Patient Referrals: What Is Unethical?

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By Bonni Wilke

I have worked on the administrative side of O&P practices for over 20 years. It is not a secret that certain physicians prefer to refer patients to specific O&P practices. There are many reasons why the physician may have a preference. It could be the location of the facility; perhaps there aren't any other facilities in the area that the physician is familiar with. The facility may have a marketing strategy that inundates physicians with information and therefore gets the lion's share of the referrals, or the physician could have developed a longstanding and satisfactory relationship with the facility.

While these reasons are all reasonable, our office recently experienced a preferential situation that crossed an ethical line.

The surgeon who performed our new patient's amputation refused to write an order for a prosthesis because the patient was not going to use the prosthetic facility the surgeon wanted him to use. The surgeon would only provide a referral to one prosthetic facility in an area with more than a dozen.

Initially it seemed like an easy fix for us to treat our patient: We would have another physician of the patient's write an order. However, the payer, a vocational rehab service, said that the order must come from the surgeon.

This scenario posed a question I decided to ask my peers on the OANDP-L listserv: Is the surgeon's conduct unethical?

I would say that it is. My colleagues and I have a common goal of improving the life of each of our patients. Because we only provide prostheses, rather than treating short-term injuries, our relationship with a patient is lifelong. I cannot wrap my head around the idea that if a patient needs an order to start his or her journey of ambulating again, why would any medical professional prohibit or delay that goal in any way? In this case, why would a surgeon, who should work in the patient's best interest, not support the choice of O&P facility? What ethical reason would a surgeon have to believe that only one O&P facility could provide an acceptable prosthetic device to his patient?

Most responses to my listserv post said to just move on, to have the patient get an order from another physician. This response leads me to believe that other facilities have faced this same sort of discrimination and have not pressed the case. Other responses suggested we contact our state insurance commissioner or file a complaint with the department of insurance. Those are valid suggestions, but initially we were concerned that the patient would be left without a prosthesis while the complaint was investigated. Later, the vocational rehab corrected its requirement, and we were able to proceed with an order from another physician.

We are not pursuing a complaint with the insurance commissioner for one reason: We remain hopeful that this surgeon, who is by all accounts an extremely good surgeon, will realize that we are just as good at and just as passionate about our jobs as he is his.

The goal of anyone in the medical field should be to provide the best options for patients to meet their goals. Period. When you can, if you can, be their advocate. The world of physician referrals can be grizzly at times, and even though we need their referrals, we must focus on positive patient outcomes.

Bonni Wilke is part of the administrative staff at Precision Prosthetics, Memphis, Tennessee. She can be reached at bwilke@precisionprosthetics.com.