MANAGED CARE November 2009. ©MediMedia USA
You don’t have to be an experienced psychiatrist to puzzle out the ethical dilemmas of health care delivery today. But for this ethics-program pioneer, it helps.
“All’s fair in love and war,” wrote a 16th century English poet, but what is fair in health care? Probably no one is more qualified to discuss that than James Sabin, MD, a clinical professor in the departments of psychiatry and population medicine at Harvard Medical School, director of the Harvard Pilgrim Health Care Ethics Program, founder of a consulting organization known as the Ethics and Strategy Group, and author of more than 135 articles and book chapters on organizational ethics, resource allocation, and clinical practice. He and Norman Daniels are co-authors of Setting Limits Fairly (Oxford University Press, 2002; second edition, 2008) and he collaborated with Steven Pearson, MD, and Ezekiel Emmanuel, MD, on No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence (Oxford, 2003). He was a practicing psychiatrist for 37 years until 2007, and today he blogs about health-system ethics at http://healthcareorganizationalethics.blogspot.com/ [1]. Sabin recently joined MANAGED CARE Editor John Marcille for a conversation.
MANAGED CARE: What do you see as the big ethical questions that health plans should be addressing today?
JAMES SABIN, MD: The cost of health care is one deeply ethical issue, and our country is doing a terrible job with it — though I don’t think one could really expect more right now, the way the health reform process has unfolded. Take the bashing of insurance companies. Now, insurers aren’t perfect, and a lot can be criticized in what the industry has done, but we’re operating with a national fantasy that high costs somehow are the insurance companies’ fault. As your readers who are clinicians will understand, organizations have to be viable, and that’s part of ethics, too. We have practice patterns that are often profligate and sometimes downright irresponsible. Indeed, the public should be outraged that we’ve done as little research as we have into the comparative effectiveness of different treatments. But health plans were asked back in the 1990s to manage care — and then as a nation we blamed the messenger.
MC: How so?
SABIN: We pretended that if it weren’t for health plans we’d be able to do anything we wanted. Any individual doctor could make any decision he or she wanted and it would automatically be paid for. I see that as a deeply unethical way of conducting a health care system if we’re talking about shared funds. I’m getting hot under the collar as I talk about this.
MC: Go on.
SABIN: Again and again in the health care-reform discussion, we hear things like, “Do we want a bureaucrat — either a government bureaucrat if a public option or Medicare is being discussed, or an insurance bureaucrat — making decisions about your health care?” The question is structured as one between good and evil, as if the path of goodness is that every clinician, regardless of the state of clinical knowledge or what incentives might apply to the way he or she makes recommendations, should have free reign, and it would be disgraceful if someone else, a government bureaucrat or an insurance bureaucrat, entered into the process.
MC: Of course, both sides make simplified arguments. What bothers you most about this “good-and-evil” formulation?
SABIN: What it is really saying is that we should continue with a status quo that has led to out-of-control costs that have hurt workers by taking away from their salaries and hurt the companies they work for by reducing competitiveness. The auto industry may be the best example. This kind of self-righteous political dialogue really serves to defend cost trends that are wounding people. So the question for health plans is: How can they enter in?
MC: And the answer?
SABIN: It’s quite hard, but we need, as a country, to learn to think about value in health care and to make the sort of thoughtful choices that children start to make when you give them an allowance. We have done our best to avoid this in health care. And I think an ethics program is relevant here. When Harvard Pilgrim started its ethics program, it focused on this interface of managing cost and the human meaning of health care expenditures and saw that as a central area that an ethics process would engage with.
MC: Let’s talk about ethics programs. Why does a health plan need one?
SABIN: If the problem were that the leadership and the organization itself were unethical, an ethics program would be a waste of time. Look at Enron — it had an elegant ethics statement. An ethics program can’t turn around an organization that is in some way dishonorable. So my starting point for thinking about this is the question of whether and how an ethics program can support the aims of the leadership and board of directors. When Harvard Pilgrim Healthcare started its ethics program in the mid-1990s, we had been talking about starting one for a couple of decades. But we encountered some concerns that I know are not uncommon. One was that leadership said, “What do we need an ethics program for? We’re ethical people. We think about values.” And that’s true. They were ethical people. There was also a concern that if we established an ethics program it might “de-skill” people, give them the idea that dealing with value questions required a specialized function the same way that in clinical practice consultants can sometimes be brought in before primary care clinicians have deeply engaged with a question they might have been able to solve themselves.
MC: What finally led to the decision to launch the program?
SABIN: There was a merger between the Harvard Community Health Plan Program, which at that time was still a staff-model HMO, and Pilgrim Healthcare, which was a physician-directed, not-for-profit independent practice association. They were both not-for-profit, clinician-led, and very respected organizations. But there were enough differences between them that — I’m told —when they came together, the folks from each organization would say behind closed doors, “Are those other folks unethical the way they seem?” I’ve heard that the same thing happened when two Catholic hospital systems merged. I forgot which saint each one was associated with, but each was backed by a saint! In our merger, the leadership of Harvard Pilgrim at the time was, in my view — I wasn’t part of this, so I can praise it — wise enough to say, “What we’re seeing is a reflection of different internal perspectives on values, and it’s the sort of thing that we might best address by forming an ethics program where we could hash out questions and work through them and give advice.” So that was the initiating factor.
MC: What was the ethics program’s official mandate?
