Ethics and Managed Care

1. Ethics and Managed Care Where did it go wrong? (If it did?)

2. Louis Harris Poll, 1980 • 97% of HMO enrollees satisfied, would renew • 30% of non-members find HMO concept very attractive

3. WARNING The following slide contains adult language.

4. “Fucking HMO bastard pieces of shit!” --As Good As It Gets (1997)

5. You know you’ve joined a cheap HMO when….….They give you Viagra tablets in different colors with little “m’s” on them. --David Letterman

6. What is managed care? • Same organization combines two functions • Insurance • Delivery of services • Specified, covered population • Prospective financing of services from a limited budget • Buchanan, 1998

7. The first HMO’s • 1940’s • Either labor union-driven or community cooperative (all non-profit) • Payment per member per month (capitation) • Financial incentive to keep people healthy • Group practice/clinic model

8. Turning Point: 1970-1980 • Health care share of GDP went up from 4% to 10-12% since 1945 • Big Three realized they were paying more on a per-car basis for health care than for steel • For first time, HMO’s attractive as a way to cut costs, not as a way to change the direction and quality of care

9. 1980-2000 • New Federal legislation encourages creation of HMO’s • Some evidence early that this led to a slow-down in rise of health costs (temporarily) • Suddenly for-profit managed care is the fastest growing segment of industry

10. Kaiser plan, 1970 • Has served same population for 30 years • Very stable group of physicians and staff • Most work there out of choice • Work as team to assure that quality of care is kept high • The “competition” is very wasteful, so even a modest trimming of costs makes Kaiser the best deal

11. Acme HMO, 2000 • May have been created yesterday • Physicians are tied in “virtual” network, no history of teamwork • Rapid turnover of patients, no way to capture savings from preventive care • Competition lean and mean; can’t compete unless costs cut to the bone

12. Does the term “managed care” specify an entity with a constant, predictable set of ethical problems?

13. Basic ethical problem • Physician or nurse as “gatekeeper” • Gatekeeper may recommend care as “medically necessary” or not • Plan pays for “medically necessary” care • If less care recommended, staff may make more money (or may be retained, not fired)

14. Rationing • Bedside Rationing

15. Rationing • There is a limited amount of resources available • Need/demand exceeds the available resources • We must have SOME system to decide who gets how much • Ability to pay • Lottery • Degree of need • Etc.

16. Where Rationing Occurs Administrative Level Bedside Level

17. Administrative Rationing • Policymakers set very general guidelines based on data of effectiveness and cost • Physicians at bedside merely apply those guidelines with virtually no discretion • Examples: • No one over age 70 gets renal dialysis • No one gets expensive anti-ulcer medication for more than 2 months

18. “[I]t is society, not the individual practitioner, that must make the decision to limit the availability of effective but expensive types of medical care.” --Norman Levinsky (p. 102)

19. Bedside Rationing • Physician/nurse caring for individual patient • Makes a decision not to provide some treatment • Decides on basis of relative need of this patient vs. other patients in “plan”

20. Trust and Rationing • Levinsky’s argument: • If administrative rationing, physician is still uncompromising in personal dedication to patient welfare • If bedside rationing, physician a double agent-- willing to compromise patient welfare in name of cost saving or service to “society” (= other patients)

21. Fee-for-service practice • Patient (or insurance company) paid a set amount for each service • Strong financial incentive for physician to recommend or perform unnecessary services • Return office visits • Unnecessary surgery • Unnecessary labs, x-rays

22. No one has yet designed a way of financing health care that pays the providers when, and only when, they do something beneficial for the patient --so every plan has some perverse incentives

23. Is Less Care the Problem? • Assume ethical flaw in managed care is that physician is rewarded for doing less for the patient • Assumes that more care is always better care • If so, should see consistent trend in research for managed care to have worse outcomes (not so)

24. One Example: ABMT • ABMT for advanced breast cancer: thought to provide 10-15% chance of survival when all else has failed • Costs ~ $150,000 • Many women sued HMOs successfully when ABMT denied because “experimental” • Latest research-- ABMT adds nothing to survival in advanced breast cancer

25. The real question • Is gatekeeping ethical? • Can gatekeeping be avoided?

26. What is Gatekeeping? • Physician cares for a population of patients • Limited budget • If patient #1 gets something, there is something that the other patients will not get • Comparative judgments of relative priorities of need among patients

27. Example 1. ICU nurse • Nurse has 2 patients • Mr. Smith: Just about ready to transfer out but has a lot of questions • Mrs. Jones: Acutely unstable, impending multiple organ system failure; unsure of cause • Who will you spend more time with?

28. Example 2. Primary care office • NP has waiting room full of patients • Mrs. Green: Has a 10-min appointment, starts to complain of several new problems which she has had for years • Mr. White: Has a 10-min appointment; “Oh by the way” chest pain • Will you reschedule or run overtime?

29. Inevitability of Gatekeeping • Time and not just money is a limited resource • So long as you have more than one patient in your practice, you must always make tradeoffs among needs of different patients • Seems reasonable to make tradeoffs based on best assessment of relative need

30. Inevitability of Gatekeeping (Morreim) • Policy-makers write clinical guidelines to save money and maintain quality • All guidelines have “wiggle room” • Physician must decide whether to adhere to guideline or try to declare this patient an exception-- both “bedside” decisions impact on resources available to other patients

31. Eddy’s Argument • Two positions • First position: I am generally healthy, my chances of getting any one particular disease are relatively low • Second position: I already have developed an advanced disease

32. 30yo Healthy Woman • Would rather have lower premiums and put money in kid’s college fund, etc. • Strong interest in funding preventive care e.g. mammograms • Little interest in funding “desperation” care like ABMT

33. 45yo Woman with Metastatic Breast Cancer • Prevention is now of no use • “I’ve paid my premiums for all those years; now it’s my turn to get something back” • Strong interest in having funding for “last ditch” measures even if low likelihood of success

34. Eddy: The Conflict • Should we interpret the ethical question as “the patient vs. society”? • Or is it ourselves at one point in our lives vs. ourselves at another point in our lives? • If the latter, which of the two positions is ethically privileged in terms of taking a moral priority for health policy? • Eddy argues: First position

35. When is Gatekeeping Unethical? • Very generally-- when financial incentives are so intrusive into physician’s thoughts that she is highly likely to place financial concerns ahead of concerns for the well-being of the patient

36. Bowman Case (TN) • Prisoner died of pneumonia; had known sickle cell disease • For profit prison management firm had capitated contract with physician • By denying care physician could double his annual income • No “carve out” for prisoners with known serious illnesses

37. Gatekeeping cases: spectrum Predominant duty is to conserve scarce resources for others Predominant duty is to do what’s best for sick person Example:IV antibiotics for pneumonia “Gray zone”-- tough choice (e.g., treatment very expensive but also very beneficial) Example: MRI scan for tension headaches

38. For-Profit Managed Care • Is this form of financing inherently unethical? • Is a for-profit plan inherently less trustworthy?

39. Non-Profit Plan

40. For-Profit Plan

41. For-Profit vs. Nonprofit • Unless for-profit plans considerably more efficient, they will have less $ to spend on care • No evidence of such efficiency • BUT at least a few non-profit plans spend less on care than a few for-profit plans, tho on average NP spends greater percentage than FP