One of my primary areas of research is in conflicts of interest (COI). I generally focus on the financial relationships between physicians/researchers and the pharmaceutical industry. See Here Here and Here.
However, COI researchers and policy makers need to expand our scope to include other health care professionals who have relationships with other key health care industries, other than pharma and device companies. In this blog, I focus upon the relationships between discharge planners and long-term care providers (including home care, skilled nursing facilities and others). Long-term care is a growing part of health care expenditures, and represents an area where patients’ preferences and best-interests should be the primary obligations of discharge planning professionals — who are not biased due to industry marketing.
As I reflect back upon my almost two decades in health care, as a clinician, researcher and bioethicist, I am amazed at how pervasive marketing activities are in hospitals… other than seeing drug reps visiting doctors (in fact, this was banned in the hospital I worked). For example, during my first clinical internship, at a rural hospital near Atlanta, home care agency marketing reps were often bringing food and providing educational/marketing materials to the Case Management/Social Work office. We all hung out together. Same thing happened in NYC; although I was not directly involved in discharge planning, home care and post-acute care providers bestowed small gifts, food and other marketing materials – obviously, with the hope of building goodwill, and hoping that as a clinical social worker, I would indirectly influence referrals to their businesses. In addition to gifts and marketing, representatives from these health care companies were often ever-present in the inpatient units to help the Case Managers and other clinicians with the necessary paperwork, insurance reviews, and overall referral facilitation. From what I understand, this type of post-acute care industry “detailing” still occurs in American Hospitals with frequency.
In many ways, this is typical of relationship marketing, common in many businesses – where trust and interpersonal connections help pave the way for often productive and efficient business to business (B2B) interactions. However, it also represents a conflict of interest: it is the duty of discharge planning professionals (often nurses or social workers) to work in the best interests of their patients and to promote patients’ autonomy to make important decisions in their own care. One way discharge planners do this is by providing a list of reasonable post-acute options to patients as they are being discharged from this hospital; and certainly most, if not all, discharge planning professionals do this.
However, research demonstrates that conflicts of interest can create unconscious bias, which may increase the likelihood that even the most dedicated and ethical discharge planner will prefer one home care agency over another, which may not be in the patients’ best interests. For example, smaller home care companies might specialize in providing specific care, which may be better for some patients. However, if the larger agencies have representatives “in-house” at hospitals, helping to direct referrals their businesses, the smaller, more appropriate home care agency might not be provided as an option to the patient.
In addition to patient choice, long-term care in this U.S. is big business, and it is growing: there are over 12,000 home health agencies, over 1,100 inpatient rehabilitation facilities, almost 450 long-term care hospitals, and over 15,000 skilled nursing facilities. And, the number of home care agencies has grown a lot: approximately a 6.4% annual percent change between 2003 to 2011 (MedPac, A Data Book, June 2012). Additionally, Medicare’s expenditures on all post-acute care reached $63.5 billion in 2011 (up from $26.6 billion in 2001). Given the aging of our population, and the increasing costs of long-term care to society and to individuals, we should pay more attention to what drives care in this important sector of health care in the U.S., including how and why people get referred to receive these types of care.
In summary, we need to think about the ways COI may impact clinicians, and the quality of care patients receive. Perhaps we should not only focus our efforts on physicians and researchers, but also on other providers, who are gatekeepers to key health care resources in the U.S.