SABIN: The program was structured — wisely, I believe — so that it had no bureaucratic authority. No one had to consult with it. Any advice that it gave was just that, advice. I was an adviser to the program till 2000, and I’ve been responsible for it since. It is an excellent pressure on the program, a constructive pressure, that we have to earn our spurs. No one has to use us. We have to make ourselves useful.
MC: How has the program evolved?
SABIN: One way is simply by keeping up with the evolution of the field itself, and recognizing and working with the ethical implications of changes in the field. In the 15 years that we’ve had our program, health insurance itself has evolved a lot. There is much more variation in the health insurance product. There is more self-insurance on the part of companies.
MC: How is the program structured?
SABIN: Its central piece is the ethics advisory group. What we concluded in the course of an extended exploration — a lot of interviewing of people within the organization and with external stakeholders — is that because a health plan is in the middle of a network of components of society, we wanted to have voices from all of those stakeholder groups as part of our process. I’ve seen the same issues come up at other organizations, and this was kind of a gutsy decision.
MC: How so?
SABIN: Gutsy in the sense that it established an element of openness. It said, “We’re going to talk about things that may be quite sensitive — with outsiders as well as insiders.” And that requires a lot of trust on all sides and a careful management process for making it work. But that, I think, has turned out to be crucial.
MC: How does an issue come before the ethics program?
SABIN: We decided that a topic could only come to our organizational ethics group if it was brought by the responsible manager. We wanted to structure our program as something that wasn’t an internal foraging organization that could and would go into a department and say, “Show us what you are doing,” the way external inspectors might do. There is a role for that function in organizations, but the ethics program is different. It’s about ideals and core values, how they are fleshed out, how they are dealt with when conflicts among values occur. So we decided to work in concert with management, and sometimes the head of a department will come to me and flag an issue.
MC: Can you give an example?
SABIN: A few years back, care management nurses were troubled by the fact that people who had similar medical conditions might have different access to services because they had different insurance products. And the basic teaching of ethics, going back to Aristotle, is that likes should be treated alike. The nurses said, “Here we’ve got two clients with related conditions, and we can’t offer the same thing to each of them even if their circumstances are the same.” They were troubled by that, and they were right to notice that fact.
MC: So what was the determination?
SABIN: Well, it really wasn’t true that the nurses were treating identical people differently, because the people weren’t identical in terms of how the insurance decisions had been made by their employers. If Smith and Jones were next-door neighbors, it would be important for them to know that Smith’s company provided a certain rehabilitation benefit and Jones’s company did not. Mr. Jones might want to agitate at his company for that benefit.
MC: But isn’t there the possibility that a management person could suspect that an ethics recommendation might inhibit him or her, and therefore not bring it to you?
SABIN: That’s both a problem and an opportunity. The threat is that people could just go underground, you know, and say, “Oh, I don’t want to bring this to light, because it doesn’t smell right.”
MC: Right.
SABIN: Well, if you are in an Enron situation, the whole enterprise is going to go down the tubes and should go down the tubes. But from what I’ve seen — and I think this would be true for the organizations your readers are involved with — the vast majority of organizations and individuals want to do right by human beings.
MC: Organizations as well as individuals?
SABIN: That’s right. I’ll give you a good example. In the late ’90s our organization encountered a financial problem. For about a year we were in receivership. And what the COO said was, “Give us advice about an ethics framework for making decisions in a time of significant financial crisis.” It’s one thing to say that we value A, B, C, D, and E, and we do, but when the financial situation is very tight, we may not be able to do A, B, C, D, and E. For a hospital, a typical issue is that a service line that is deeply attached to the mission may be also deeply unprofitable. To carry out your mission, you have to have a margin. That’s the title of a book that two colleagues and I did a few years ago. Often you’ll encounter a situation — I’m not talking specifically about Harvard Pilgrim here, but about the world — where people say, “This is about business, not about ethics.” Actually, that’s a misconception. What they are saying is, “We think the viability of the organization should be weighed heavily here.” For them, ethics can seem to be some sort of goody-goody thing like being charitable. Not to put that down, but an organization has to be viable, and that’s part of ethics too. There are circumstances where one wouldn’t want to work with an ethics program because maybe it is too shut out of the organizational planning process. So the answer to your question about whether there might sometimes be a problem is that there could be. And if that were the case, I would advise someone I was consulting to, if the important issues don’t surface, to take on another role or leave the organization. But I would expect that most of your readers want to do good and do well.
MC: How should an ethics program work in a for-profit plan?
SABIN: Our organization is not-for-profit, so I have not had the experience of running a program in a for-profit structure. But in principle there is no reason the same function can’t be carried out, except that one would have to factor in the voice of equity ownership.
MC: What is a difficult issue your program has dealt with?
SABIN: We retired a set of products in New Hampshire. And because decisions like this were going to come up again, the people who were responsible there wanted to use this as a learning opportunity. What turned out to be the most useful part of the meeting was that they’d given me the letters that had gone out to employers and members explaining the change. These letters talked about pricing products, adverse selection, and some aspects of insurance that are poorly understood outside of the insurance world. And an outside person, a physician from the network, looked at the letters and said, “I think you could do a lot better here. These letters are not educative.” Frankly, we all agreed. That’s an example of something that could have been tense if the outsider had said, “This is disgraceful. I’m going to go to the Boston Globe. Up against the wall, you corporate offenders!” The company would be unhappy. An ethics program could act as a loose cannon, and it could be seen as a dangerous spotlight for exposure. But frankly it’s worked rather well over the years.
MC: Thank you.
We’re operating with a national fantasy that high costs somehow are the insurance companies’ fault.
An organization has to be viable, and that’s part of ethics too.