Almost two-thirds of ambulatory surgery centers (ASCs) are owned solely by physicians. More than 90% of centers include at least some physician ownership.1 “We are in a unique time where surgical care is transitioning out of the hospital to outpatient facilities at a record rate,” notes Amit Jain, MD, one of the study’s authors and the chief of minimally invasive spine surgery at Johns Hopkins Hospital.
The COVID-19 pandemic accelerated this trend, when patients felt uncomfortable going to hospitals unless absolutely necessary. Outpatient facilities, such as ASCs, often are run or operated by surgeons.
“Thus, surgeons have an important role to play, not only as clinicians but also as healthcare managers. We have an ethical duty to be good custodians of healthcare resources,” Jain says.
However, physician ownership creates an inherent conflict of interest, known as “dual agency.” This means the physician has a personal financial stake that could conflict with the ethical obligation toward patient well-being. “These conflicts have become increasingly more common,” Jain notes.
Jain says that for physicians, it is important to engage in open conversations and think about how to provide the best care for patients without putting them at financial harm.
Jain and colleagues proposed some tactics for appropriate navigation of these conflicts of interests. These include disclosure of ownership status, institution of clinical pathways, and adherence to accepted clinical practice guidelines for materials selection and surgical indications. “The bottom line is we should always uphold the patients’ best interests,” Jain says.
Regardless of exactly how physicians go about it, disclosure of financial conflicts always is going to be the best policy.
“The guiding principles should always be informed consent, shared decision-making, and keeping the patients’ interests first,” Jain says.
If a surgeon owns an ASC where they practice surgery, patients may assume all recommendations are made based on the best interests of the patient, but the surgeon might be making recommendations that reap financial benefits.
“The issue is that patients should reasonably assume that their surgeons would make recommendations based on patient benefit, what we refer to as beneficence,” says Peter Angelos, MD, PhD, FACS, MAMSE, director of the University of Chicago MacLean Center for Clinical Medical Ethics.
If a surgeon is making recommendations based on financial benefit, patients would have no way to know this. “Disclosure is the first step in mitigating the problem of dual agency when a surgeon owns a stake in an ambulatory surgical center in which they practice,” Angelos says.
Still, disclosure may not be enough. Surgeons also should be willing to engage in peer review of practice patterns to ensure patient benefit is the central focus of the recommendations made. “Patients should know that the potential financial conflict of interest exists, and they should clearly know if their surgeon is making recommendations based on something other than what will most benefit the patient,” Angelos says.
REFERENCE
1. Xu AL, Jain A, Humbyrd CJ. Ethical considerations surrounding surgeon ownership of ambulatory surgery centers. J Am Coll Surg 2022;235:539-543.
Physician ownership creates an inherent conflict of interest, known as “dual agency.” This means the physician has a personal financial stake that could conflict with the ethical obligation toward patient well-being.
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