Gail J. Povar, MD; Helen Blumen, MD; John Daniel, MD; Suzanne Daub, MSW; Lois Evans, DNSc, RN; Richard P. Holm, MD; Natalie Levkovich; Alice O. McCarter, MSW; James Sabin, MD; Lois Snyder, JD; Daniel Sulmasy, OFM, MD, PhD; Peter Vaughan, PhD; Laurence D. Wellikson, MD; Amy Campbell, JD; the Medicine as a Profession Managed Care Ethics Working Group*
Povar GJ, Blumen H, Daniel J, Daub S, Evans L, Holm RP, et al. Ethics in Practice: Managed Care and the Changing Health Care Environment: Medicine as a Profession Managed Care Ethics Working Group Statement. Ann Intern Med. 2004;141:131-136. doi: 10.7326/0003-4819-141-2-200407200-00012
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Published: Ann Intern Med. 2004;141(2):131-136.
Cost pressures and changes in the health care environment pose ethical challenges and hard choices for patients, physicians, policymakers, and society. In 2000 and 2001, the American College of Physicians, with the Harvard Pilgrim Health Care Ethics Program, convened a working group of stakeholders—patients, physicians, and managed care representatives, along with medical ethicists—to develop a statement of ethics for managed care. The group explored the impact of a changing health care environment on patient–physician relationships and how to best apply the principles of professionalism in this environment. The statement that emerged offers guidance on preserving the patient–clinician relationship, patient rights and responsibilities, confidentiality and privacy, resource allocation and stewardship, the obligation of health plans to foster an ethical environment for the delivery of care, and the clinician's responsibility to individual patients, the community, and the public health, among other issues.
*For members of the Medicine as a Profession Managed Care Ethics Working Group, see the Appendix.
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Jeoffry B. Gordon
August 10, 2004
Ethics in Managed Care Practice
OCEAN BEACH MEDICAL GROUP
1947 CABLE STREET
SAN DIEGO, CA. 92107
August 10, 2004
"Annals of Internal Medicine" To The Editor:
When I saw the title of your article "Ethics in Practice: Managed Care..." (AIM:141, 2, 131-136, 20 July, 2004) I was very excited to see what it had to offer. I am a family doctor and 60 per cent of my patients are in HMOs. Furthermore, I am active in the governance of my main IPA which contracts with the HMO insurance companies and on the Bioethics Committee of a local hospital. I must say that by and large I found the discussion and conclusions sorely lacking and virtually inapplicable to my experience as a physician on the individual patient care, IPA or hospital level.
Most importantly, nowhere in the "Statement of Ethical Principles" is an explicit statement made that the current paradigm of clinician- patient-employer-insurance company relations is a commercial, competitive market mechanism where, of necessity, the nexus of relationships must be monetary and profit oriented. Thus nowhere are the inherent conflicts between this paradigm and the professional medical model explicitly discussed. How can "Respect, Truthfulness, Consistency, Fairness, and Compassion" even be considered when one agency (an insurance company) is out to maximize monetary profit from its agents' ("clinicians'/physicians'") services to its consumers ("patients")? "Trust" is of extremely low value in a market transaction ("Caveat emptor!") and of maximum value in the clinician-patient relationship. More practically important, and also overlooked, is the extreme asymmetry of power and information among the parties involved. The health plans are massive national corporations and naturally have motivations and practices which are virtually devoid of professional characteristics and any attendant concern with trust, ethics, or compassion. Nor, frankly, should we expect them to be concerned with these matters.
The fine abstractions in the article are virtually useless. It is not difficult to give some concrete examples. Our IPA is often caught in cut throat negotiations with insurance companies who literally have draft letters written to their enrollees moving them to other doctors and medical groups if we physicians as a group do not accept their inadequate rates or their mandated care limitation designs. We are all aware that in many parts of the Country senior "Medicare+Choice" HMOs unilaterally just decided that they were not making any (or enough profit) and closed down altogether, essentially abandoning clinician-patient relationships in a massive way. In my own practice a "Medicare+Choice" senior HMO on January 1 two years ago stopped paying for ANY brand name pharmaceuticals for its enrollees without any appeal process and without regard to clinical efficacy or medical importance. The rational given was that the pharmacy benefits financial consequences were unacceptable (to the company,) and, any way, "Our enrollees still had a better pharmacy benefit the any Medicare patient." Nonetheless, the HMO's quality assurance program continued to audit my practice for the use of cholesterol lowering agents after a hospitalization for myocardial infarction at a time when there were no generic statins. It was left up to me to help patients decide whether to pay cash for their medicines, or to eat, pay rent, go to Mexico, use Canadian medicines, or go without appropriate medical treatment. Where in your position statement am I given guidance on how the cope with this situation?
Frankly I find Section II of the article, especially Paragraphs B and F, to be totally inappropriate and especially artful in using the semantics of an ethics discussion to impose the will, needs, and motivations of the insurance companies on practicing physicians and our patients. The tenet that "All affected parties should help determine whether treatments or coverage options are cost-worthy. The effort should be collaborative and on terms that are mutually acceptable, and should be conducted in an open and equitable manner so that trust in the system can be generated and maintained," is so contrary to actual reality that it is risible. My patients and I are continually the passive victims of coverage policy and decisions and no one has ever invited us to "collaborate" in any "equitable" way ever. In sum then I hope this brief communication can help the Journal make an effort to reconsider this issue and develop a more coherent and realistic and valid ethical platform upon which the profession of medicine can stand.
Jeoffry B. Gordon, MD, MPH
Ethics, Healthcare Delivery and Policy.
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