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Previous Volume 329:1627-1631 November 25, 1993 Number 22 Next

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ABSTRACT

Background Physicians have long provided care free of charge or at a reduced rate as a professional courtesy to other physicians and their families. We conducted a stratified national mail survey to assess the extent to which this practice has changed in recent years.

Methods Using the American Medical Association's 1991 master list of physicians, we selected a random sample of 4800 practicing physicians from 12 direct-care specialties. These physicians were asked about their current policy and opinions regarding professional courtesy.

Results Of the 2224 respondents, 2127 (96 percent) offered professional courtesy, defined as providing free or discounted health care to physicians and their families. Psychiatrists were less likely to offer professional courtesy than physicians in any of the other specialties (80 percent vs. 91 to 99 percent, P<0.05). The forms of free or discounted care offered as a professional courtesy included billing only the insurance company (75 percent), providing care at no charge (49 percent), and giving a partial discount (23 percent). Twenty-three percent of the respondents reported that they had changed their policy regarding professional courtesy since starting to practice. Among those who had changed their policy, the most common changes were to increase the practice of billing only the insurance company (67 percent) and to provide care at no charge less often (58 percent). The majority of physicians responding to the survey thought that professional courtesy solidified bonds between physicians (79 percent) and was sound business practice (62 percent); 12 percent believed that it was too expensive to offer free or discounted care as a professional courtesy, and 14 percent thought that the practice had negative effects on the physician-patient interaction.

Conclusions Our survey of physicians involved in direct patient care indicates that, with the exception of psychiatrists, almost all American physicians offer free or discounted care as a professional courtesy and support the practice.

Despite the change in the AMA's position on professional courtesy, as well as changes in medical practice as a whole, we do not know whether physicians' practices with regard to professional courtesy have changed. According to three surveys conducted between 1958 and 1966, approximately 90 percent of physicians provided free or discounted care as a professional courtesy during that period^6,7,8. In the largest and most recent of the three surveys, conducted by the Judicial Council of the AMA in 1966, between 91 and 100 percent of physicians, with the exception of psychiatrists, offered such care as a professional courtesy⁸.

Because the practice of medicine has changed considerably since the 1966 survey, we undertook a national study of professional courtesy. The goals of this study were to describe the current practice of giving free or discounted care as a professional courtesy, to determine whether individual physicians have changed their policy concerning professional courtesy, to investigate physicians' attitudes toward professional courtesy, and to compare the current practice with that in 1966.

Methods

Study Population

The study group was derived from the AMA's 1991 master list of physicians. This list contains information on all licensed physicians (both AMA members and nonmembers) in the United States. To obtain a sample representing a wide range of physicians providing direct patient care, 400 names were randomly selected by the nth name technique⁹ from each of 12 specialties: family practice-general practice, pediatrics, psychiatry, obstetrics-gynecology, general internal medicine, general surgery, surgical subspecialties, ophthalmology, dermatology, neurology, invasive internal medicine (cardiology, pulmonary medicine, and gastroenterology), and noninvasive internal medicine (all other internal-medicine subspecialties). Medical trainees (residents and fellows), military physicians, and specialists not involved in direct patient care (e.g., pathologists and radiologists) were excluded. A sample size of 400 physicians per specialty group was chosen to ensure adequate statistical power to detect a 15 percent difference between specialties in their practice of professional courtesy.

Because we hypothesized that the professional-courtesy practices of primary care physicians would differ from the practices of procedure-oriented specialists, we grouped the specialties into primary care specialties (general internal medicine, family-general practice, pediatrics, and obstetrics-gynecology) and non-primary care specialties (general surgery, surgical subspecialties, ophthalmology, dermatology, neurology, invasive internal medicine subspecialties, and noninvasive internal medicine subspecialties). Whether invasive and noninvasive internal medicine subspecialties were included in the primary care group did not affect the analyses. Psychiatrists were classified separately because in previous studies they offered professional courtesy at a substantially lower rate than did other physicians^8,10.

Survey Methods

Five mailings, at approximately three-week intervals, were conducted between August and November 1991. The first mailing went to the entire sample of physicians, and the subsequent mailings went to nonrespondents. Mailings 1, 3, and 5 each consisted of a cover letter, the survey, and a postage-paid return envelope. Mailings 2 and 4 were postcards reminding recipients to complete and return the survey. Each survey recipient was assigned a number for tracking purposes. The survey was approved by the Institutional Review Board at the University of Pittsburgh.

