Ethical Issues in Managed Care
Although the term “managed care” refers to a rather heterogeneous group of institutions, a feature common to all managed care organizations (MCOs) is a systematic approach to controlling what had been a skyrocketing escalation in the country’s healthcare costs. The increasing prominence of both medical ethics and managed care over the past three decades has resulted in, if not a head-on crash, a number of well-publicized collisions between the two. Managed care, on the other hand, has clearly concerned itself with the health of not only individual patients, but the collective health of a defined population, namely the MCO’s membership or so-called “medical commons.”
Relevant Principles of Medical Ethics
There are six principles of medical ethics with special relevance to managed care:
Autonomy refers to 1) a person’s right to be fully informed of all pertinent information related to his/her healthcare, and 2) the person’s additional right to choose or refuse among the available treatment options.
Beneficence is the commitment to “do good.”
Nonmaleficence is the commitment to “do no harm.”
Fidelity is the notion that the physician should be faithful and loyal to the individual patient.
Veracity refers to the physician’s responsibility to be truthful to the individual patient.
Justice implies that all patients should be treated fairly, without regard to their race, ethnic background, socioeconomic status, or educational level.
Ethical Issues Faced by MCO Managers
MCO executives face a variety of ethical challenges on an ongoing basis. Some of these ethical dilemmas are analogous to those faced by physicians, whereas others are quite different.
- Persuasive advertising and selective marketing In the world of advertising, veracity is usually not uppermost in the minds of those who produce radio, television, or print media commercials. Unfortunately in the case of MCO advertising, this can result in the prospective MCO member being misled, as when the ad implies that members of the MCO in question can see whichever specialist they please. Although selective marketing might be accepted behavior in most businesses, from an ethical perspective, healthcare organizations should refrain from engaging in such practices.
- Disclosure of information Patients should have a right to be informed of all pertinent diagnostic and therapeutic options related to their healthcare and have the right to be informed of all financial arrangements between the MCO and its physicians (including incentives and disincentives) that could potentially affect patient care. Honesty should be the rule for MCOs not only when dealing with prospective members but also when dealing with those already enrolled in the plan. “Gag rules” where physicians are instructed to withhold information from patients, should be prohibited.
- Financial incentives/Disincentives From an ethical standpoint, it is important that such incentives/disincentives be based on the performance of a sizable group of physicians and not be of such magnitude as to place the physician’s personal financial interests in direct conflict with the interests of the individual patients under his/her care.
- Ensuring quality From an organizational standpoint, ensuring quality can be accomplished in several ways, such as; contracting only with well-trained and credentialed physicians and specialty consultants, establishing evidence-based diagnostic and therapeutic guidelines, developing MCO’s up-to-date drug formulary, providing performance-based feedback to physicians, and evaluate physicians performance by using patient satisfaction measures.
- Appeal procedures MCOs need to have a clearly outlined appeal procedure in place. This appeal protocol should be logical, reasonable, and fair, and should not based against individual patients in their attempt to have their grievances addressed. In addition, it must be clear that the MCO will never act in punitive fashion or “take retribution” against either patients or physicians who challenge the MCO’s decisions or who otherwise participate in the appeal process.
- Confidentiality MCOs need to have systems in place to carefully protect patient confidentiality.
- Allocation of resources: MCO’s must remain economically competitive in a market economy, priorities in allocating healthcare resources need to be established. MCOs should pursue these allocation decisions in an open manner, with input from physicians and the MCO’s membership.
- Fostering the social good: There are several domains that may be considered under the general heading of “social good.” Including: 1) medical education and training of future healthcare professionals, 2) biomedical research, and 3) the care of the uninsured. The responsibility of healthcare organizations to promote the social good is not merely an issue raised by “ivory-tower” ethicists. The code of ethics of the American College of Healthcare Executives, for example, includes the following statements: “The healthcare executive shall work to identify and meet the healthcare needs of the community … work to ensure that all people have reasonable access to healthcare services … and consider the short-term and long-term impact of management decisions on both the community and on society.”