The Permanente Medical Group of the Kaiser Permanente health plan organization, which operates in nine states and Washington, D.C., recently updated its conflict-of-interest policy for its more than 5,000 Northern California physicians to make it much stricter. Basically, these docs cannot accept any gifts.

“If you look at the AMA guidelines for interactions with physicians, or the AdvaMed Code, they say the physician should take nothing of a value greater than $100,” says Sharon Levine, MD, a pediatrician and associate executive director of the Permanente Medical Group in Northern California. “Our feeling was that once you start arguing about price, you've lost the battle. There's a great deal of behavioral research that supports the fact that it is the bestowal of the gift, not the size of the gift, that creates a sense of loyalty and obligation. Whether it's a $5 Starbucks coupon or a $100 textbook, the exchange of value between industry and physicians is just not appropriate.”

Kaiser also changed its policy around continuing education. “We have a department of physician education and development which helps to support CME in the medical group,” says Levine. “We have asked that now all unrestricted educational grants not be between an individual and a vendor, but between a department and the vendor.”

The world has changed since the original policy was put into place 30 years ago, Levine says. “For the past 20 years, most of the potential for conflict related to the relationship with drug companies. In the past five years, with the explosion of the rest of the technology industry — devices, medical equipment, orthopedic implants — the opportunities for physicians to interact with industry has grown in scope and in scale. There used to be much less money involved, and many fewer opportunities for mischief.”

Levine says, it also was an opportunity for the Permanente Medical Group, as the largest physician group in the country, to develop a policy that would not cut off physicians from appropriate interactions with industry, but would make clear what the boundaries are.

Breaking the Triple-F Cycle

The whole point of the new policies, she says, is to “take the physician out of the cycle of food, friendship, and flattery. We just wanted a policy that addressed both real conflicts and the perception of conflicts. We take care of 3.2 million people in Northern California, and we wanted our patients to have total confidence that physician decisions are not being driven by self-interest, that they are driven by what is best for the patient. This is true at the corporate level, where purchasing decisions are made; at the clinical peer level, where utilization decisions get made; and at the individual physician level, in the exam room.”

So far, she says the policy has received a positive reaction from the group's physicians, and she thinks it will influence more than just the group's Northern California docs. “I think this direction is going to be one that the profession is going to have to adopt. It's been slow in coming, but you can't pick up a newspaper without a disclosure that's at least embarrassing, if not humiliating, to the person described. The reputation of our profession is one of the most precious things we have, and if we want to continue to earn the trust that's essential for the therapeutic relationship, we must behave in a manner that's above suspicion,” says Levine. “I think our physicians were very proud that we were able to reach consensus about moving in this direction. It also enables us to put the vendors on notice: Here's our policy, and we have sanctions in place if you violate it.”