THEORETICAL REFLECTIONS
5. A TEMPLATE FOR RESPONSIBLE HEALTH CARE DISTRIBUTION The number of stakeholders in health care is impressive, but they can be grouped
into five main categories: society, government, MCOs and their investors, professional organizations and associations, and, finally, patients or consumers.
Each category has specific activities and interests; thus, every single category has a specific content area of responsibility with compliance measured by subsequent related criteria. Yet, in their role as participants in the health care system, all these stakeholders are expected to contribute to the objectives of health care and to accept accountability for the results of those objectives.
With the move from indemnity insurance to managed care, health care has been earmarked by confusion about how to properly identify the respective content areas and by disagreement about how to delineate the criteria of responsibility. Thus, the principle of genuine responsibility aims to facilitate the discussion about who will take responsibility for what in health care. Once the content areas have been clearly identified, the competing interests can be prioritized.
To that end, the moral weight and degree of self-proficiency of all claimants must be determined. Moral weight is assessed by evaluating the content of each stakeholder’s claim. Assessment of each claimant’s self-proficiency depends on an evaluation of the degree to which all rights and interests are defended by that claimant.
The primary responsibility of society is to decide what kind of community to create for its members. The idea that the sick have a legitimate claim on the rest of society appears to be deeply rooted in U.S. society. Many people consider health care a social good that is necessary to achieving, maintaining, or restoring health.
Nevertheless, choices must be made about how to prioritize health care within an extensive set of competing interests. This decision determines whether there is a need for the rationing of health care. If so, society must agree on which strategies will be used to achieve the objective of a just rationing process and how to delegate 164
any subsequent responsibilities accordingly. Just rationing of health care requires the formulation of substantive rules on the cost-efficiency of health care services.
For proprietary managed care to be considered a viable public policy option, society must embrace a role change for health care business. This new role is not based on the classic libertarian principle of maximizing profits but instead on liberal egalitarian premises that require the social partners and other legitimate stakeholders to accept a participatory role not only for themselves but also for government. Society is also the primary responsible party for validating the premise of universal accessibility to health care.
To promote institutional structures that best reflect societal values and best serve societal interests, government must commit itself to active involvement in this process of change. Government must also recognize its responsibility for instituting proper arrangements among public and private entities in health care regarding (universal) access and the establishment of minimum standards of care. Finally, government must participate in the development of the criteria by which compliance with normative standards can be measured, both at an institutional level and at the level of individual providers.
The principle of genuine responsibility elicits significant changes in how society expects MCOs to conduct their business. MCOs must become good corporate citizens and must acknowledge a broad domain of stakeholders as covenantal partners. This repositioning of MCOs will affect how the organization defines and manages its internal and external goods. Profit is considered an essential safeguard for the strategic activities that incorporate a sufficient understanding of the organization’s internal goods (i.e., intangibles such as customer and employee satisfaction). This conversion implies that a mechanism exists to facilitate a discussion of the interests of all parties, to prioritize those interests, and to incorporate the outcome into the organization’s strategic goals. Finally, MCOs will need to establish appropriate mechanisms of control, that is, the parameters by which they plan to monitor the transformation process of strategic ambitions into actual products.
The commitment of health care professionals to covenantal partnering implies acceptance of the responsibility to provide cost-effective, appropriately proportioned, high-quality care to patients. Evidence-based medicine (EBM) is one of the more recent approaches in health care for achieving some of these goals. EBM emphasizes the importance of scientific evidence for clinical decision making and promises to reduce variability from physician to physician. However, EBM does not validate all rationing any rationing or cost-containment decisions. The questions of who is to benefit from cost savings and at whose expense any rationing is done are both issues that, in principle, are subject to public discussion and decision making. But EBM could certainly help settle some of the criteria of responsibility in the distribution process.
Members of society are integral to the debate on health care reform. They should participate in the discussions about the rationing of health care. The principle of genuine responsibility nurtures the sense of responsibility about personal health and also shapes the responsibility of individuals as members of the moral community.
Individual members of the moral community not only are participants of the
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discussion but also are, as patients, recipients of the distribution process. Despite the fact that their role may be constantly changing, their status as moral agents does not change. As genuinely responsible community members, they remain accountable for the actualization of decisions that have been made about the arrangement of social interactions. The notion of justice as appropriation as a logical extension of the principle of genuine responsibility provides legitimacy to the notion of rationing and validates the discussion and implementation of substantive rules regarding access to health care.
