Can Accountable Care Organizations Embody Justice? March 5, 2013 | Presence Health

1. Can Accountable Care Organizations Embody Justice? March 5, 2013 |Presence Health Thomas Nairn, OFM, Ph.D. Senior Director, Ethics The Catholic Health Association

2. Can Accountable Care Organizations Embody Justice? Overview • This presentation will try to answer three questions. . . • What does the Catholic Church mean when it speaks of justice? • What are Accountable Care Organizations (ACOs), and (how) do they promote Catholic social teaching in general and the virtue of justice? • How do the mission and values of Presence Health affect this discussion?

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4. Can Accountable Care Organizations Embody Justice? A Philosophical Understanding of Justice “The terms fairness, desert, and entitlement have been used by various philosophers in attempts to explicate justice. These accounts interpret justice as fair, equitable, and appropriate treatment in light of what is due or owed to persons. Standards of justice are needed whenever persons are due benefits or burdens because of their particular properties or circumstances, such as being productive or having been harmed by another person’s acts. A holder of a valid claim based in justice has a right, and therefore is due something. An injustice involves a wrongful act or omission that denies people resources or protections to which they have a right.” Beauchamp and Childress, Principles of Biomedical Ethics, 7th Edition

5. Can Accountable Care Organizations Embody Justice? The Catholic Social Tradition and the Virtue of Justice • Justice consists “in the constant and firm will to give their due to God and neighbor.” (Catechism of the Catholic Church, 1807) • Justice and solidarity • “The full truth about humanity makes it possible to open up for justice the new horizon of solidarity and love.” (Compendium of the Social Doctrine of the Church, 203) • Justice and charity • “Charity goes beyond justice, because to love is to give, to offer what is “mine” to the other; but it never lacks justice, which prompts us to give the other what is “his” or “hers,” what is due to him or her.” (Pope Benedict XVI, Caritas in veritate, 6) • Justice as righteousness • “Covenant faithfulness when dealing with realities that involve fundamental and unavoidable moral duties. (Compendium of the Social Doctrine of the Church, 569)

6. Can Accountable Care Organizations Embody Justice? Justice as Solidarity Justice as Righteousness The Catholic Social Tradition and the Virtue of Justice TENSION

7. Can Accountable Care Organizations Embody Justice?

8. Can Accountable Care Organizations Embody Justice? Presented by Jack Ebeler

9. Can Accountable Care Organizations Embody Justice? Affordable Care Organizations • A network of physicians and medical centers that share responsibility of providing care to patients. • In accordance with the ACA, ACO’s would manage health care needs of a minimum of 5000 patients for at least three years. • Benefits of ACO • Ability to provide and manage a continuum of care across different kinds of institutional settings. • Capability of prospectively planning budgets and resource needs. • Sufficient size to support comprehensive, valid, and reliable performance measurement. • More efficient and effective care would help eliminate current incentives for overutilization of health care facilities and technology.

10. Can Accountable Care Organizations Embody Justice? Affordable Care Organizations • ACOs demand sharing of risks and benefits across network of providers. • ACOs have potential in improve the quality of care while reducing healthcare spending. • ACO’s and the Ethical and Religious Directives (ERDs) • Opportunities • Witness responsible stewardship • Provide poor and vulnerable with equitable access to care • Challenges • May limit witness • Scandal • Not all share our values and beliefs • Some in network may be engaged in what the Catholic Church considers wrongdoing

11. Can Accountable Care Organizations Embody Justice? ACOs as Opportunities to Extend the Healing Ministry “If one seeks to influence, shape, direct, heal, elevate, and enrich a complex industrial democracy, it cannot be done simply by the integrity of individual witness. It is done by institutions that lay hands on life at the critical points where life can be injured or fostered, where people are born and die, where they learn and teach, where they are cured and healed, and where they are assisted when in trouble. . . . Institutions always make a difference for good or for ill.” • J. Bryan Hehir

12. Can Accountable Care Organizations Embody Justice? ACOs as Opportunities to Extend the Healing Ministry As citizens of the state, Christians are to take part in public life in a personal capacity. They cannot relinquish their participation in the many different economic, social, legislative, administrative and cultural areas, which are intended to promote organically and institutionally the common good. • Pope Benedict XVI, Deus Caritas Est, § 29

13. Can Accountable Care Organizations Embody Justice? ACOs as Opportunities to Extend the Healing Ministry • Church’s institutions need coordination for effectiveness of charitable service. • Church’s institutions need transparency. • Church’s institutions need faithfulness to duty of witnessing to love. • Church’s institutions must witness to an unselfish love which shows itself to be a culture of life by the very willingness to “lose themselves” for others. • Pope Benedict XVI, Deus Caritas Est, § 30

14. Can Accountable Care Organizations Embody Justice? ACOs as Opportunities to Extend the Healing Ministry • Commitment to charity entails collaboration with other entities • With charitable agencies of other Churches • All have same fundamental motivation and same goal • Building of a better world • With state agencies • Mutual coordination can only help the effectiveness of charitable service • Pope Benedict XVI, Deus Caritas Est, § 30

