a discussion of the risks and benefits doesn’t count; the patient must follow through. It’s as if to imply that if a patient doesn’t get screened, the doctor has failed. The patient’s preferences and goals of care are pushed down to be of the lowest priority.
I’m starting to wonder if primary care physicians should be disclosing this conflict of interest given the immense pressures. Disclosing conflicts of interest is crucial for patients to make an informed decision. It’s no secret that surgeons may be biased toward doing more surgeries. Even conflicts of interest related to Big Pharma is now legally mandated to be disclosed publicly thanks to the Sunshine Act.
Disclosing the policies that pressure doctors to persuade someone to undergo a screening colonoscopy should be no exception.
P.S: This essay is not an argument for or against current cancer screening guidelines. Nor do I attempt to argue for or against incentivizing cancer screenings, and whether or not this policy is a net benefit for the population.