Mrs. Goodwin is 42. She has been infected with HIV for four years and is asymptomatic. She has just landed a job as an office assistant, and is seeing Dr. Beale for a pre-employment physical and a screening mammogram. Mrs. Goodwin's new company does not pay for the physical and her HMO does not cover the cost of annual mammograms.
Mrs. Goodwin's exam is completely normal, except for mild fibrocystic disease bilaterally. The pre-employment form asks Dr. Beale if the patient has any serious medical problems.
"Doc, do you have to write that I have HIV? I can do the job."
"Also, shouldn't I have a mammogram anyway? Can't you write that I have a lump or something?"
For individuals, integrity is a virtue. For organizations, it is a business necessity. Integrity and honesty go hand-in-hand — but in managed care, too often the hand has been faster than the eye. Health plans on the sixth floor of a six-floor walk-up without an elevator may not be exactly illegal, but aren't exactly poster boys for good behavior.
Integrity is what patients expect from health plans, and integrity is what they will get, even if they have to go to regulators to get it. But patients are worried about the fracture of honesty and truthfulness in medicine-- can't physicians do something about it?
How have organizational values changed in the era of managed care? Are they fundamentally stronger, more virtuous, open and community-minded? Or have they lost their way? How has integrity fared?
Integrity combines a sense of duty to others with proper business conduct. Though integrity is now on everyone's lips, it has been in short supply. Problems posed a decade ago by self-referral to physicians and the resulting overuse of services, as well as today's corporatization of health care by profit-motivated companies, illustrate why medicine has lost its sense of integrity in the eyes of the public.
Integrity is now organizational, not just personal. That is the change in integrity. As the delivery of care has been integrated with its financing, patients have come to expect that their physician is no longer in charge. To many patients, physicians today are the personification of a health plan's billing and informing practices and of a hospital or health system's community conduct.
Business ethics actually involve the same sort of standards medical ethics do. The ethical obligations of business are integrity and honesty. In medicine, the same obligations apply, as well as altruism, beneficence, nonmaleficence, respect and fairness. Like medicine, business regards the law as a floor for ethics — it is the least anyone should do.
Ethical issues in business have always been a consideration for managed care — though, as in medical practice and medical research, sometimes they are not enough of a consideration. Fraudulent billing, upcoding and unbundling, kickbacks, ownership deals, economic credentialing and patient-dumping are at the top of the heap. There' s no telling what is at the bottom. These issues are why many people think of "managed care ethics" as an oxymoron.
This does not have to be. Managed care must clean up its organizational act, and it needs tough new public standards to do it. As in medicine, teaching others how to think about ethical issues is more important than teaching what to think about them. As in medicine, black-and-white answers are few — except for those issues of integrity, fraud and abuse.
Unfortunately, bioethicists seldom put ethics and economics in the same sentence. In some way, 150 million people are in managed care; more than 41 million more lack access to any care, managed or unmanaged. Basic ethical questions, still unanswered, arise:
Should a family physician inflate a diagnosis of diabetes IIB to diabetes IIB with peripheral neuropathy because a 77-year-old man wants to talk about whether he should switch to a Medicare HMO, and needs another five minutes?
Should a nurse practitioner upcode a young man's macular truncal lesion by adding a family history of melanoma to the medical record to assure he reaches the dermatologist?
Should a general internist do a pap smear and endometrial biopsy on a woman with irregular, intermittent bleeding when a gynecologist gets the same capitation rate with little or no difference from the risk pool?
Everyone is in favor of ethics, but no one wants to pay for it until trouble comes along. Some of the best corporate ethics programs are the ones created because they were federally mandated. These are not token efforts created for the purpose of trotting them out at ceremonial events. But often they focus on legal compliance and standards of business integrity. This is a place to start, but not one to end.
A matter of priorities
"What do you think I should write?" Dr. Beale asks. "We don't want you to get fired, but I don't want to lie to your company. About the breast lump, either."
"Hmm — don't you have something you can write for everyone?" Mrs. Goodwin asks. "What they care about is whether I can work. I can work. The rest should be none of their business."
"You have no medical conditions that compromise your ability to perform the job. That's true. We can write that. But if I say you have a mass and the truth really is you can't afford the mammogram, then what?"
"Doc, I don't know. Why don't you just tell them that, then?"
Dr. Beale calls the HMO for permission to order the mammogram, but the line is busy twice, and once he is put on hold for what seems like forever. His assistant reaches an authorizing nurse on the fourth call. She promises to fax the appropriate form for submission and review.
For patients to receive honest, personal care from someone they trust, integrity in managed care should become the first priority. Improving access, overhauling billing, coding and referring systems, addressing moral and quality concerns head on — these are the actions that can restore managed care's tarnished credibility.