With all the ongoing changes in healthcare, such as physician contract clauses, new regulatory requirements, private equity ownership, and physician leadership, hospitals worry about the implications on revenue, patient satisfaction, and compliance. There also are important ethical considerations.

The authors of a new policy paper from the American College of Physicians (ACP) examined these.1 “This paper was generated in response to the significantly changing practice environment,” says ACP President Jacqueline W. Fincher, MD, MACP.

Current central ethical concerns include the patient-physician relationship, putting patient welfare over the physician’s self-interest, and the role medicine plays as a moral community. Incentives in the shift to value-based care and physician contract clauses that affect care also carry major ethical implications.

“There is more consolidation of healthcare organizations and practices, changes in physician employment, and practice model shifts,” Fincher says.

Concurrently, clinical priorities are shifting from individual patient health to population health. “There is a need for more physician leaders,” Fincher adds.

Overall, the changing practice dynamics place greater focus on the business aspects of medicine. “We, as internal medicine physicians, are absolutely committed to patient-centered, high-value care,” Fincher says. “We don’t want the financial bottom line and shareholder profits dictating care of patients.”

On the other hand, physician practices are businesses that must be run efficiently, or they will close and be unable to provide care to anyone.

“As physicians, we have a high ethical calling to be good stewards of the resources we have. We just want to make sure that the financial bottom line and profit-making are not the focus and at the center of what physicians do,” Fincher explains.

There are many potential ethical implications for hospitals. Many facilities are consolidating to create better economies of scale and increase the number of “covered lives” in their regions.

“They do so knowing that consolidation will provide more leverage with payers for payment,” Fincher notes. “But, in turn, it may well have more accountability for quality and fiscal prudence.”

Hospitals seek to align all physicians to support “in-network” referrals to specialists and for diagnostic testing. All this generates more revenue. “But this consolidation also can have a ‘feed the beast’ mentality, a sense of pressuring or incentivizing physicians to provide the referrals for specialists and procedures,” Fincher cautions.

This could interfere with physicians’ ethical obligation to the patient. “There are clearly differing obligations of corporations to shareholders vs. physicians’ obligations to patients,” Fincher adds.

Considering all these concerns, ethicists can provide a moral compass. “Ethicists and ethics committees can help identify emerging issues,” Fincher says.

Ethicists also can use their expertise in bringing various stakeholders together “to keep patient care and the trusted physician-patient relationship at center of these discussions,” Fincher offers.


  1. DeCamp M, Snyder Sulmasy L. Ethical and professionalism implications of physician employment and health care business practices: A policy paper from the American College of Physicians. Ann Intern Med 2021; Mar 16. doi: 10.7326/M20-7093. [Online ahead of print].