Some doctors at Jefferson Health, one of the region’s largest medical networks, are pushing back after being asked to refer at least one “grateful” patient each month to the system’s fund-raising office, a practice they said they were told could impact the size of their annual bonus.

Known in philanthropy circles as Grateful Patient fund-raising, the practice has been in place in health networks for years. But the Jefferson doctors say the directive from their leadership took it to a new level by increasing pressure on doctors to provide names.

Two Jefferson doctors, who described the changes to The Inquirer on the condition they not be identified because they feared retribution, said some of their colleagues have complained that the initiative could damage the doctor-patient relationship. The two doctors said they won’t make the referrals, bonus or no bonus.

“There’s a widespread feeling among physicians at Jefferson that this strategy is not going to be fruitful in that it is unethical,” one said.

Jefferson said in a statement that it does not require physicians to make referrals and does not penalize physicians for not participating, but that there are departmental goals.

“Only department chairs (not every member of our medical staff) are asked to achieve department grateful patient referral targets in order to draw more funds for department use on research and education initiatives,” said John Brand, Jefferson’s chief communications officer.

The system acknowledged that incentive pay for department chairs includes a “grateful patient referral metric” that was added in September. Whether the referred patients end up donating is not a factor in a chair’s incentive pay, Brand said. The metric is based on a calculation of the average number of gratitude referrals per month and the percentage of physicians participating, he said.

It’s unclear if there are differences in how department chairs have communicated the effort to their physicians.

“It’s important to note that these discussions are always initiated by the patient and we encourage our chairs to follow up on these requests in order to connect the patient to the right donation opportunity,” Brand said.

Jefferson has swiftly grown into one of the dominant health systems in the region and state. It employs 32,000 workers, including more than 1,400 doctors, and includes 14 hospitals and Thomas Jefferson University.

Its new fund-raising approach came as COVID-19 was slamming hospital systems nationwide, resulting in hundreds of millions in losses. Jefferson was hit hard by the virus, which reduced elective surgeries and nonurgent care and led to more expenses. The hospital finished fiscal 2020 with a nearly $300 million operating loss, even with $325 million in government aid. The health system is erecting a new $762 million outpatient pavilion at 11th and Chestnut Streets.

“Today, more than ever, we are relying on philanthropy to ensure Jefferson’s continued financial strength,” wrote Edmund Pribitkin, executive vice president of Jefferson Health, in a September email to physicians obtained by The Inquirer.

Even though Jefferson says it doesn’t require physicians to refer patients, the institution last year created a new tool to allow doctors to attach patient referrals to the fund-raising office through the patient’s electronic health record. In a tutorial, Jefferson’s institutional advancement office explains how it works.

The new tool “will notify (institutional advancement) when a patient or patient’s family member has expressed gratitude, or if there are other reasons they might be a potential benefactor,” Pribitkin said in the email. “The way it works is simple and straightforward — you place an OIA Philanthropy Communication order … the way you would any other communication order.”

“I’m appalled,” said one doctor. “There should be a fire wall between development and patients and to put a mechanism for a referral directly from the patient’s chart is unethical. … If I were a patient, I would be furious.”

The Jefferson doctors aren’t the only ones who see a problem with tying patient referrals for fund-raising to a doctor’s compensation.

“To the extent that is happening, it’s not OK,” said Dr. Joseph Carrese, a professor of medicine at Johns Hopkins Berman Institute of Bioethics. “It crosses into the territory of a frank conflict of interest, when you are tying a physician’s personal financial gain to the activity of securing money from their patient when [physicians’] primary obligation should be putting their patient’s best interest first and foremost.”

The practice could potentially damage the doctor/patient relationship, he said.

“If the patient worries that your ongoing devotion to them or focus on them is somehow a quid pro quo and is tied to a gift, then that’s clearly a huge problem and not something that should be happening in clinical medicine and the doctor-patient relationship,” he said.

It’s unclear whether Jefferson’s practice is unusual among local hospital systems. Neither Temple University nor the University of Pennsylvania responded to questions about whether they ask physicians to refer patients to their fund-raising office or tie physician bonuses to the referrals.

Penn Medicine said it started a grateful patient giving program more than 40 years ago “in response to a growing number of inquiries from patients and their families about how they could support our research, clinical care, and medical education programs to help advance these missions and pave the way for more patients to benefit.”

Hospitals have become increasingly reliant on the philanthropy of patient donors to support educational, research, and clinical programs that otherwise couldn’t be funded, Carrese said. Charitable gifts to health-care systems nationally bring in about $10 billion annually, he said.

“It’s something that is here to stay,” Carrese said. “The question then becomes how do we do this appropriately and ethically.”

A recent survey led by a University of Michigan researcher showed that the public frowns on some elements of grateful patient fund-raising. Less than 15% of the general public surveyed for the study published last summer in the Journal of the American Medical Association (JAMA) said they found it acceptable for doctors to ask patients to donate if the patients hadn’t raised the issue first. Less than 10% said they thought it was acceptable for doctors to give patients’ names to the fund-raising office without their knowledge. And more than 80% said they thought doctors talking to patients about fund-raising could interfere with the doctor-patient relationship.

It’s one thing if a patient brings up wanting to make a donation and quite another if it’s the doctor raising the issue, Carrese said.

“Personally, I would only feel comfortable if it was initiated by the patient,” he said, in which case he would refer the patient to a development officer.

He acknowledged that some doctors are more comfortable playing an active role in fund-raising.

Carrese said hospital systems engaging in grateful patient referrals should accompany those efforts with an “institutional commitment to raise awareness and educate physicians, development officers and institutional leaders about ethical concerns and considerations involved. … If not, the worry is, for example, some number of physicians may stumble into ethical minefields without knowing it, damaging the doctor-patient relationship and the institutional-patient relationship.”

Hospital fund-raising officers routinely look for patients with financial means, according to a 2018 article in Academic Medicine, of which Carrese was coauthor. Such “wealth-screening” practices are done by 97% of health-care institutions, the article said.

“Despite its ubiquity, it is unlikely that many patients are aware of this practice, which raises ethical concerns about transparency and privacy,” the authors wrote.

The American Medical Association supports physicians’ involvement in fund-raising but says in its code of ethics that they should refrain from soliciting contributions from their own patients, especially during clinical appointments, and should protect patient privacy by not acknowledging a patient is under their care when approached by fund-raising personnel unless the patient has consented. They can help with fund-raising by making literature available in their office or speaking at fund-raising events, the code says.

Not all Jefferson doctors objected to referring patients and having it linked to a portion of a bonus. One doctor, who also requested anonymity, said a lot of patients are grateful for the high-quality care they receive and do want to help.

Pribitkin, the Jefferson executive who sent the email to physicians, said COVID-19 has shown the world that health-care workers are heroes and that more than ever, patients are grateful for the care they receive.

“We know that oftentimes appreciative patients and their families are inspired to give back as part of their journey to wellness — it is why we say `generosity heals,’” he wrote. “Identifying gratitude can lead to gifts that support the work we do to improve lives.”