John La Puma, M.D.
MANAGED CARE September 1997. ©1997 MediMedia USA

John La Puma, M.D.

Managed care has been called a lot of things. Uncaring. Unethical. Unfriendly. Unfair. And a few more "un" words that cannot be printed here.

Why the "uns"? Enrollees lose choice of doctors and hospitals. The doctor-patient-payer relationship seems more important than the doctor-patient relationship. Doctors are pressured to see more patients in less time and to avoid the infirm elderly — while making fewer errors and documenting everything possible.

The frustration level with managed care is high and growing among both patients and physicians. Savvy managed care organizations might just want to call on their ethics teams to save them from the media mill waiting to grind them into unrecognizable little bits.

But should ethics be employed as a marketing device? And if it should, can it restore managed care's tarnished image? What are the advantages and disadvantages to using ethics as public relations?

The advantages are three: popular, practical and moral.

The most important reason to make ethics programs a conspicuous part of managed care is that the public perceives that managed care needs ethical attention, badly. Managed care seems out of control and into stratospheric profits. It is seen as cost-containment central, with little care for other values.

Yet an organization that champions consumer choice champions patient autonomy. A health plan that honors cultural pluralism honors respect for persons. An HMO that provides open access to specialists provides beneficence in spades. A managed care organization that treats all members equally and recognizes special need when it exists recognizes fairness as an ethical principle. And cost savings are possible in an organization that honors and pays attention to ethics.

Not by going through the ICU to discover who has an advance directive and who does not. Or by discontinuing ventilators and transferring people to hospital beds in the name of patient preference. (Having a systematic advance care planning clinical service, structured CME sessions for physicians or a quality rating for advance care planning might accomplish similar savings ethically, and within a primary care relationship).

Ethics — in assuring that billing, coding and referring are done honestly, carefully and with integrity — should save lawsuits, investigations and upheaval. It should also win customer loyalty. How? By addressing head-on the duty to others that all health care involves. Managed care organizations are part of their local communities. Preventive ethics is as important as preventive medicine.

Can academic centers help?

Here is a role for academic health centers: becoming partners with managed care organizations that need expertise in ethics. These centers specialize in credibility and prestige. Many also train medical ethicists, sometimes 10 at a time. In return for advising managed care plans on ethics, academic health centers could learn how to use demand management and practice guideline programs from managed care people with years of experience.

Finally, there are moral arguments for using ethics as public relations for managed care. An organization that recognizes ethical dilemmas is halfway to resolving them. An organization that acknowledges that not everyone can have everything if there is to be room for all provides a reason for limits, and makes a promise to use monies saved for the purpose of inclusiveness. An organization that believes that fairness is the ethical principle that underlies accountability to others believes in population-based health care.

What could be wrong with ethics as public relations? A lot, in the same three areas: popular, practical and moral.

The most important flaw is that no one will believe it. Who will credit that plans want to place quality above cost, and service above restraint? Yet that is just what is required.

A second flaw is that ethics, in the popular mind, is now associated with violations of laws and rules, not adhering to principle and trying to do what is right. Congressional committees, investigations and political scandals have changed the popular perception of ethics from one characterized by scholarship to one whose soul is regulation.

As in so many things, the perception is not the reality. Ethicists are seldom public figures, tend to be introspective, and are more likely to spend their time studying in libraries and worrying about nuanced argument than producing reams of numbers or attending to their suit buttons.

Practical problems in using ethics include the distinct possibility that there is no real money in it. Reviewing advance directives, assuring proper consent and protecting confidentiality may save lawsuits, but ethics consultations generate little revenue. Few trained medical ethicists know anything about the ethics of billing, coding and referring. And a great many trained medical ethicists are tied up handling more palliative care cases than they can count.

Finally, there are moral disadvantages to using ethics in this commercial, market-driven way. Ethics is a discipline that asks good questions, and tries to help people to see each other's reasoning. Whatever issue is chosen as the lead "marketing issue" would be the wrong one, as no single issue adequately conveys the complexity of difficult choices so commonly encountered in practice. The lead issue is unlikely to address groups most in need — African-Americans, Hispanics, the disabled — new enrollees in managed care who need access to it. And outpatient clinical ethical issues are considerably less well researched than inpatient ones: who knows what they really are?

"Doing ethics" in managed care is full of challenges. Those who are doing it well should be rewarded. Maybe one day an "ethics rating" will be a factor in how patients choose their health plan. How can this be made real? For a start, here is a list of a few medical and nonmedical options for end-of-life care, laid out last month:

Measure and monitor the quality of life at the end of life as part of the National Committee for Quality Assurance's Health Plan Employer Data and Information Set (HEDIS). Code and register "do not resuscitate" orders practice- and planwide. Train physicians, physician assistants and nurse practitioners in supportive care methods, skills and techniques, and in pain control. Implement systematic advance care planning. Expand hospice services. Communicate about patients' real fears. Insist on independence from HMO cost-benefit analyses.

Those thinking ahead cannot afford to be behind on ethics.

John La Puma, M.D., practices internal medicine with Alexian Brothers Medical Center in Elk Grove, Ill., and is a Chicago-based speaker and educator. Managed Care Ethics: A Guide to Decision Making in the New Era of Medicine, based on his columns for Managed Care, will be published by Hatherleigh Press in November.

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