Survey Questionnaire

A prototype questionnaire developed by the authors was administered to the full-time faculty of the Division of General Internal Medicine at the University of Pittsburgh, volunteer faculty at the University of Pittsburgh, and physicians in the local community. Each group gave both verbal and written feedback, and we revised the questionnaire on the basis of these comments.

The final questionnaire (available on request from the authors) contained 20 questions (18 multiple choice and 2 open ended). Question 1 asked whether the respondents gave professional courtesy, defined in the survey as free or discounted care to physicians and their families. Those answering "yes" completed questions 2 and 3, which asked about the form of professional courtesy offered ("bill at no charge," "bill insurance company only," "give a partial discount," or "other") and how frequently it was offered for services of various costs ("never," "occasionally," "often," or "always"). Question 4 asked whether the respondents had changed their policy regarding professional courtesy since starting to practice medicine. Those responding "yes" completed questions 5 through 7, which asked how their policy had changed, when the change had occurred, and the reason for it. Question 8 asked whether the respondent accepted professional courtesy from other physicians, and question 9 inquired how often the respondent's family members received free or discounted care as a professional courtesy. In question 10, the respondent was asked to agree or disagree with a number of statements concerning professional courtesy. Question 11 asked about other patients who were offered free or discounted care. Question 12 was an open-ended question concerning the respondent's thoughts about professional courtesy. Questions 13 through 20 covered demographic information and medical-practice characteristics, including the respondent's age, year of graduation from medical school, sex, race or ethnic group, type of primary practice, frequency of caring for physicians as patients, and income.

Statistical Analysis

Subgroup responses to the questionnaire were compared by the chi-square test for categorical variables and Student's t-test for continuous variables. Trends in proportions were assessed with the chi-square test for trends. A two-tailed P value under 0.05 was considered to indicate statistical significance for all bivariate comparisons. In many analyses, the responses "often" and "always" were combined into a single response category.

One of the investigators developed categories of responses for the open-ended questions. Responses were independently coded by the investigator and a trained research assistant in 100 randomly selected questionnaires. Since the overall agreement was high in this sample (92 percent agreement for all items), the remainder of the responses were coded by the research assistant alone.

Results

Of the 4800 questionnaires mailed to physicians in the sample, 2224 (46 percent) were returned. The respondents were predominantly white, middle-aged men who were in group or solo fee-for-service practice (Table 1).

View this table: [in this window] [in a new window]   Table 1. Demographic and Medical-Practice Characteristics of Physicians Offering Professional Courtesy.

 
Professional-Courtesy Practices

Of the 2224 respondents, 2127 (96 percent) offered some form of free or discounted health care as a professional courtesy to physicians or their families. Male sex, older age, private practice, fee-for-service income, and higher income were all positively associated with the provision of such care (P<0.01) (Table 1).

Over 90 percent of respondents in all specialties except psychiatry offered free or discounted care as a professional courtesy (Table 2). The rates of providing such care were significantly lower in psychiatry (80 percent) than in primary care (95 percent) and non-primary care specialties (98 percent, P<0.001).

View this table: [in this window] [in a new window]   Table 2. Provision of Professional Courtesy, According to Specialty Group.

 
The physicians who offered free or discounted care as a professional courtesy did so in several ways: 75 percent often or always billed only the insurance company, 49 percent often or always provided care at no charge, and 23 percent often or always gave a partial discount (Table 3). Non-primary care physicians were most likely to bill only the insurer (80 percent often or always), psychiatrists were most likely to give a partial discount (33 percent often or always did so), and primary care physicians were most likely to provide care at no charge (56 percent often or always did so).

View this table: [in this window] [in a new window]   Table 3. Form of Professional Courtesy Offered.

 
Free or discounted care was commonly offered as a professional courtesy regardless of the treatment setting or the cost of the service provided. Of the physicians who offered professional courtesy and answered that the type of service was applicable to their practice, 1856 (88 percent) often or always offered it for routine office visits, and 1489 (79 percent) often or always offered it for routine hospital visits. Although the cost of a service was inversely related to the proportion of physicians providing it as a professional courtesy, even the most expensive treatments were commonly offered free of charge or at a discounted rate. As the cost of a service increased from under $100 to between $100 and $500 to more than $500, the proportion of respondents who often or always offered that service as a professional courtesy decreased from 77 percent to 73 percent to 70 percent, respectively (P<0.001).

Changes in the Practice of Professional Courtesy

Of the 2224 respondents, 502 (23 percent) had changed their practice regarding professional courtesy since starting to practice medicine. The most common changes were an increase in the practice of billing only the insurer (336 respondents) and a decrease in the provision of care at no charge (290 respondents). Roughly equivalent numbers of physicians had increased (156 respondents) or decreased (94 respondents) the frequency with which they gave a partial discount.