15. Can Accountable Care Organizations Embody Justice? Challenges Presented by ACOs to Extend the Healing Ministry • Limitations to such collaboration • “Faith and healthy Christian discernment lead us to pay prophetic attention to ethical problems.” • “We must exercise critical vigilance and, at times, refuse funding and partnerships that, directly or indirectly, foster actions and projects that are contrary to Christian anthropology.” • Pope Benedict XVI, Address to Pontifical Council Cor Unum, January 19, 2013 • “Prophetic” discernment • Not all organizations share our values and beliefs • Some may be engaged in what the Catholic Church considers wrongdoing • Justice as Solidarity/Justice as Righteousness • Importance of the Principle of Cooperation

16. Can Accountable Care Organizations Embody Justice? Integrity and Challenges Presented by ACOs • Question: How does the Catholic organization maintain its integrity when partnering with another organization to achieve some good when the partner does not share some or all of our basic values and/or may be engaged in wrongdoing? • ERDs call for careful moral analysis: • “If a Catholic health care organization is considering entering into an arrangement with another organization that may be involved in activities judged wrong by the Church, participation in such activities must be limited to what is in accord with the moral principles governing cooperation” (#69).

17. Can Accountable Care Organizations Embody Justice? Integrity and the Principle of Cooperation • The principle of cooperation • The principle has been part of Catholic ethics for over 400 years; it helps determine whether and how one may be present to the wrongdoing of another. • Modes of presence: ownership, governance, management, providing services (e.g., staffing, supplies, billing), financial benefit.

18. Can Accountable Care Organizations Embody Justice? Integrity and the Principle of Cooperation • To determine whether the cooperation with a wrongdoer is permissible, must analyze cooperator’s intention and action. • Cannot approve of or intend the wrongdoing • Action must be non-essential • There must be a proportionate reason • Scandal must be avoided

19. Can Accountable Care Organizations Embody Justice? Integrity and the Principle of Cooperation

20. Can Accountable Care Organizations Embody Justice? Integrity and the Principle of Cooperation • Intention: Intending, desiring or approving the wrongdoing is always morally wrong (formal cooperation). • Action: Participating in the wrongdoing or providing conditions for the evil to occur (material cooperation). • Material cooperation can be immediate or mediate. • Mediate material cooperation can be proximate or remote.

21. Can Accountable Care Organizations Embody Justice? Integrity and the Principle of Cooperation • Being present to the wrongdoing of another in a non-essential way (i.e., the cooperator’s act assists in the performance of the wrongdoing but is not itself essential) can be morally licit when there is a proportionately grave reason (mediate material cooperation). • Cooperator’s action should be as distant (in causal terms) as possible from wrongdoer’s. • The more proximate (in causal terms) the cooperation, the more serious the reason.

22. Can Accountable Care Organizations Embody Justice? Integrity and the Principle of Cooperation • Catholic moral theology forbids Catholic health care institutions from engaging in immediate material cooperation in intrinsically evil actions (e.g., sterilization). • Immediate material cooperation with regard to partnerships would include ownership, governance, management, financial benefit, material and personnel support.

23. Can Accountable Care Organizations Embody Justice? Integrity and the Principle of Cooperation • Scandal, that is, leading others to wrongdoing through bad example, must also be avoided: • Likelihood of serious scandal can foreclose cooperation, even if morally licit. • Scandal can often be avoided by a good explanation. • Importance of transparency • Diocesan bishop has final responsibility with regard to assessing and addressing scandal (#71).

24. Can Accountable Care Organizations Embody Justice? Integrity and the Organization as Partner • Importance of consulting with the diocesan bishop or his representative: • “Decisions that may lead to serious consequences for the identity or reputation of Catholic health care services, or entail the high risk of scandal, should be made in consultation with the diocesan bishop or his health care liaison” (#67). • Importance of mission discernment and due diligence efforts in assessing such arrangements, with the help of ethicists.

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26. Can Accountable Care Organizations Embody Justice? Organizational Mission, Values and New Business Arrangements • Often, the theological/ethical conversation ends with assessment of material cooperation. • This approach is both short-sighted and negative in scope. • Stressing what ought not be done • For a robust analysis, must begin and end with organization’s mission and values. • ERDs can help situate this analysis. • “Christian love is the animating principle of Catholic health care” • “Healing and compassion – a continuation of Christ’s mission” • “In faithful imitation of Christ we serve the sick, suffering and dying in a variety of ways” • “The dialogue between medical science and Christian faith has for its primary purpose the common good of all human persons”

27. Can Accountable Care Organizations Embody Justice? Mission, Values of Presence Health • Mission of Presence Health • Inspired by the healing ministry of Jesus Christ, we Presence Health, a Catholic health system, provide compassionate, holistic care with a spirit of healing and hope.

28. Can Accountable Care Organizations Embody Justice? Mission, Values of Presence Health • Values of Presence Health • Honesty – The Value of Honesty instills in us the courage to always speak the truth, to act in ways consistent with our Mission and Values, and to choose to do the right thing. • Oneness – The Value of Oneness inspires us to recognize that we are interdependent, interrelated and interconnected with each other and all those we are called to serve. • People – The Value of People encourages us to honor the diversity and dignity of each individual as a person created and loved by God, bestowed with unique and personal gifts and blessings, and an inherently sacred and valuable member of the community. • Excellence – The Value of Excellence empowers us to always strive for exceptional performance as we work individually and collectively to best serve those in need.

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