title: Fee Splitting among General Practitioners: A Cross-Sectional Study in Iran.
abstract: BACKGROUND
  Fee splitting is a process whereby a physician refers a patient to another physician or a healthcare facility and receives a portion of the charge in return. This survey was conducted to study general practitioners' (GPs) attitudes toward fee splitting as well as the prevalence, causes, and consequences of this process.
  
  
  METHODS
  This is a cross-sectional study on 223 general practitioners in 2013. Concerning the causes and consequences of fee splitting, an unpublished qualitative study was conducted by interviewing a number of GPs and specialists and the questionnaire options were the results of the information obtained from this study.
  
  
  RESULTS
  Of the total 320 GPs, 247 returned the questionnaires. The response rate was 77.18%. Of the 247 returned questionnaires, 223 fulfilled the inclusion criteria. Among the participants, 69.1% considered fee splitting completely wrong and 23.2% (frequently or rarely) practiced fee splitting. The present study showed that the prevalence of fee splitting among physicians who had positive attitudes toward fee splitting was 4.63 times higher than those who had negative attitudes. In addition, this study showed that, compared to private hospitals, fee splitting is less practiced in public hospitals. The major cause of fee splitting was found to be unrealistic/unfair tariffs and the main consequence of fee splitting was thought to be an increase in the number of unnecessary patient referrals.
  
  
  CONCLUSIONS
  Fee splitting is an unethical act, contradicts the goals of the medical profession, and undermines patient's best interest. In Iran, there is no code of ethics on fee splitting, but in this study, it was found that the majority of GPs considered it unethical. However, among those who had negative attitudes toward fee splitting, there were physicians who did practice fee splitting. The results of the study showed that physicians who had a positive attitude toward fee splitting practiced it more than others. Therefore, if physicians consider fee splitting unethical, its rate will certainly decrease. The study claims that to decrease such practice, the healthcare system has to revise the tariffs.
authors.affiliation: Medical Ethics and History of Medicine Research Center, Department of Medical Ethics, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Mojtaba
authors.initials: M
authors.lastname: Parsa
authors.affiliation: Endocrinology and Metabolism Research Center, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Bagher
authors.initials: B
authors.lastname: Larijani
authors.affiliation: Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Kiarash
authors.initials: K
authors.lastname: Aramesh
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Saharnaz
authors.initials: S
authors.lastname: Nedjat
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Akbar
authors.initials: A
authors.lastname: Fotouhi
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Mir Saeed
authors.initials: MS
authors.lastname: Yekaninejad
authors.affiliation: Islamic Azad university, Tehran, Iran.
authors.forename: Nejatollah
authors.initials: N
authors.lastname: Ebrahimian
authors.affiliation: Department of Health Information Management, Faculty of Allied Medicine, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Mohamad Jafar
authors.initials: MJ
authors.lastname: Kandi
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D004992:Ethics, Medical; D005260:Female; D005607:Fraud / Q000941:ethics / Q000706:statistics & numerical data*; D058005:General Practitioners / Q000941:ethics / Q000706:statistics & numerical data*; D006801:Humans; D007492:Iran; D008297:Male; D012017:Referral and Consultation / Q000941:ethics / Q000706:statistics & numerical data*; D012051:Reimbursement Mechanisms / Q000941:ethics / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires