THE CONCEPT OF MANAGED CARE AND ITS PRACTICAL IMPLICATIONS
10. CHANGES IN MANAGED CARE
business practice in a traditional market. The market is characterized as traditional because of the goals pursued: short-term returns on investments in a highly privatized market (i.e., with the least number of regulations imposed from entities outside the marketplace).
THE CONCEPT OF MANAGED CARE AND ITS PRACTICAL IMPLICATIONS studies, or write the legal decisions will bear some of the moral responsibility that we now vest in physicians. (p. 6)
The justification for the current concept of managed care depends on whether health care must be solely understood as a commodity that operates within a self- regulating, free-market environment or whether it also should be defined in terms of a moral enterprise and an exercise in the humane treatment of human beings. Thus, the justification for the practice of managed care depends on the intent behind organizing health care into the format of managed care. The concept itself is ethically laudable if managed care is defined as a system of care delivery that sets forth plans for helping the clinical provider of medical services make decisions that result in efficient, compassionate, high-quality care. These requirements are validated by appreciating health care as a social good (i.e., by the nature of the services provided and the needs involved).
However, if the primary intent of transforming the health care system is cost containment for the purpose of enhancing profits and the result is a negative impact on society and patients, then managed care should be considered morally reprehensible. The only grounds for proving the latter premise false is societal consensus that the format emanates from the choice regarding the kind of society we prefer (i.e., a society in which the sick have no claim on the rest of society).
Furthermore, in the United States, managed care health plans are founded on libertarian principles and operate within a free-market economy. This environment generates a specific set of questions regarding corporate responsibilities. All the problems in health care appear to be related to the questions of who is responsible for whom and for what.
Thus far, these questions have been asked within the context of the long tradition of rights-oriented ethics in health care, which confers entitlement on the patient and defines the responsibility of health care providers mostly in terms of compliance.
This particular interpretation has the potential to mitigate the legitimacy of the widely held belief system that we are all born with equal rights to the likelihood of taking advantage of opportunities fairly distributed to us all. If there is any doubt about the validity of any aspect of this belief, then the subsequent focus should be on determining an appropriate domain of responsibility and how that responsibility should be defined.
In defense of its compliance position, the managed care industry points to its libertarian foundation. The only option for change would be if the industry could open up to the idea of a more egalitarian foundation. Identifying socially and ethically acceptable solutions to the many problems found in managed care hinges on an acceptable interpretation of the concept of responsibility. The existing legal and moral paradigms, however, are increasingly the focus of unbearable tension.
The rights-oriented ethical models in health care, combined with the libertarian foundation of the distribution system, generate a perspective on responsibility that may be less productive in resolving distribution issues and restructuring health care.
We play a shell game with responsibility, foisting it onto committees, courts, or corporate boards, but we don’t talk about what it means for anyone, be they doctor, nurse, parent, judge, government bureaucrat, or insurance CEO, to care for someone
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who is incurably sick, interminably dependent, or dying. (Lantos 1997, p. 40)
Considering everything said thus far, the obvious question is whether the managed care system in the United States is merely perceived as unjust or is, in fact, the object of valid concerns. In other words, is all the criticism justified? The answer to the question of whether a health care system consisting to a large extent of proprietary MCOs should be considered unacceptable—or even repugnant—depends on our willingness to accept three premises.
The first premise is that fiduciary obligations constitute the primary and maybe even the exclusive responsibility of business organizations. Maximizing the returns of investors is the primary, or perhaps even the only, obligation of the MCO business manager. From that perspective, then, any strategy would be morally justifiable if it helps achieve this ultimate end without violating contractual agreements that lie at the root of the organization’s strategic activities.
Although most people would probably be unwilling to accept this premise as it stands, agreement on the role of business in society has yet to be established. In the absence of such agreement, criticizing the moral worth of prioritizing fiduciary responsibilities in managed care seems unproductive, because the question of the extent of corporate responsibility cannot be answered in full without an agreed-to perspective on the moral status of business. The existing status allows only for
The second premise is that the responsibilities of clinical providers are restricted to direct patient care. Physicians consider themselves in the unique position of being absolved from any fiscal responsibility in their efforts to provide the best possible health care service to each patient. Physicians should not have to deal with gatekeeping functions. The only responsibility they have is toward the patient who seeks medical assistance.
However, not everybody agrees with this position. Opponents would argue that, in light of the financial burden health care places on society and the fact that health care is only one of a set of competing interests for resources (e.g., financial support), it would seem reasonable for clinical providers to take responsibility for providing services in a cost-effective manner. It would also seem reasonable to expect clinical providers to participate in debates toward developing criteria for gauging the therapeutic efficacy of medical interventions.
