Ethical Issues in Managed Health Care Organizations

Selected Citations from May 30, 1997, Meeting

Introduction

The following citations (stylistically edited for grammatical purposes) are taken from the transcript of our May 30, 1997 seminar meeting. They recall highlights of both substance and mood of the views shared that day on the ethical quandaries managed health care participants experience. They are loosely gathered under headings.

1. Decision making, as the key to ethical quandaries in managed health care.

  • Physicians are used to making decisions to benefit their patients. Now we have a third party in the decision-making process, the managed care organization, the party I represent. Where do we fit into that?
  • Who makes the decision? As an MCO, we may not think the procedure being requested should be done in a hospital setting, but somewhere else.
  • I think the crucial questions are who makes the decision, and how does it get made. As an MCO we think we have ways to put together the best way to make a decision, because we face them on a daily basis. We function on the basis of benefit coverage determinations from the employer group.
  • Our approach is to partner with our clients, i.e., the employer group. This network is the foundation of that delivery system. Our responsibility is to enhance the networks.
  • How do we make allocation of resources decisions?

2. Decision making constitutes a system, a network, with multiple deciders.

  • Who decides who's in the network?
  • I believe in our system we have a very good structure where we have nurses who take the first request. They use written guidelines that were developed by our practitioners, approved by our oversight committee.
  • "Whose decision is it anyway?" comes up every single day. Despite putting together some very complete plans, criteria, indicators, trying to decide "who decides," etc., every particular case becomes extremely difficult, extremely problematic.
  • And again, it comes down to who makes the decision. As an MCO, we have, I think, a very good system using a number of physicians across the state to try to decide what's currently investigational or not.
  • If the guidelines on which the managed care company is delivering its decision had the input of the providers and the support of the providers, there would be far fewer telephone challenges.
  • Both the provider and the insurer want to manage this process. There needs to be someplace where they come together to make joint decisions on the process of care.
  • Does the physician make the decision? It's the Benefits Committee that has members of both the health plan and the physicians group.
  • The legislatures are now trying to step into the appeal process.
  • There are multiple points in the system. I think it's really important to carry through the process of working together on the challenges we face in common.
  • The outcome which we are all looking for in health care is a delivery system and a payment mechanism. If an MCO creates a true partnership with the provider's perception of quality and links that together, the results are so powerful that it will enhance the partnership.

3. Typical tensions:

a. Physicians questioning the managed care manager (procedures, outcomes, etc.)

  • Physicians want more autonomy, but aren't willing to share it. How do you apportion risk, reward, and liability?
  • The consumer wants to hear from the provider that the payer is the villain.
  • The one area that absolutely pits physicians against managed care systems is the area of rationing.
  • We sometimes see patients in "motion." Because of health policy changes, they have to see a new physician who is on the preferred provider list.
  • We are frequently forced to discharge patients earlier than they ought to be.
  • There is a denial of access to specialty care.
  • Often when I am talking to an MCO, I'm talking to a 21-year-old who has no medical education--they don't understand the disease.
  • Drug formularies are overly restrictive. There are some patients who only respond to one drug. I am not talking about generic substitutions. I am talking about therapeutic substitution.
  • The physician's role is different in the managed care setting. There are more players and he/she sees the patient for less time. What is the physician's advocacy responsibility for patients in this setting? How can you be an advocate for a patient you have only seen 10 minutes?
  • Hold harmless clauses make the physician responsible for some of the errors of the managed care plans.
  • In a managed care environment we physicians are thrust together with physicians whom we do not know and whose standards we do not necessarily share. We do not always respond in the same way in caring for a patient.
  • Because of the bureaucracy we fail to get approval for a procedure in a timely fashion.
  • There is a loss of doctor/patient bonding.
  • There is a loss of confidentiality (e.g., pharmaceutical companies)

b. Managed care administrators resenting pressures for exceptions.