5.1 Realism or Idealism?
The questions that I raise in this book are who should be responsible for whom and for what? The answers ought to be that we all are, and should be, responsible and that we all can thus be held accountable. However, it could be argued, and without a doubt will be, that the outcome of this philosophical exercise is too idealistic and without practical merit. According to this rather pessimistic (or ideological) view, society will not be able to implement such substantial changes.
Those critics may be right, at least for the time being. But if Kuhn’s (1962) paradigm theory is anywhere near correct, the ever-increasing problems of scarcity and society’s inability to deal with such issues in a morally adequate manner will most likely result in a change in the moral paradigm.
I offer the theory of genuine responsibility as an alternative strategy and as a contribution to the debate on moral strategies for the redistribution of the social good of health care. A broad public discussion will ultimately have to decide whether this alternative has any practical relevance. In other words, as the American novelist John Steinbeck (1962) once wrote: “None of it is important or all of it is.”
Assuming that all of what has been presented thus far will prove to have some importance and that the moral paradigm may indeed eventually shift, would it then still be reasonable to expect that society might be willing to change its moral perspective? Or is that expectation unrealistic? It is impossible to predict the future but one could speculate on the reasonableness of assuming that, should moral agents be willing to reflect on the standard of morality, the process of change will occur but will take time. Change may be slow but it is certainly not impossible; thus, the theory of genuine responsibility may not be overly idealistic.
One more optimistic perspective on the possibility of change is furnished by the tipping point theory, which is the fundamental lesson of nonlinearity. The tipping point theory is actually the theory of epidemics that was first applied in the 1970s to the science of human behavior by Harvard University economist Thomas Schelling (1978). The idea is to approach social problems as if they were infectious agents with the understanding that epidemics function according to their own set of rules.
Epidemiologists often try to determine the point at which an ordinary and stable phenomenon can turn into a public health crisis. At some point, a slight increase in the number of infections can cause a full-blown epidemic. Thus, small changes can produce huge effects and relatively large changes can produce small effects. In the end, all that matters is the tipping point.
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A good illustration of this principle is in Crane’s (1991) article describing the relationship between the presence of role models in a community and their effect on the lives of teenagers. The author found that when the number of role models dropped below 5 percent, there was a resulting increase in the problems of teen pregnancy and school dropouts. Crane suggested that neighborhoods at the 5 percent tipping point can move almost overnight from relatively functional to greatly dysfunctional.
Is there any meaning to the principle of nonlinear phenomena that could be relevant to health care reform? If so, it is surely the assurance that small changes can sometimes produce enormous results. If scarcity of social goods and poor distribution procedures are considered infectious agents that have caused an epidemic, then the moral theory of genuine responsibility may be viewed as a possible option for change that is needed to reach the tipping point and thus cure the disease underlying the epidemic.
For some people, the economic urgency of these problems is enough of a reason to take another look at resolving the dilemmas facing health care. However, other people may postulate that the social and moral problems that could arise from not resolving the issues provide sufficient reasons for a renewed moral discourse on critical notions in health care that have long been considered self-evident. From whatever direction it may come, change in the health care system seems inevitable.
At some point, we will all be faced with the question of whether the concept of genuine responsibility is a practical and viable alternative approach to reorganizing health care. Is it feasible to implement a health care system that incorporates the notion of genuine responsibility and yet continues to operate in a free-market environment? What are the main obstacles to such a change and wherein lie the opportunities? In the next chapter, I will elaborate on these two questions. In addressing them, we will see that a key issue will prove to be the choice of society that we would all prefer to live in.
CHAPTER 7
IMPLEMENTATION IN THE U.S. HEALTH CARE SYSTEM: CHALLENGES AND OPPORTUNITIES
1. INTRODUCTION
Discussions about health care reform in the United States have been numerous, especially since the 1980s. The proponents of both a nationalized health care system and a model based on private enterprise have brought forward various proposals for change. The battles thus far have been fierce. As a result, the subject of health care reform has been highly politicized and, more importantly, even polarized, thus forcing participants in the debate to take a position on just one of seemingly only two sides present in the discussions.
Such polarization greatly minimizes the prospects for problem resolution, because it limits the number of possible outcomes of any such discourse to only two:
either right or wrong. This either-or choice prohibits the participants in the discussion from venturing out and seeking other possibilities that might produce outcomes most people would be able to appreciate as morally appropriate, socially acceptable, economically sound, and ideologically closer to neutral.
Politics and polarization, however, are not the only confounding factors. Other preferences that exist in American society also contribute to the seemingly irresolvable problem of health care. For that matter, it has been well documented that the dominant socioeconomic model in the United States is still firmly grounded in the belief that a (classic) libertarian free-market economy, coupled with a strong commitment to individualism, provides people with unique opportunities to build their own lives and promote their own well-being.
