Ethics and Managed Care: ACEP Takes a Stand
Despite the financial pressure imposed by managed care, emergency physicians must ensure that the best interests of individual patients remain top prioritythat’s the message behind the American College of Emergency Physicians’ recent policy statement on managed care and emergency medical ethics.
As many MCOs move to incentivize emergency physicians through capitation contracts or reduced fee-for-service, leaders in the medical community are striving to provide ethical guidance in a world increasingly dominated by market forces, says Wesley Fields, MD, FACEP, chairman of the college’s section on managed care.
"For the first time, emergency physicians are being given incentives to not provide care," Fields says.
When a patient comes to the ED with a complaint, the physician now is encouraged to do just a basic workup and then send the patient out to a primary care doctor or to a another facility instead of delving into the "second stage" of care, Fields explains.
Because these incentives are usually driven by a desire to reduce costs and not based on clinical practice, there is great potential for ethical conflicts, Fields says.
"These agreements can undermine the doctor-patient relationship," he claims.
Managed care contracts are not necessarily detrimental to this relationship. Some plans have been very progressive in developing methods of both containing costs and ensuring good patient care, he says.
The problem is, there is no set standard for individual MCOs, and subscribers to health plans have almost no way of distinguishing between good plans and bad, he says.
"Every plan does things a different way," Fields says, noting inconsistencies in the way authorizations for ED visits are handled and the lack of a standard definition of an emergency.
"It’s almost impossible for patients to know the difference, but their care can be drastically impacted."
As a way of answering these concerns, ACEP’s board of directors adopted its policy statement "Managed Care and Emergency Medical Ethics" in September. The text of the statement was recently published in the Annals of Emergency Medicine.
The four main points of the statement are:
• The ethical obligations of emergency physicians do not change when practicing in a managed care or any other environment. The physician’s primary responsibility remains with the patient.
• When economic interests of physicians, hospitals, purchasers of health services, or managed care organizations are in direct conflict with patient welfare, the highest priority is patient welfare.
• Because the financial resources of our society are finite, emergency physicians have a responsibility to practice medicine in a cost-conscious manner. Regardless of the payment structure, the emergency physician should not provide care without reasonable expectation of patient benefit.
• Emergency physicians should follow only managed care policies and utilization-management guidelines that are ethical, compassionate, and consistent with professionally accepted standards of emergency care.
The guidelines are needed because the basic philosophies of managed care and emergency medicine are very different, contends Arthur Derse, MD, JD, FACEP, FCLM, Associate Director for Medical and Legal Affairs at the Center for the Study of Bioethics at the University of Wisconsin.
The guiding principle of emergency medicine is providing the best care to each patient, while the MCO focuses on maintaining the health of the group, he says.
"Managed care organizations want to deliver the lowest cost [care] to the healthiest population possible," he notes. "They want the younger, healthier patientsthey don’t want the older and sicker ones."
A member of ACEP’s ethics committee, Derse also co-wrote an article on managed care ethics and emergency medicine that accompanied the policy statement in the December issue of the Annals of Emergency Medicine.
Because the emergency room has been charged with seeing patients regardless of their ability to pay, managed care’s stance is essentially forcing ED physicians to be the "guys in the black hats."
"Increasingly, you have emergency physicians trying to get patients admitted or seen by a [primary care] physician and that physician says, I’m in this plan, they’re not. I am not obligated to treat them,’" Derse says. "I don’t think society really wants emergency physicians to be the bad guys and say, Too bad, you don’t have insurance, you’re out on the street.’"
"I’m not saying that managed care is the bad guy either," he continues. In fact, many studies indicate that managed care, in the areas it has been established, has been able to reduce health care costs overall.
The problem is that too many of the indigent, elderly, or unemployed fall through the cracks, Derse says.
"I can’t say that people are sicker or are losing their lives because of managed care," he says. "But, the elderly people and sick people are not taken care of as well."
Another concern among the medical leadership is that while executives at managed care organizations are turning big profits, 41 million Americans are still have no health insurance, Fields says."I think that’s where ACEP is coming from."
Fields acknowledges that standard fee-for-service medicine had its share of ethical problems with the profit tied the number of tests ordered and procedures done.
"These sorts of excesses of the past, they deserve to go just as much as the [MCO] gag rules," he says. "There has to be some sort of happy medium."
Both Derse and Fields say the upcoming reintroduction in the House of Representatives of the "Access to Emergency Medical Services Act," which would establish federal standards for access to emergency services, including a standard definition of an emergency, is currently the best hope for remedying some of the ethical conflicts between managed care and emergency medicine.
"There has been a sea of change going on in the past couple of months," Fields notes.
The government has been using its status as a payer (i.e., Medicare, Medicaid) to set standards for the rest of the industry, he says. And, some MCOs have begun to proactively develop new arrangements with physician groups to address some of the problems.
"I think the gravy days of all the for-profit stuff are about to be curtailed," he says.
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