  • The patient appeals to advocacy groups and an exception is made to the benefit structure of the organization's contractual coverage. The ethical issue of justice is violated.
  • The issues we face fall into categories having to do with our external relationships with regulators and legislators.
  • We are asked to intervene in the health care system and change it to improve quality. On the other hand, we are expected not to intervene in such a way that disturbs the doctor/patient relationship.
  • There is a resource allocation issue. It gets back to special interests: what might be good for an individual in the short term is in competition with interests of the greater population in the long term.
  • The providers are convinced that what we use protocols and guidelines in order to ration care. Actually, what we're trying to do is make care more rational.
  • When a member wants a service that is not paid for by their policy, its hard for them to understand that a big insurance company can't cover everybody.

c. The employer and the program.

  • Most managed care organizations will tell me without any hesitation that all this talk about the employer's concern for quality is just talk. When they sit down at the negotiating table with purchasers, the real issue is cost.
  • There is a movement toward viewing the purchase of health services as an investment in human growth--as opposed to a device for managing costs. If a person has bad medical care and they miss several months of work, it is not productive for our company.

d. The unpredictable impasses

  • There is a massive disconnect in understanding between what is and what people think there is.
  • Managed care begs the question that we're managing costs rather than coordinating care.
  • Is it going to be service, quality, and efficiency, or is it going to be what has been the basis of competition for insurance companies, namely, the ability to avoid risk?
  • Doctors are being treated like tools of production and patients are being treated as products of production.
  • Our researchers (in medical schools) are now working with pharmaceutical companies, forming their own corporations. One of the biggest businesses in this country is technology transfer.
  • How can you be an advocate for a patient when he or she is asking for a therapy which the plan they have selected doesn't cover? They pick the low-priced plan when they are well and when they are sick, they come to the doctor to be their advocate.

5. Especially vexing issues

  • A care decision is often pre-programmed and inflexible. "Medical necessity" tends to be based on protocols that are heavily influenced by cost benefits analysis.
  • I like to talk about health care in the context of social justice. When you bring health care into the marketplace you encounter a different definition of the word "deserving." In social justice, the "deserving" person is the one who has the need.
  • We seem to have forgotten those who have no access to care except in emergencies.
  • In a nation that promises life, liberty, and pursuit of happiness, access should be considered a human right.
  • Conscientious practitioners are often perplexed about how they should act when they are caught up in a web of economic, political, business practice, and social responsibilities. As a profession physicians must take the lead in advising policymakers.
  • [Managed care] has not carried its load by contributing to research and medical education.
  • Public goods have traditionally been the function of urban academic health centers, e.g. charity care. Not only have most managed care companies escaped contributing to financing these public goods, but have gained competitive advantage by contracting with hospitals that don't incur these costs.

6. Should quality be defined?

  • Quality in service areas is defined as meeting or exceeding customer expectations. Is that the definition of quality in health care? It's probably both outcomes and meeting some customer expectations.
  • There are good definitions of quality in health care that basically talk about optimizing outcomes against a backdrop of what is known and what the system is capable of doing.
  • The search has to be for best practices, understanding that all the various professions have to recognize both their vulnerabilities (frequently illustrated in the anecdotal material) and considerably higher levels of accomplishment (which ought to be encouraged in whatever we come up with).
  • A lot of people identify and equate quality with patient satisfaction. It has to be more than that. In trying to achieve quality, managed care has to overcome a long-held assumption that more is better. I think quality can often mean less for the patient rather than more.

7. Can quality be measured?

  • I think our salvation will lie in the measurement of quality in the future.
  • I think that the questions of measuring, or the creation of a metric for what we mean by quality, is directly tied to the kind of ethical tradeoffs we are posing. I always think of the quality metric problem as the foundational question.
  • It is very difficult to write guidelines that will assure quality, when there are many ways to treat patients with the same diagnosis--the outcomes can't be measured except by crude outcomes such as mortality, cost per stay, etc.
  • In order to give quality in a service sector, you do the opposite of what you do in production. In service, you free up people in the front lines to make decisions.
  • I heard a very profound commentator on educational issues say that you can seek quality and you can seek access, and of course, you will seek cost control, but you will only achieve two of the three.
  • In this study, we should address the question of how to seek quality, access, and cost control.

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