JAMA commentary: Medical commons -conflict of interest?

The journal of the American College of Physicians (ACP), the Annals of Internal Medicine, in 2006 featured a five page article in which the former CEO, and then current board member of Aetna, Dr. John W. Rowe, pontificated on the "moral basis for physicians..to participate in...[P4P]." I commented on that article at the time and noted that Aetna's reputation among practicing physicians was such that Dr. Rowe might not have been the most credible witness to present the case for P4P , a movement which the ACP has tended to favor.

More recently, the current President and CEO of the ACP, Dr. Christine K. Cassel, has teamed with another officer of Aetna, Dr. Troyen E. Brennan, to offer further ethical and moral pronouncements regarding the "responsibility" of physicians. This commentary, " Managing Medical Resources-return to the Commons?", can be found in the June 2003,2007 issue of JAMA (vol.297,no.22 pg 2518).

I will leave a more detailed analysis of their apparent proposal for the establishment of "integrated delivery systems" as "accountable care organizations" (sound like big HMO-like entities to me) and the assumption of those groups of responsibility for a population to another time and focus now on what seems to be a major conflict of interest regarding Dr. Brennan.

Early in the article the authors correctly point out that the inclusion of the duty on the part of physicians to "manage medical resources" that is found in the Physician's Charter on Medical Professionalism is controversial as it conflicts with the primary duty of the physician to the patient. They then ask is "this [responsibility] really our duty?

"Our" is used by Dr. Brennan to apparently speak as a member and express commonality with the group of physicians who "live and work in [what he describes] as a medical commons and bear responsibility for it". Dr. Brennan does hold a M.D. degree and has practised medicine but he is currently an officer (A senior vice president) of large insurance company involved in medical insurance and managed care and as such has a fiduciary duty to foster that organization and work to improve its profits.

The authors , later in the commentary, again correctly note that practicing physicians are skeptical about any savings generated by "quality" or P4P programs will find its way to actually improving or expanding medical care. Would not this firmly based skepticism regarding the motives and actions of insurance companies not also target any proposal made by a officer of Aetna?

I cannot understand how officers of ACP and editors of their journal believe that their case for whatever changes they recommended in U.S. health care will be moved forward by having as a partners in that advocacy officers of a insurance company whose business practices ultimately lead to a very large settlement in a class action brought by a number of state medical societies. (Details of that settlement can be found here). When one argues for a given proposal tactical concerns would seem to favor presenting a credible spokesman.

The capitation type system proposed is unlikely to gain traction as long as physicians continue to believe and act as if their primary duty is to the individual patient and not to the collective.This article seems , in part, an effort to disabuse physicians of this ethical imperative which the authors may consider an obstacle to their scheme to "ensure proper allocation of health care resources".

Both Dr. Cassel and Dr. Brennan close their disclosure statement stating that the views expressed are those of the authors and do not necessarily reflect the opinions of either institution. It would be hard to believe that Aetna would allow one of its officers to publish an article in a widely read medical journal without agreeing with its contents.