Tide is changing to fight unethical health plans
Do MCOs have the right to deny last-chance therapies?
The only option left to treat your cancer, the oncologist has just informed you, is a bone marrow transplant. And the last chance of ridding yourself of the disease, you find, is considered experimental by your managed care organization and won't be covered.
What may sound like a rare occurrence, however, is gaining ground among medical ethicists and patient advocates as a wrong that must be righted. One physician has even questioned the very fabric of "traditional medical ethics" and asks whether current ethics should be preserved or modified to fit a population-based system of health care delivery.
But intentionally providing minimally acceptable care to some for the benefit of others - adopting a practice of distributive ethics - is wrong, says Jerome P. Kassirer, MD, editor in chief of The New England Journal of Medicine.1 Kassirer's editorial appeared in the Aug. 6 issue.
Kassirer states further that "customizing care on the basis of a patient's insurance coverage is also wrong. When patients are sick and vulnerable, they expect their physicians to be their advocates for optimal care." (For more on a controversial experimental procedure, see related story, p. 99.)
Kassirer's editorial is just one of several instances calling for change among the practices of managed care organizations. The most prominent, of course, are the two versions of a proposed patient bill of rights currently being debated on Capitol Hill.
Two researchers take a different spin on the subject and examine the political philosophy of last-chance therapies and managed care. Their report appears in the March-April 1998 issue of the Hastings Center Report.2
The authors ask why the public should accept decisions made by managed care organizations that limit access to unproven last-chance therapies, especially if some clinicians and their patients believe them to be effective? The authors also question why the public grants the organizations to make "morally controversial decisions that affect our well-being in such fundamental ways."
"The impetus for change is coming from both the physicians and individuals who have probably been denied care by their managed care organization," says Diana Tuell, MHA, director of patient relations at Central Baptist Hospital in Lexington, KY. Tuell is currently serving as president of the Society for Healthcare Consumer Advocacy, a subsidiary of the Chicago-based American Hospital Association.
Some plans reimburse their members for contraceptives but consider in vitro fertilization an experimental procedure - even though the first procedure was performed in the late 1970s, notes Tuell. "Although our ethics committee hasn't really gotten involved in instances where care is denied, I can see us getting into that situation. Our area, however, still has not seen an increase in managed care penetration."
Costs, benefits are high
Patients who invariably get caught in a situation like this are "in a Catch-22," says Tuell. And the costs and benefits for both the payer and the patient are high. Not covering treatments that ultimately prove to be effective allow curable patients to die prematurely. But treatments that are not covered - even when ultimately proven ineffective - create the impression that critically ill patients are abandoned by the managed care organization.
Denials of coverage are also highly visible. Even when the plans use "impeccable science and patient-centered deliberation while trying to hold the traditional, contractually specified line against unproven therapies, risk horrendous publicity, expensive litigation, and legislative mandates requiring coverage," say Daniels and Sabin in their Hastings Center Report article.
Legislation likely
While individual patient advocacy is necessary, it will likely take legislative action for change in managed care policies, says Tuell.
Kassirer agrees, but says the belief for change should also come from the individual. "A system in which there is no equity is, in fact, already unethical. We gave up the idea of having an equitable system when we decided several years ago to give up on a proposed national health system with consistent coverage for the entire population."
Kassirer urges physicians to work on three areas to help bring about change:
1. Refuse to participate in plans that may, because of finances, tempt them to "provide suboptimal care."
2. Refuse to sign contracts that prevent full disclosure of financial incentives or of beneficial options not covered by a plan.
3. Work to reform plans that keep the level of resources for patient care artificially low while spending large amounts of the health care dollar on administration, advertising, and stockholders' profits.
There's good news for ethics committees already facing the dilemma of denied care for last chance therapies. The Medical Care Management Corporation in Bethesda, MD, offers several programs for providers, payers, and patients.
The Medical Care Ombudsman Program consists of a network of more than 250 physicians affiliated with more than 100 medical centers nationwide. The physicians help provide information on whether or not patients can expect to benefit from high-tech or high-risk procedures. The organization has reviewed over 2,500 cases.
References
1. Kassirer J. Managing care - should we adopt a new ethic? New Engl J Med 1998; 339:397-398.
2. Daniels N, Sabin J. Last chance therapies and managed care: pluralism, fair procedures, and legitimacy. Hastings Center Report 1998; 28(2): 27-41.
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