Payment reforms that link health care providers’ reimbursements to their performance on various metrics incentivize providers to improve the quality and efficiency of care they provide to patients. Unfortunately, these reforms also create strong incentives for providers to reject patients who do not adhere to medical advice. This commentary argues that providers’ avoidance of non-adherent patients flouts the medical profession's commitment to patients’ best interests, undermines patients' trust in health professionals, and aggravates disparities in health. Moreover, the economic incentives under (...) payment reforms that encourage quality and efficiency gains are weakened when providers can escape the financial penalties for poor outcomes by simply firing their non-adherent patients. (shrink)

The rise of managed care initiated a steady decline in solo and small group physician practices and the emergence of new delivery models built around large health care organizations. Health care reform has only accelerated this trend as public and private payors shift to new payment methodologies that reward clinical and financial integration among providers. As a result, patients increasingly receive care from physicians and other health professionals organized into collaborative partnerships with one another and institutional providers, such as hospitals. (...) As described below, this new organizational dynamic profoundly influences the clinical judgment of physicians. No longer can society simply depend on the professionalism of individual physicians to ensure ethical integrity in the health care setting. Rather, ethical integrity in the health care setting also requires a strong foundation of organizational ethics. (shrink)