The most common reasons given for changing the practice of professional courtesy were that more physicians carry insurance (100 respondents), other physicians' policies regarding professional courtesy have changed (89 respondents), and offering professional courtesy is too expensive (85 respondents). Only 18 respondents cited an adverse effect of professional courtesy on the physician-patient relationship, and only 12 cited concerns about the legality of forgiving copayments.

Opinions about Professional Courtesy

Most of the physicians who responded to the survey had a positive attitude toward professional courtesy (Table 4). Ninety-two percent agreed with the statement, "I consider it an honor to care for other physicians," 79 percent agreed that "professional courtesy solidifies bonds between physicians," and 62 percent agreed that "giving professional courtesy is sound business practice." Only 15 percent agreed with the statement, "Professional courtesy discourages physicians from appropriately seeking care," only 14 percent agreed that "professional courtesy interferes with the formation of an appropriate physician-patient relationship," and only 12 percent agreed with the statement, "It is too expensive for me to offer professional courtesy."

View this table: [in this window] [in a new window]   Table 4. Physicians' Opinions about Professional Courtesy.

 
The respondents' attitudes toward professional courtesy were related to whether they offered it. For example, the 97 physicians who did not provide free or discounted care as a professional courtesy were approximately four times more likely to think that it was too expensive to provide such care (39 percent vs. 10 percent, P<0.001) or that it interfered with the formation of an appropriate physician-patient relationship (45 percent vs. 12 percent, P<0.001). Psychiatrists, who were the least likely to provide professional courtesy, were more likely than other physicians to believe that professional courtesy was too expensive (34 percent vs. 10 percent, P<0.001), that it interfered with an appropriate doctor-patient relationship (34 percent vs. 12 percent, P<0.001), and that it discouraged recipients from appropriately seeking care (22 percent vs. 14 percent, P = 0.03).

Comparison with Earlier Rates of Professional Courtesy

To ascertain how the practice of professional courtesy has changed with time, we compared our results with those of the 1966 AMA study⁸. To make the two studies comparable, we classified physicians in the 1966 study as providing professional courtesy if they never or rarely charged patients when the insurance benefit paid less than the usual and customary fee. For this analysis only, physicians in our study were classified as providing professional courtesy if they often or always billed only the insurance company, gave a partial discount, or provided care at no charge.

A smaller proportion of physicians offered professional courtesy in 1991 than in 1966 (88 percent vs. 94 percent, respectively, P<0.001). For six of the eight specialty groups in which comparisons could be made (general practice, general surgery, internal medicine, obstetrics-gynecology, pediatrics, and ophthalmology), the decrease in the proportion of physicians offering professional courtesy was statistically significant (P<0.05). However, the absolute change in that proportion was less than 10 percent for each specialty.

Comparison of Respondents and Nonrespondents

To determine whether there may have been a nonresponse bias, we conducted a telephone survey of a random sample of nonrespondents (i.e., those who did not respond to the initial survey). The sample included 10 nonrespondents from each specialty group, for a total of 120. Usable responses were obtained from 117 of the 120 nonrespondents (98 percent). These physicians were similar to the respondents in terms of practice setting and income type (73 percent in fee-for-service practice and 87 percent in private practice) but were more likely to see no physicians as patients per month (41 percent of nonrespondents surveyed vs. 11 percent of respondents). Most important, 90 percent of the nonrespondents offered free or discounted care as a professional courtesy -- a proportion similar to that for respondents. Of the nonrespondents who provided professional courtesy, 57 percent often or always billed only the insurers, 33 percent often or always provided care at no charge, and 16 percent often or always gave a partial discount.

Discussion

Professional courtesy is a tradition that determines the context in which almost all physicians receive their health care. In this survey of current practices and attitudes regarding professional courtesy, we found that, except for psychiatrists, nearly all physicians provide free or discounted care as a professional courtesy. Demographic characteristics accounted for only small differences in the proportions of physicians who said they offered professional courtesy. Physicians reported offering professional courtesy for both hospital and office visits, and even though professional courtesy was offered less frequently for more expensive services, it was common practice even when the cost of the service was over $500.

Since 1966, the rate of providing professional courtesy has decreased between 5 and 10 percent -- a surprisingly small change. During this time, dramatic changes in the practice and financing of medicine have occurred. The cost of medical care has increased greatly, and third-party payment has become the rule. The AMA has become less supportive of professional courtesy, and academicians have increasingly questioned its ethical propriety. These changes do not appear to have affected physicians' willingness to provide free or discounted care as a courtesy to colleagues and their families.

