1. PAYING to PLAY: Ethical Considerations in the Financial Arrangements between Orthopaedic Surgeons and Athletic Teams AAOS ETHICS COMMITTEE Matthew J. Matava, MD 1

2. Objectives Identify the ethical implications of financial relationships with athletic teams Understand the advantages and disadvantages of various partnership agreements involving orthopaedic groups, hospital systems, and athletic teams Comprehend the importance of maintaining sound ethical principles when considering a financial relationship involving an athletic team Understand an orthopaedic surgeon’s ethical right to fair and reasonable compensation for providing medical care to an individual or group 2

3. Case A major league baseball team is seeking a new multi-specialty orthopaedic group to provide medical care. A number of practices have expressed interest Jupiterimages/Thinkstock in caring for the team. 3

4. The team has suggested that the selected orthopaedic provider pay a $500,000 “marketing agreement” as a prerequisite to providing medical care. The team has also stated that they will not pay the orthopaedists a stipend for medical services rendered beyond what insurance pays for imaging studies, laboratory tests, and surgical fees. 4

5. What are the practical issues? What are the medicolegal issues? What are the ethical issues? 5

6. You are a senior partner of the group most favored by the team, which happens to be the only professional sports franchise in your city. Your practice’s business manager calculates that caring for the team would potentially increase new patient iStockphoto/Thinkstock visits by 20% annually. 6

7. Your group has recently hired a new board-eligible orthopaedic surgeon with an interest in sports medicine who is anxious to develop his practice his practice. Stockbyte/Thinkstock The CEO of the hospital where your group practices has offered to “support” your interest in caring for the team by offering to pay the $500,000 “marketing agreement” in exchange for all player care being conducted at that hospital. 7

8. Can the orthopaedic group provide competent care? Should the group provide medical services without appropriate compensation? Should the group pay a $500,000 “marketing agreement” for the “right” to provide medical care for the team? Should the group partner with the hospital and allow them to pay the “marketing agreement”? 8

9. What are the General Issues? Pros Increased community exposure caring for the team Increased patient visits due to assumed expertise Enhance the practice of the young orthopaedist Partnership with hospital Cons Perception of “buying” the right to care for the team Limited experience in caring for professional athletes No financial remuneration for many hours of services Exclusive relationship with hospital 9

10. The orthopaedic group elected not to care for the team due to their relative lack of expertise in caring for elite athletes and their unwillingness to “buy the right” to provide medical care. 10

11. Summary Selection of a team orthopaedist should be made on the merit of the medical provider based on his or her education, training, and experience in caring for injured athletes. A team orthopaedist should expect reasonable and appropriate compensation for medical care rendered. 11

12. Any marketing arrangement between a medical provider and athletic team should remain separate from the contractual arrangement to provide medical care. 12

13. References American Academy of Orthopaedic Surgeons: Code of Medical Ethics and Professionalism for Orthopaedic Surgeons, I.A, I.B. Adopted 1988, revised 2011. http://www.aaos.org/about/papers/ethics.code.asp American Academy of Orthopaedic Surgeons: Standards of Professionalism on Providing Musculoskeletal Services to Patients, Mandatory Standards 10, 14, 15, 16. Adopted April 2005, amended April 2008. http://www3.aaos.org/member/profcomp.provuscserv.pdf American Academy of Orthopaedic Surgeons: Team Physician Definition, Qualifications, and Responsibilities, Information Statement 1021. Adopted 1999, reviewed 2007. http://www.aaos.org/about/papers/advistmt/1021.asp 13

14. Caldarone J: Professional team doctors: money, prestige, and ethical dilemmas. Sports Law J, 9: 131-152, 2002. Keim T: Physicians for Professional Sports Teams: Health Care Under the Pressure of Economic and Commercial Interests. Seton Hall J Sports Law, 196: 218, 1999. Stovitz S, Satin D: Professionalism and the Ethics of the Sideline Physician. Current Sports Medicine Reports, 5: 120-124, 2006. Lemak L: Financial Implications of Serving as Team Physician. Clin Sports Med, 26: 227- 241, 2007. 14

15. Dunn W, George M, Churchill L, Spindler K: Ethics in Sports Medicine. Am J Sports Med, 35: 840-844, 2007. Pennington B: Sports Medicine; Sports Turnaround: The Team Doctors Now Pay the Team. The New York Times, May 16, 2004. Bernstein J, Perlis C, Bartolozzi A: Practice Makes Perfect? Ideal Standards and Practice Norms in Sports Medicine. Clin Orthop, 420: 309-318, 2004. 15