Potential backlashes to this type of economic system are believed to far outweigh the disadvantage of free-market injustices. In regard to health care, this belief has led to the political decision that health care issues are best addressed by allowing the invisible hand of the free market to correct whatever the more reasoned discussions have not been able to accomplish: the fair distribution of high-quality health care.
Proponents of health care as a commodity argue that positioning health care in a competitive business environment will ultimately be the strategy of choice. They suggest that this strategy will prove to be both cost-effective and beneficial. The rationale for this viewpoint is that the change from a system of retrospective, cost- based reimbursement to a market-based system of focused coordinated care is in the best interests of all the parties involved in health care. In fact, it may be the only viable alternative to a government-run health care delivery system.
Market-based health care is believed by some supporters to be the only means of guaranteeing high-quality care at competitive prices. However, this argument can be taken to an extreme when its supporters postulate that investor-owned for-profit plans are the only ones uniquely suited to accomplish these objectives. Whether
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these plans are indeed more creative, more aggressive, and more responsive to the demands of consumers for service, quality, and affordability is debatable.
Nonetheless, their supporters view nonprofit plans as unable to compete because they “are not structured for market competition” (Hasan 1996, p. 1056).
On the other hand, opponents of this view suggest that there are value differences between for-profit and not-for-profit health care plans. They have concluded that for-profit plans provide health care services for the purpose of making profits whereas not-for-profit plans seek profits in order to be able to provide health care services. Because the primary legal, fiduciary, and ethical duty of for-profit health care plans is the return of profits to stockholders, Nudelman and Andrews (1996) pointed out that it is no surprise that patients and public welfare come in second. In other words, the prioritization of profit converts medicine from a
“practice” into an “instrumental activity” (Trotter 1998).
However, the validity of the premise that profit-oriented health care management is a de facto contributor to the quality and accessibility of health care has been challenged by demographic and financial data showing that the number of uninsured people is increasing. Since the late 1990s, annual cost increases have been in the double digits once again. Many critics of managed care persist in the belief that the quality of the care delivered is getting progressively worse while the corporate profits of managed care organizations (MCOs) remain at healthy levels.
Although the fact of a renewed increase in the cost of health care cannot lead logically to the conclusion that the system of managed care is failing, it is indicative that responding to market trends in consumer behavior in order to maintain a competitive edge for business may not be the most appropriate strategy for controlling the cost of health care. Solely for strategic business reasons, the unconditional accommodation of ever-increasing consumer demands, such as unrestricted access, is as detrimental to the objective of providing health care services under reasonable resource constraints as it was within the fee-for-service system.
Whereas the objective of managing (the cost of) health care is convoluted by the unrestricted right of individuals to make their own health care decisions, and by the perception that entitlement to health care should have no limitations, concerns about excessive corporate profits in the health care industry complicate the issue even further. The challenges posed by how corporate profit motivation effectively turns health care services into a commodity account for only some of the difficulties encountered in establishing a fair and affordable distribution system of high-quality health care. For instance, the deeply ingrained belief that individualism should indeed be valued as the cornerstone of U.S. society holds consequences for how people view the role of government, the issue of solidarity, and the appreciation of what many people consider to be the right to free and unrestricted choice in accessing health care providers or services.
Always giving priority to individual rights over community needs does not facilitate discussion about how to distribute health care more fairly under reasonable resource constraints. A widely held societal preference to limit the role of government as much as possible presents an impediment not only to defining and implementing health care business regulations but also to government taking a
IMPLEMENTATION IN THE U.S. HEALTH CARE SYSTEM: CHALLENGES AND OPPORTUNITIES
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Against this background, it is reasonable to consider whether the concept of genuine responsibility could contribute to a constructive debate about health care reform or whether it should be dismissed as a social reformist ideal too far distanced from the socioeconomic reality of everyday life in the United States. Is it possible for the notion of genuine responsibility to assist us in reaching a tipping point for health care reform and, thus, to contribute to a model of health care that is just and affordable, as well as of high quality?
Although the likelihood of a successful implementation of a health care model based on the concept of genuine responsibility seems farfetched, the necessity for establishing strategies to meet the health care needs of all members of society with fairness under reasonable resource constraints has become more evident over time.
Appropriate management of health care at all levels of the distribution process has become more than an economic necessity; just as importantly, it is also a moral imperativeif any significance can be placed on the claim that we are collectively striving to achieve the goal of a just society.