Commentary on the Code of Medical Ethics and Deontology

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Chapter XIII: Fees

It is only fair that the physician should obtain from his professional practice what he needs to live with ease and dignity. When working in the service of a medical institution, whether public or private, his or her contract should provide, in addition to a fair salary that is constantly adjusted to the rising cost of living, the salary supplements necessary to enable him or her to face the risks of illness or disability without concern, and also to obtain a decent retirement pension. When physicians are self-employed, their professional income consists of the fees paid to them by their clients, source . This chapter sets out the rules for physicians to follow at subject for fees. It also contains criteria for other income that is more or less directly related to his or her professional work .

article 44.1. The medical act may never be performed for profit.

Fairness and moderation must govern all economic aspects of internship of medicine: not only fees and salaries, but also expenses and investments.

By stating that the medical act may not be performed for profit, it is implied that its primary purpose is for the benefit of the patient, not for the physician's own profit or utility. A physician may not take advantage of the ignorance, anxiety or fear of patients or their families to charge excessive fees, or to prescribe unnecessary or fictitious medical acts that serve only to increase his or her profit. He will do everything and only what is objectively indicated to treat his patient with skill . It is obviously immoral to perform superfluous examinations, especially if they are invasive, costly, or risky. It is equally unethical to order tests or examinations solely for the safety of the physician, who thus wants to protect himself against possible accusations of negligence. The ethics of diagnostic or therapeutic indication prohibits wastefulness, the pursuit of profit, or defensive medicine.

Justice and the duty not to discriminate oblige physicians to provide humane and competent care to all their patients, without lowering the quality or intensity of their care on the basis of the social class of their patients or the circumstances (internship private or in a public institution) of their work. Therefore, even if the amount of the fees charged is very different because of the different economic status of the patients, the physician may not provide them with medical or surgical treatment of a different quality. Nor can the doctor be allowed to refer patients to his private enquiry that he treats when he is employed: "diverting patients from public consultations of any kind to his private enquiry for self-interested purposes" is one of the prohibitions contained in article 44, l) of the EGOMC.

On the moral obligation to care for financially insolvent patients, see the following article , in fine.

article agreement 44.2. The practice of medicine is the livelihood of the physician, who is entitled to be remunerated in accordance with the importance of the service provided, his or her own skill and professional qualifications, any particular circumstances and the financial circumstances of the patient status .

It has already been stated above that it is only fair that the physician should obtain from his or her professional practice what is necessary to live a life of ease and dignity. The setting and collection of professional fees is part of the medical act. reference letter The grade fee or, as the case may be, the fee line on the invoice to be paid by the patient, primarily refers not so much to the technical skill as to the intellectual work and moral responsibility of the physician. In theory, the medical act is not subject to any economic valuation, it has no price: the doctor is compensated with a fee.

And, although fees occupy a secondary place in the doctor-patient relationship, they are not to be regarded as negligible or vexatious. The doctor must declare, when asked by the patient, the calculated amount of his fees and specify on his budget of expenses which part corresponds to the fees for his actions and which part corresponds to the expenses caused by the medical care (stay in the clinic, medicines, materials, services). He/she will also indicate how they can be paid and, if necessary, the social organisations that can help the patient with the payment of medical expenses. There is no objection to the frequent practice of delegating to secretaries or nurses all matters relating to the setting and collection of fees internship . However, physicians should not refuse to see patients who wish to discuss this problem with them personally.

This article points out that, within the deontological limits, the doctor must take into account certain circumstances when setting his fees: the services he has provided, his skill and prestige, the economic condition of the patient, the circumstances of the case. The importance of his services depends on their technical complexity and the skill required, the risk of the intervention, the time involved employee , and social and cultural factors: traditionally, higher fees are charged in certain regions, social strata or medical specialties.

The level of fees customarily charged by a given physician serves, to some extent, to make a spontaneous top-down and bottom-up selection of the patients who come to him or her. Low fees are often unattractive to wealthy patients, while very high fees exclude poor patients from the practice. Although such behaviour seems to be socially accepted, or at least tolerated, it cannot become an exclusionary rule , as it would lead to unethical behaviour, as noted by article 4.2. A physician who systematically refuses to accept poor or insolvent patients on his or her enquiry would demonstrate that he or she is dominated in his or her professional internship by economic prejudice. A physician has a general moral obligation, out of solidarity and charity, to admit to his enquiry some indigent patients. And if, once the doctor-patient relationship has begun, because of the unforeseen course of the disease, the fees initially calculated fall far short of those actually earned, it is the duty of the physician to continue to provide his services, even if the patient is unable to pay them immediately.

article 44.3. Medical fees shall be dignified but not abusive. They may never be shared without knowledge of the payer or charged for acts not performed.

Four important criteria are noted in this article . The first one recalls that dignity must inform the financial aspects of the internship medical practice. The second sets the deontological limits for the amount of fees. The third is the prohibition of dichotomy. The last one condemns the internship of the falsification of the grade of fees.

