Medical Directors Are Physicians First

"Physicians in administrative and other nonclinical roles must put the needs of patients first. At least since the time of Hippocrates, physicians have cultivated the trust of their patients by placing patient welfare before all other concerns. The ethical obligations of physicians are not suspended when a physician assumes a position that does not directly involve patient care." -- Opinion 8.02, AMA Council on Ethical and Judicial Affairs, issued in 1994.

One of the side effects of the transition from the solo practice of medicine into group practice has been the proliferation of medical directors. These physicians serve a variety of institutions and organizations, including hospitals, nursing homes, group practices, insurers and managed care organizations.

Perhaps the most significant development has been the increasingly important role of medical directors who are employed by third-party payers -- usually insurance companies and managed care groups -- or by entities performing medical appropriateness determinations for payers. These physicians' duties, which include making coverage determinations, go far beyond the administrative tasks performed by earlier generations of medical directors. Today's health plan medical director is in a position of responsibility not only for the best interests of the individual patient, but also for the best interests of the plan's enrollees as a whole.

Recognizing the critical role played by this new generation of medical directors, and the difficult decisions they face, the AMA's Council on Ethical and Judicial Affairs in June provided a carefully worded, thoughtful statement that spelled out the ethical obligations of these physicians.

Many of the medical directors' decisions, the council emphasizes, fall within the professional sphere of a physician; thus they are functioning under the professional sphere of physicians "and must uphold ethical obligations, including those articulated by the AMA's Code of Medical Ethics." The overriding ethical obligation is to promote professional medical standards, the council states, including "placing the interests of patients above other considerations, such as personal interests (e.g., financial incentives) or employer business interests (e.g., profit). This entails applying the plan parameters to each patient equally and engaging in neither discrimination nor favoritism."

It also is ethically incumbent that plan medical directors use equitable criteria when making care-related decisions, the council stresses. This includes contributing professional expertise to ensure that plan guidelines provide fair and equal consideration of all plan enrollees, and that decision-making mechanisms are objective, flexible and consistent and apply only ethically appropriate criteria.

Finally, the council calls for the medical director to work to achieve widespread access to adequate medical services, encouraging employers to provide services that meet AMA guidelines for an adequate level of health care. One step toward meeting this goal is for medical directors to encourage their employers to provide access to services that would be considered an adequate level of health care.

Clearly, the physician serving as a health plan medical director faces many difficult decisions. Most of their activities fall within the professional sphere of physicians, because they draw on professional knowledge and values gained through medical training and practice, and they affect the care of patients and groups of patients.

However, the assumption of a title or position that removes the physician from direct patient-physician relationships does not override the physician's ethical obligations.

The new AMA statement provides physicians with valuable guidance to ensure that those ethical obligations are met in a manner that best serves the interests of patients -- individually and collectively." [American Medical News, Vol. 42, No. 34, Sept. 13, 1999:17]