Just as most of the physicians we surveyed reported that they offer some form of free or discounted care as a professional courtesy, most had a positive view of the practice. They believed that professional courtesy is good for the profession and their business and that it causes little harm. Only psychiatrists, who were less likely to provide professional courtesy than other physicians, were more negative in their assessment of the practice. These predominantly positive attitudes are in contrast to the opinions found in the medical literature, which are nearly equally divided between those in favor of and those opposed to the practice of professional courtesy^1,3,4,5,6,11.

In any survey, nonresponse is a concern. Our response rate was similar to the rates obtained in other recent surveys of physicians^12,13,14. Our large, randomly selected sample was taken from the most comprehensive national listing of physicians available and included physicians in a wide range of patient care specialties. In addition, the results of our nonrespondent survey indicated that the physicians who did not respond to our mailed questionnaire were similar to the respondents in their practice of professional courtesy and their work settings. Finally, our respondents were typical of American physicians with regard to sex and income¹⁵. Thus, we believe that nonresponse bias was not a major problem in this survey.

An additional concern with survey research is that it measures the behavior reported by respondents, not their actual practice. Clearly, what respondents say they do may be different from what they actually do. However, the fact that 76 percent of physicians reported that they often or always were offered free or discounted care as a professional courtesy supports the conclusion that the practice is widespread.

The nearly universal offer of professional courtesy to colleagues and their families raises important medical and economic questions. What is the effect of professional courtesy on the willingness of physicians to seek care and the quality of the care provided? Does the receipt of free or discounted care lead to overuse of medical services, or does it result in underuse because physicians wish to avoid imposing on their colleagues? Does professional courtesy result in higher medical or insurance bills for nonphysicians? Many people argue that insurance plans contribute to health care costs by decreasing incentives to save money on the part of both doctors and patients. Does professional courtesy decrease patients' awareness of costs even further, and, if so, how might this diminished awareness affect physicians' practice styles?

We believe there are ethical reasons to prohibit professional courtesy. It does not seem fair that discounted care is provided to physicians, who generally can afford to pay for it, when so many Americans cannot afford health care or have limited access to it. Preferential treatment of colleagues seems to be an unjustifiable attempt by physicians to insulate themselves from the rising health care costs that others must pay.

The most common way of forgiving payment -- billing only the insurance company -- raises additional issues. A physician who bills a third-party payer enters into a contract with the company to bill the patient for any copayment and thus has a contractual obligation to collect that copayment. The American Dental Association¹⁶ explicitly states in its code of ethics that the practice of billing only the insurer is overbilling and thus unethical. One might therefore argue that the failure to collect a copayment is morally more problematic than the failure to bill the patient or the patient's insurance company at all¹⁷.

From a legal standpoint, the failure to attempt collection may be fraudulent. In at least one state, Colorado, forgiveness of copayment is illegal¹⁷. In the legal case that addresses this issue, a chiropractor made an explicit agreement with a patient that he would not bill the patient for copayments. The court found that the chiropractor had violated his contract with the insurance carrier by making this arrangement and was therefore not entitled to any insurance payment¹⁸. We found it noteworthy that only 12 respondents in our survey voiced any concerns about the legality of billing only the insurance company as a form of professional courtesy.

Medical associations have failed to provide physicians with guidelines for addressing these important issues. We believe that an attempt should be made to formulate a position on the propriety of offering free or discounted care as a professional courtesy. We hope that our survey data will serve as a starting point for the medical community to reevaluate the practice of professional courtesy.

Supported by grants from the Richard King Mellon Family Foundation and the National Heart, Lung, and Blood Institute (R01 HL36735). Dr. Kapoor was the recipient of a Research Career Development Award from the National Heart, Lung, and Blood Institute (K04L 01899).

We are indebted to Lynn Sukevic for assistance in mailing the surveys and entering data, to Barbara Hanusa for assistance with the statistical analysis, to Michael Karpf, Laura Siminoff, and Robert Richardson for helpful comments on early drafts of the paper, and to Margie Sigafoos for assistance in the preparation of the manuscript.

Source Information

From the Division of Primary Care/Geriatrics, Medical Center of Central Massachusetts, Worcester, Mass. (M.A.L.); and the Center for Medical Ethics, Department of Psychiatry (R.M.A.), and the Division of General Internal Medicine, Department of Medicine (M.J.F., W.N.K.), University of Pittsburgh, Pittsburgh.

Address reprint requests to Dr. Levy at the Division of Primary Care/Geriatrics, Medical Center of Central Massachusetts, 119 Belmont St., Worcester, MA 01605.

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Abstract Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

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