In addition to these challenges, physicians need to formulate an answer to the question of whether it is morally appropriate to provide every intervention that is medically possible. Are health care professionals morally obligated to provide all possible care to every patient regardless of the individual circumstances? A consideration in answering this question is the fact that most practicing physicians, either individually or in groups, are in essence private entrepreneurs for whom maximization of net operating income as a business goal is as important to them as it is to large corporations. Clinical providers can thus have mixed interests that result in mixed or even conflicting responsibilities.
The arguments favoring a gatekeeping function for physicians appear more compelling when they are viewed as taking into consideration the operational aspects of practicing medicine. Indeed, physicians must be the ones to take responsibility for minimizing overutilization, for taking a critical look at each patient’s medical wants versus his or her actual medical needs, and for addressing assigning business either no responsibility or some responsibility, the extent of which is still undefined.
THE CONCEPT OF MANAGED CARE AND ITS PRACTICAL IMPLICATIONS
medical necessity versus defensive or income-based ordering of diagnostic or therapeutic interventions.
The third premise is that the government’s laissez-faire strategy, its reliance on the market to take care of quality of care and access to care, is justifiable and preferred. The federal government can legitimately delegate to private business its responsibility to create accessible, affordable, and high-quality health care for all citizens. Yet, the government is not prescribing a division of obligations between private and public sectors in order to secure such access. Nor is it playing any role in coordinating the discussions about the minimum standard of care or any role in reaching social agreement on what should be included in the entitlement to health care.
The reality is that all parties to the process can legitimately claim that they have behaved responsibly. The problem is that each party considers itself a responsible agent in accordance with a party-specific concept of responsibility. Each stakeholder has its own definition of responsibility. As Emanuel and Emanuel (1996) have pointed out, there is no single shared, unifying paradigm of responsibility. They argue that the loci, the domains, and the procedures of accountability in health care are too diverse to warrant successful implementation of a single model of accountability. Instead, they advocate a stratified model of accountability.
Emanuel and Emanuel (1996) have distinguished three dominant models of accountability: the professional, the economic, and the political. The professional model guides the physician-patient relationship. Within the economic model, in which the market is brought to bear on health care, accountability is mediated through consumer choice of providers. The political model, in which physicians and patients interact as citizen-members within the community, requires physicians to account for their practice to a governing board elected from members of the community, such as the board of a managed care plan. Issues related to health care are usually pertinent to one of these three models, and the resolution process, according to Emanuel and Emanuel (1996) should be guided by a model-specific interpretation of responsibility.
Yet, among the various models, both responsibility and subsequent accountability can be defined in an almost mutually exclusive manner. There is no agreement among the parties about how to define responsibility within each of the dominant models. For instance, within the economic model, the fulfillment of fiduciary obligations can be legitimately valued as an exclusive responsibility. Thus, any effort to minimize the cost of providing services or any strategy to reduce the medical loss ratio is in itself justifiable and praiseworthy. However, the decisions made at this level certainly affect what goes on in the physician-patient relationship, and not all consumers can afford an exit strategy.
It is not only possible but also absolutely necessary to develop a single paradigm of responsibility, a basic understanding of the concept of responsibility within which each party has ample opportunity and space to further define responsibility in a locus-specific, appropriate manner. Opting for managed care and, more specifically, for a proprietary form of managed care is morally justifiable if—and only if—we can reach agreement on a unifying paradigm of responsibility in which the interests of all parties will be fully recognized, impartially considered, mutually respected, 59
and decided upon in concert with a shared basic understanding of who is responsible for what. Only with a shared basic understanding of the concept of responsibility can we start addressing how to distribute care—morally, appropriately, and in a fiscally sound manner.
The question of whether the problems inherent in managed care are real or just a figment of human imagination can be decisively resolved only after society has committed to a basic understanding of the concept of responsibility. Without a shared understanding of responsibility, the prospect of morally validating any solution to the problems seems unlikely or even impossible.
Before debating possible solutions to the problems of health care, it would be wise, for two reasons, to further clarify the meaning and relevance of the notion of ideology. First, ideology is one of the components that has helped shape health care in the past and probably will continue to do so in the future. Second, ideology has a significant impact on morality. If ethics is defined in terms of a rational process of moral decision making that requires moral agents to reason about the legitimacy of moral standpoints, then, for obvious reasons, communication is a key element in ethics. Through communication, asymmetric relations of power can be established that should affect the social reality that the moral debate has been putting under construction.