10. Dr. Jones’ large multi-specialty clinic provides a year-end bonus if his percentage of external specialist referrals is below the clinic average.
#	Response Date	Comment
1.	Wed, 3/14/07 12:23 AM	No COI if the same service is available within the practice and quality metrics are equivalent or better.
2.	Wed, 3/14/07 12:53 AM	Counting on Dr. Jones' good character, it need not be a conflict of interest at all.
3.	Wed, 3/14/07 1:58 AM	It depends if the specialists in the group are of high quality and can provide the necessary care required.
4.	Wed, 3/14/07 3:22 AM	This is more an issue of professional ethics than a COI per se
5.	Wed, 3/14/07 4:56 PM	If good specialists are available withing the practice/
6.	Wed, 3/14/07 10:04 PM	does this compromise patient care?
7.	Wed, 3/14/07 10:10 PM	If there are appropriate in-house referral options and if out-of-house referrals are screened by a panel of peers for appropriateness, then he could be "docked" for excess referrals out without having patient care compromised.
8.	Thu, 3/15/07 1:04 AM	Not sure this is a COI. Seems more like just poor medical practice.
9.	Fri, 3/16/07 2:35 PM	This could present a challenge, but is also may be a good business model, as long as there are checks and balances (i.e. opportunity for reviews and appeals)
10.	Sat, 3/17/07 1:33 PM	This is difficult. Is patient care hampered by this policy of limiting referrals? Individual provider practice styles will greatly influence this policy as well.
11.	Mon, 3/19/07 12:13 AM	If the quality of care provided by Dr Jones is excellent there is no conflict
12.	Mon, 3/19/07 4:17 PM	Depends on the quality of care maintained and whether services of similar standards are secured for patients.
13.	Mon, 3/19/07 5:30 PM	Dr. Jones is caught between the lure of $ and the duty to refer when appropriate.
14.	Mon, 3/19/07 9:11 PM	depends on size of bonus in relation to overall income
15.	Mon, 3/26/07 3:14 PM	could be a COI, but if the practice had procedures in place to review providers for care quality, the likelihood would be reduced
16.	Mon, 4/23/07 3:41 PM	It would be OK if Dr. Jones always refers to the best/most qualified specialist, no matter if internal or external
17.	Tue, 4/24/07 1:37 PM	If there is a quality review to be sure that referrals are made when appropriate it may not be a COI. HMO's use this technique to change Dr. behaviors.
18.	Thu, 4/26/07 9:19 PM	would need to be based upon quality measures not just volumes
19.	Tue, 5/8/07 3:29 PM	...
20.	Wed, 5/9/07 1:02 PM	If Dr. Jones believes the specialists in his clinic are of equal or better quality than outside specialists, then no conflict exists.