1. Dignity in fees does not only refer to the quantitative aspect, as discussed in the following point. It refers above all to the circumstances of restraint and tact that should surround them. There are behaviours that are considered normal in many businesses or other professions, but which in medicine would be inelegant or undignified. Thus, for example, a physician may not demand advances from his patient for services not yet rendered. A different matter is the periodic payment of fees and expenses when, once the doctor-patient relationship has begun, it continues over time: it is then normal to be paid at the end of each visit. Nor is it compatible with dignity for the doctor to extort money from the financially strapped patient, to demand payment in kind, to seize the patient's assets by court order, or to hire the services of individuals or agencies that are more or less notoriously involved in the collection of arrears. The doctor must be tolerant of patients who forget to pay and will not refuse to treat them again. In rural areas, agreement with local traditions and economic cycles of plenty and scarcity, doctors will accept gifts in kind, sometimes of more symbolic than monetary value, as compensation for their professional services.

It has never been more than a mere project what is foreseen in subject of fees by article 34, j) of the EGOMC: the possibility for the Colleges, if they have the appropriate administrative and accounting services, to take charge, in general or at the request of the members who request it, of the collection of professional fees, remunerations and fees.

2. The deontological limits of the amount of fees.

Fee moderation is, to begin with, a statutory obligation. The article 64, 2, d) of the EGOMC classifies as less serious misconduct, which carries the sanction of a warning by official document, "the manifest abuse of the grade of fees or that these are lower than those established as minimums".

A physician who carelessly or intentionally exceeds the grade fee shall, upon complaint by the patient, agree to reduce the fee to a reasonable level.

Moreover, it is mandatory to adhere to the minimum fee rates set by the competent bodies. The fixing of minimum fees is based on the need to protect professional decorum, to maintain a certain social esteem for the physician's performance. The physician is prohibited from lowering his or her fees beyond a critical minimum level, since fees are a symbol of the physician's human and technical qualities. The doctor's self-respect prevents him from asking for derisory compensation for his work . The respect he owes to his colleagues prohibits him from entering into an unfair skill with them and, so to speak, declaring a war of rebates.

In the matter of fees, the physician's conduct should be regulated by an all-or-nothing law: it is incomparably more dignified to offer one's services free of charge to those who cannot afford them than to demand an undignified and mean stipend. The doctor is free to demand or not to demand payment of his fees: he may even demand them, and then return them. For reasons of kinship, friendship, charity or collegial solidarity, a physician may, and indeed should, provide his services free of charge. For this conduct to be deontologically correct, an essential condition must be met: there must be no difference in the quality of professional care or in the respect due to the patient between free and remunerated internship .

Certain bodies (national medical speciality associations and societies) publish and keep up to date the minimum fee rates. This is a function conferred on the Professional Associations by Law 2/74, in its article 5, section ñ) and which the EGOMC places in the hands of the Provincial Associations, according to section i) of article 34 of the EGOMC, which states, among the specific competences of the Provincial Associations, that of "regulating the minimum fees corresponding to the free practice of the medical profession".

The deontological notion of decorum and dignity of the profession must also be present in the negotiations for setting the scales of financial compensation for the different medical acts established by the free insurance companies or agreed in the service agreements with the Social Security. agreement This is stated in section i) of the aforementioned article 34 of the EGOMC, when it attributes to the Colleges the function of "informing in procedures in which medical fees or tariffs are discussed and, in general, representing and defending the interests of the medical profession before the Administration, Institutions, Courts, Entities and individuals, in accordance with the provisions in force in each case".

Some have questioned the deontological nature of both the setting of minimum fee rates and the WTO's participation in reaching consensus on scales before the Administration or the free Insurance Entities, arguing that this is strictly a trade union matter subject . While recognising the decisive role of the trade unions in these negotiations, it must be stated that the matter constitutes an immediate skill matter for the medical profession, since it is not simply a conflict between professionals of different trade union or socio-political tendencies, but rather the common interest of the entire profession, which is to determine the ethical conduct of doctors in their demands for financial compensation.

3. The prohibition of hidden fee splitting.

Each of the doctors involved in the care of the same patient must, in the exercise of their freedom and independence, indicate the amount of their own fees and pass the corresponding grade. This way of proceeding has obvious advantages: it eliminates the danger of anonymity that always threatens team medicine, it makes the financial and fiscal management of each one more transparent, and it avoids conflicts between colleagues when it comes to distributing the fees.

But, above all, it inhibits the internship of dichotomy, i.e. the hidden sharing of fees between two or more doctors, or between doctors and members of other health professions. Typical of this more or less asymmetrical sharing of fees is its mercantilist character: it is a commission given and received for dealing in medical actions.

In its ethical structure, the hidden fee splitting is almost always an injustice. First of all, it is an injustice if it leads to an increase in the regular fees by an additional amount: the amount which is submission precisely as a commission to the colleague. The injustice is even greater if it leads to over-prescription or to superfluous indications for diagnostic ( laboratory, radiological, various specialities) or therapeutic (surgical, rehabilitative, psychotherapeutic) procedures.

The very existence of the dichotomy profoundly disrupts the internship of medicine, because the doctor no longer puts the patient's interests first, but his own economic advantage: he sends his patients not to the most competent colleague, but to the one who gives him the most generous commission. The patient then tends to pay more money for a lower quality of service. This may go unnoticed for some time, but it eventually comes to light, bringing discredit to the doctors involved and to the profession as a whole. Giving commission and receiving commission are both unjust actions, as they create a state of injustice among physicians. status Doctors of integrity who reject the dichotomy are placed in a position of economic inferiority compared to others who are less qualified but more venal, but who obtain more work thanks to their participation in the dirty game of the dichotomy.

There are doctors who think that the dichotomy is justified and that it is even a remedy for certain irregularities. They say that, for example, submission of a commission from the surgeon to the general practitioner who has sent the patient to him for surgery is a fair compensation for the usual asymmetry in the fees charged by one and the other. But it is morally unacceptable to claim that one injustice can be remedied by another.

4. The prohibition of fictitious fees.

Fortunately, the phenomenon of fictitious fees is rare among us. It occurs, for example, when a doctor with a guilty conscience and a patient with a guilty conscience conspire to pass on to a third party, who is responsible for paying for the medical care, a hefty grade falsifying the issue and the nature of the services provided (home visits, examinations, treatment, therapeutic sessions, etc.), in order to increase the grade fee. The two accomplices in the fraud share the amount defrauded. This action is not only ethically but also statutorily condemned. article 44, d) of the EGOMC forbids "to join agreement with any other person or entity to achieve utilitarian ends that are unlawful or in violation of professional dignity".

article 44.4. Only in exceptional cases may a physician sell medicines, drugs or appliances directly to the patient. He may not receive commission for his prescriptions or accept or demand remuneration from intermediaries.

This article echoes that of article 44 of the EGOMC, whose points f) and h) respectively prohibit "selling or administering drugs, medicinal herbs, pharmaceutical products or own specialities to clients, using their status as a doctor", and "accepting direct or indirect remuneration or benefits in any form whatsoever, from the houses of medicines, medical devices, spas, mineral or medicinal water companies, opticians, etc., as a commission, as a propagandist or for other reasons other than work entrusted in accordance with the regulations in force", on commission, as an advertising agent or provider of clients, or for other reasons than work commissioned in accordance with the regulations in force".

The various forms of commercialism that may tempt the doctor are therefore condemned. The article admits, however, that in exceptional situations the physician may provide the patient with certain materials, without deriving any financial advantage from doing so. The physician may never derive commercial benefit from the products he or she prescribes. When difficulties of access to pharmacies make it advisable to set up emergency medicine cabinets in small rural areas, the doctor shall comply with the rules established by the Order of 20 February 1962, which states that the doctor is obliged to look after and ensure the proper functioning of the medicine cabinet, which shall be supplied by the pharmacist appointed for this purpose, and that he may only receive for his service the fee assigned to him for this purpose by the Town Council. He/she may never charge any commission to the public for this purpose.

When a product is to be administered to the patient in a consulting room for diagnostic tests or emergency treatment (radiological contrast, antigens, meals from test, etc.), the net cost will be included in the grade fee, without the doctor being able to increase it by any surcharge or mark-up.

The physician must refrain from any form of collusion or agreement for profit with pharmacists, opticians, suppliers of prostheses or materials for medical use; ambulance operators; managers of hotels, spas, gyms or institutes that care for body appearance; or agents of the medical or pharmaceutical industries. He shall never give rise even to the suspicion that he is benefiting financially from what he prescribes or recommends. Nor shall he engage in business dealings which, even indirectly, might reasonably give rise to suspicion that his conduct towards his patients may be influenced by commercial interests. This rule is even more pressing in the case of remedies or procedures that are not included in the orthodox internship of medicine, even if they are popularly accepted.

Tradition excludes from the activities prohibited to doctors the setting up and management of clinics for the various medical or surgical specialities. However, the spirit of this article obliges us to exclude from these activities anything that could be taken as an indication of commercial exploitation of the patients who come to them.

article 44.5. Claims and disputes concerning fees shall be submitted to arbitration by the Colleges.

The high school is obliged to act as arbitrator in complaints and claims regarding fees submitted to it. Its competences include that of "studying the economic relations of professionals with their clients, and may require and even discipline, depending on the case, those members whose actions may be detrimental to professional decorum" (article 34, h of the EGOMC).

It must be acknowledged that there are occasionally reprehensible episodes of fee abuse, which damage the image of the profession, or more subtle forms of exploitation (multiplication of high-tech examinations, unnecessary prolongation of the patient's stay in the clinic or hospital, or repetition of regular check-ups), by means of which doctors can increase their income. The medical associations should always clamp down on such abuses and sponsor is the only sensible policy to contain the medical expense : the elimination of all superfluous expense .