Managed care ethics for new millennium requires collaboration
Strengthen relationships through mutual understanding of expectations
(Editor's note: This is the second in a three-part series on ethics and managed care. Last month, Medical Ethics Advisor examined the rise of patient advocacy and determining medical necessity for members of managed care organizations. This month, we focus on the benefits of truthful disclosure among managed care organizations, providers, and patients.)
Building truthful and open relationships among care organizations, patients, and health care practitioners - which sounds like a pipe dream to most - can become reality with a little effort. The most difficult hurdle to overcome is changing the health care delivery para digm, experts say. And the existing paradigm of the patient/professional relationship is being replaced with the sites of care relationship - a basic tenet of managed care dogma.
There's no doubt, however, that the process of establishing open and honest relationships for all parties isn't free from challenges. Perhaps the biggest challenge involves the decision-making process itself. In managed care philosophy, the decision-making process is expanded beyond the phys ician and patient to include the purchasers, benefits and coverage policy analysts, those who administer health care delivery, and those who regulate health care.
So where do hospital ethics committees fit into all this? Right in the middle, say those who spoke with MEA.
The role of ethics committees is to continue to serve as the patient advocate, says Ronald Bronow, MD, president of San Antonio-based Physicians Who Care, a nonprofit membership organization formed in 1985 to protect the traditional patient/physician relationship.
An equally challenging piece of the managed care puzzle is the patient. Unfortunately, many patients discover too late that a certain test or procedure isn't covered. The experience leaves them feeling cheated by their plan. (See MEA, Sept. 1998, p. 98.)
"Patients are just frustrated. They're mad as hell. Patient dissatisfaction and fury will be mirrored in this fall's congressional election. It will be a major campaign issue," he says.
Indeed, the president is lobbying for passage of his Patient Bill of Rights, which would give patients more negotiation muscle with their managed care plans. Ethics committees can help patients by being advocates, but patients won't receive optimal care from their plans until current legislation is changed, Bronow says. "If the 1974 ERISA [Employee Retirement Income Security Act] law is modified so that patients can sue their health plans, only then do we have hopes of creating an equitable and fair system. Only a change in ERISA will force HMOs to start looking out for the welfare of their patients."
Issue examined more closely
Lately, the reorganization of health care delivery into managed care and its impact on ethics is getting more attention. The July-August 1998 issue of The Hastings Center Report published a special supplement devoted to the topic.1 A case study titled "What could have saved John Worthy?" presents a real-life scenario of a new managed care patient's experiences with the health care delivery system under managed care. The case study is a product of a two-year research project by a working group, Value Perceptions and Realities within Managed Health Care. The project is funded jointly by The Hastings Center and The Prudential Foundation.
One conclusion from the study is that the patient/physician relationship, although important, can't adequately address the challenges faced in a systematic managed care environment. The working group concludes, based on its analysis of interviews with clinicians, patient members of health plans, and corporate managed care staff, that each party involved in the relationship needs an understanding of the intended ethics and goals.
The working group calls "for a richer ethics of organizations, including an understanding of the goal(s) a health care organization is intended, or expected, to serve; the different tasks, such as determining how and by whom health care services will be delivered, that structure a health system, and the values, loyalties, and habits of thought appropriate to those tasks; and the organizational structures and practices that promote or inhibit excellence in carrying out those tasks."1
Putting theory into action
One state is putting the working group's recommendations into action - this month. What started as a goal to write an ethics code has turned into a three-phase project that began in 1996. Phase three of the Colorado Code of Ethics for Healthcare began by unveiling the code in late September, says Liz Whitley, RN, PhD, executive director of the Rocky Mountain Center for Healthcare Ethics in Denver, the sponsoring agency that coordinated the project. (For details, see story, p. 112.)
"We pulled together a 25-member steering committee comprised of everyone we identified as a stakeholder in the health care delivery system. Those members included consumers, patients, practitioners, physicians, purchasers of health plans, and health plan representatives," she says.
Distinctions were made to include representatives who otherwise might be lumped togeth er. Con sumers were identi fied not as involved in episodes of care but as purchasers of care services. Practitioners were divided into all possible categories, including nurses, chiropractors, and massage therapists. The result: the Colo rado Code of Ethics for Health care, a guide for consumers, patients, provi ders, physicians, practitioners, purchasers, employers, and health plans. It's being distributed statewide and includes principles, value statements, and standards. (See box at right.)
"It's a voluntary code, but there's been enough commitment within the state already, so there's not much need for an ethics police, so to speak. There's been a groundswell of support, and everyone involved wants to implement it because there's such a large degree of mistrust on the part of the public in general," she says.
Reference
1. Value perceptions and realities within managed health care. What could have saved John Worthy? Hastings Center Report 1998; 28(suppl):S1-18.
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