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Let's Heal Ourselves First

Richard A. Norling and Kirk O. Hanson, for HealthLeaders Media, March 12, 2009

Each day, patients trust physicians to make decisions about how to best treat illnesses. Physicians trust hospitals to provide them with the most effective medicines and medical equipment. Hospitals trust manufacturers to produce the most reliable, innovative healthcare products. Together, the healthcare industry shares a responsibility to honor this trust by abiding by the highest ethical standards.

Successful ethical standards help ensure that relationships among these healthcare actors are appropriate and transparent. Relationships between manufacturers and providers yield mutual benefits that positively affect patient outcomes. But when financial relationships that could influence decision making are established and not disclosed, a line has been crossed that can shatter patient confidence and damage credibility in an industry that depends on maintaining trust.

Understanding this reality, a groundswell of disclosure initiatives have started to emerge.

Universities such as the University of Pennsylvania and large hospital systems like the Cleveland Clinic recently started voluntarily disclosing all manufacturer payments to physicians. The top five makers of hip and knee implants have agreed to disclose all payments to physicians, and Eli Lilly, GlaxoSmithKline and Merck say they will follow suit next year. The Pharmaceutical Research and Manufacturers of America and the Advanced Medical Technology Association, two of the largest associations representing drug and device manufacturers, respectively, strengthened their codes of conduct related to gifts and other payments, and will make public the list of members who abide by the new guidelines. And, most recently, Senators Charles Grassley (R-IA) and Herb Kohl (D-WI) have re-introduced the Physician Payment Sunshine Act that would require manufacturers to disclose payments of value to physicians.

These and other disclosure efforts, when effectively executed, create transparency and can drive a more empowered culture of ethics. But today's efforts are not as comprehensive as they could be.

Trust requires that virtually every healthcare industry organization create a systematic process to ensure that all dimensions of this critical issue are thoroughly addressed.

Healthcare companies need to be regularly measured against their industries' ethics codes. Codes of conduct and the measures created to ensure compliance must be publicly disclosed. Participating companies should be benchmarked against one another to identify gaps and best practices. An external oversight body of experts in the field should provide input into the ethics and compliance process. Information about ongoing compliance should be publicly reported on a regular basis. And clear and understandable rules should be developed to punish those who fail to comply.

The Premier healthcare alliance, a healthcare group purchasing organization (GPO), has a high-level commitment to transparency, best practices in accountability and business ethics. Demonstrating that commitment, Premier led an effort to form an effective voluntary ethics oversight organization called the Healthcare Group Purchasing Industry Initiative (HGPII). HGPII provides a model for other healthcare organizations in creating a comprehensive, self-regulating program.

Developed with guidance from Kirk Hanson, a longtime consultant to industry ethics efforts and professor of business ethics, HGPII exhibits key elements of an effective voluntary effort. HGPII requires participants to follow six core ethical principles. Adherence to the principles must be documented in an annual accountability questionnaire, which is reviewed by a third-party ethics expert and updated or expanded each year to ensure it is reflective of emerging issues and ethical best practices. All responses to the questionnaire are posted publicly on the Web.

HGPII members must also participate in an annual Best Practices Forum to share business conduct practices with other GPOs and representatives from government or other organizations. HGPII plans to expand the current model to be governed by a third-party external advisory board, and to embrace third-party auditing. Failure to follow the HGPII recommendations carries the penalty of expulsion, which would raise questions about that GPO's commitment to ethics and affect its ability to attract customers.

Through HGPII, we have learned that industry ethics that are reinforced by external oversight, measurement, and reporting are effective. With HGPII's transparent system, the public can evaluate financial and business interactions to ensure they are in the best interest of hospitals and patients. In this way, GPOs are earning greater levels of trust.

Many healthcare organizations have implemented ethics programs and strategies, but the current climate demands industry-wide efforts, such as those undertaken by HGPII. Anything less will fail to convince a skeptical public that we are worthy of their trust. We need to commit to extra efforts to reassure consumers that we are serious about enforcing ethical behavior, and that we are doing everything possible to avoid impropriety.

With concerns about integrity at a critical point, and with a national healthcare debate on the horizon, we must ensure trust in the current system. We must heal ourselves first.


Richard A. Norling is president and CEO for Premier healthcare alliance.

Kirk O. Hanson is executive director of the Markkula Center for Applied Ethics at Santa Clara University.


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