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Opinion 8.021 - Ethical Obligations of Medical Directors

Assuming a title or position that removes the physician from direct patient-physician relationships does not override professional ethical obligations. The term "medical directors," as used here, refers to physicians who are employed by third party payers in the health care delivery system (ie, insurance companies, managed care organizations, self-insured employers) or by entities that perform medical appropriateness determinations on behalf of payers. These types of medical directors have specific functions, such as making coverage determinations, which go beyond mere administrative responsibility. The following stem from this understanding. Whenever physicians employ professional knowledge and values gained through medical training and practice, and in so doing affect individual or group patient care, they are functioning within the professional sphere of physicians and must uphold ethical obligations, including those articulated by the AMA’s Code of Medical Ethics. Medical directors acting within the professional sphere, such as when making decisions regarding medical appropriateness, have an overriding ethical obligation to promote professional medical standards. Adherence to professional medical standards includes:

(1) Placing the interests of patients above other considerations, such as personal interests (eg, financial incentives) or employer business interests (eg, profit). This entails applying the plan parameters to each patient equally and engaging in neither discrimination nor favoritism.

(2) Using fair and just criteria when making care-related determinations. This entails contributing professional expertise to help craft plan guidelines that ensure fair and equal consideration of all plan enrollees. In addition, medical directors should review plan policies and guidelines to ensure that decision-making mechanisms are objective, flexible, and consistent, and apply only ethically appropriate criteria, such as those identified by the Council in Opinion 2.03, "Allocation of Limited Medical Resources."

(3) Working towards achieving access to adequate medical services. This entails encouraging employers to provide services that would be considered part of an adequate level of health care, as articulated in Opinion 2.095, "The Provision of Adequate Health Care." (I, III, VII)

Issued December 1999 based on the report "Ethical Guidelines for Medical Directors," adopted June 1999