Advisory: Buying Groups, Rewards & Conflicts of Interest

Advisory: Buying Groups, Rewards & Conflicts of Interest

The Ethical Practices Committee (EPC) is the designated group that reviews member complaints of alleged ethical infractions,  inquiries from both members and the public in general, and other ethical issues that are submitted to the American Academy of Audiology (AAA). The charge of the EPC is to render an opinion, on behalf of the membership of the Academy, regarding the ethical questions and issues presented. The EPC does not establish ethical rules or principles—it serves to interpret the Code of Ethics of the Academy. While it may be uncomfortable for any professional to think of the EPC as a committee rendering an ethical judgment/decision, without such judgment/decision and penalty, enforcement of the Code of Ethics would lack substance. To these limited ends, the EPC does offer consensus opinion to the Academy Board of Directors, and has authority to sanction members determined to be in non-compliance with the Academy Code of Ethics.

The EPC receives periodic inquiries from members regarding various rewards offered through buying groups. Additionally, the EPC has received inquiries concerning the method in which institutions—hospitals, universities, large clinics, etc.—participate in buying groups and reward programs. As a major proportion of the efforts of the EPC involve the education of Academy members regarding ethics and conflict of interest issues, the EPC first prepared this short article in 2004, in hopes of clarifying some of the specific issues raised by members.

The EPC has been asked:

  1. If a manufacturer offers a trip that also incorporates elements of professional education, and because the educational elements would increase the ability of the clinician to help patients, is attendance at this conference unethical?
  2. If such a trip is offered through a buying group, with no requirement to purchase a specific amount or type of hearing instrument, is it ethical to attend?
  3. If a clinic or audiologist is a member of a buying group and purchases hearing instruments from varying manufacturers, and if the purchasing group retains money from each purchase, or otherwise offers money, equipment, tuition reimbursement, educational travel, or other inducement that is eventually returned to the clinic or audiologist, and since there is patient benefit from being able to purchase additional equipment or participate in other educational experiences, are these "rewards" or "incentives" unethical?
  4. If the business employing an audiologist (who dispenses hearing instruments) is rewarded for hearing instrument purchases, but the dispensing audiologist is not under any restrictions for purchase, does this reward system violate the conflict of interest guidelines of the Academy?

All of these questions are essentially the same; the differences in types of rewards or to whom the rewards are given, do not alter much. The intent of the conflict of interest guidelines is to avoid even so much as the appearance of a conflict of interest by a reasonable person, including patients, third-party payers, or colleagues. So, any situation that "rewards" the professional or facility in any manner that is not completely obvious (and clearly explained) to the patient would be considered a conflict of interest.

The above questions essentially involve the amount of "distance" that can be placed between the "reward" and the audiologist involved in the dispensing of the hearing instrument. In these matters, "distance" is not solely a matter of space but also can beconstrued as a matter of the time, of the number of parties, and/or a matter of the number of possible beneficial uses of the rewards.

In question #1 above, the EPC is asked if a trip paid by a manufacturer becomes ethical if the distance between "fun" and "education" is minimized. That is, does making the trip educational eliminate the conflict of interest? The fact that some professional education is involved does not eliminate the conflict of interest. Rationalizing that learning may occur and may help in the future management of subsequent patients is not sufficient to resolve the conflict. If a trip is solely educational, if there is no requirement for a purchase commitment either to qualify for the trip or to occur subsequent to the trip, manufacturer-sponsored training is permitted. In this case, however, the audiologist must be careful to ensure that only business-related events are included in the offering.

The use of buying groups, as per question #2 above, does not eliminate or absolve the audiologist from the issue of rewards. Despite the "distance" inherent in the buying group, if there is any type of reward attached to the purchase of hearing instruments that will flow back to the audiologist, the facility, the employer, or any designee, there is a hidden cost to the patient that is not evident in the purchase of the hearing instrument. This conflict is not ameliorated by any such program such as being able to purchase any hearing instrument from any manufacturer, by eliminating any minimum purchasing, or by varying the types of "kickbacks" by any time, level of technology, or manufacturer considerations. Relative to the example in #3 and #4 above, a clinician in any employment situation, including a university or hospital, creates a real (or an apparent) conflict of interest when the reward is used for the purchase of equipment or educational travel that benefits the clinic, hospital, or university even if only in the sense that the reward lies outside a restricted facility budget. The apparent good of the end does not justify the methods used to attain that end. The costs to the patient remain hidden to many, and these rewards or situations would be determined to be in non-compliance with the Code of Ethics of the Academy.

Audiologists are free to negotiate direct product pricing with manufacturers, but other incentives are not permitted by the conflict of interest guidelines. Manufacturer or group purchasing programs that reward purchases at the end of a quarter, a year, or other period of time, or designate rewards of any type that depend upon the number of hearing instruments or the amount of purchase, are also included in the conflict of interest guidelines. Furthermore, all programs that aspire to "help in marketing" or promote the development of a clinic's business, in so much as these programs are dependent upon the number and/or amount of purchases of hearing instruments, will likely be deemed in non-compliance with the Academy's code. The type of reward or the intended or actual use of the rewarded funds will not change the fact that the money, equipment, advertising, or other "in kind" reward can be viewed as a "kickback" in return for past, present, or future purchases.

Finally, our Code of Ethics applies only to audiologist members of the Academy, and cannot be applied to the manufacturer, the employer or the purchasing group if they are not members. The patient depends upon the integrity of the clinician—the audiologist—to protect his or her best interest in all aspects of the purchase and use of the hearing instrument. The audiologist is not free to deflect responsibility on any other person or entity involved in the purchase.

In as much as the Academy published the comprehensive guideline, American Academy of Audiology Ethical Practice Guideline for Relationships with Industry for Audiologists Providing Clinical Care, which was first written July 28, 2011, revised in 2013, and approved by the Board of Directors January 14, 2014, along with accompanying FAQs, and in as much as buying groups are deemed a part of industry, questions regarding relationships with buying groups are also referred to the 2014 Board-approved guideline and FAQs.

American Academy of Audiology Ethical Practice Guideline for Relationships with Industry for Audiologists Providing Clinical Care (2014).

American Academy of Audiology Ethical Practice Guideline for Relationships with Industry for Audiologists Providing Clinical Care (2014).

American Academy of Audiology and Academy of Dispensing Audiologist (2003). Ethical Practice Guidelines on Financial Incentives from Hearing Instrument Manufacturers. Audiology Today, 15(3), 19–21.

Ethical Practices Board (2004). Buying Groups, Trips, Cash Rebates and Conflict of Interest. Audiology Today, 16(1), 9.

Ethical Practices Board (1997). Guidelines on Conflict of Interest.

Ethical Practices Board (2004). To Party, or Not to Party? That is the Question. Audiology Today, 16(2), 43.

Hamill, T. (2003). Member comments: Ethical Practice Guidelines on Financial Incentives from Hearing Instrument Manufacturers. Audiology Today, 15(4), 28.

Hawkins, D., Hamill, T.A., Van Vliet, D. & Freeman, B.A. (2002). Potential Conflicts of Interest as Viewed by the Audiologist and the Hearing-impaired Consumer. Audiology Today, 14(5), 27–33.

Turner, R., and Ethical Practices Board (2003). Response to Ethical Practices Guidelines on Financial Incentives from Hearing Instrument Manufacturers. Audiology Today, 15(5), 42–44.