Managing Care -- Should We Adopt a New Ethic?

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Here is a key question for us as leaders and managers -

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Original article is at

<http://www.nejm.org/content/1998/0339/0006/0397.asp>

The New England Journal of Medicine -- August 6, 1998 -- Volume 339,

Number 6

Managing Care -- Should We Adopt a New Ethic?

The reorganization of health care is profoundly influencing the roles,

responsibilities, and even the loyalties of physicians. The accelerated

disappearance of the solo practitioner has been matched by an increase in

the number of physicians who belong to various complex organizational

groupings, including independent practice associations (IPAs),

physician-hospital organizations (PHOs), and group- and staff-model

health maintenance organizations (HMOs). No matter what the physician

reimbursement mechanism is in each plan (fee-for-service or global

capitation), plan administrators expect individual physicians or groups

of physicians to stay within a fixed budget for their panels of patients.

To achieve this goal, many try to persuade physicians to make caring for

their entire group of patients a higher priority than caring for each

individual patient. In doing this, physicians are expected to adopt what

has been called a distributive ethic, (1) in which the principle is to

provide the greatest good for the greatest number of patients within the

allotted budget. But how can physicians provide optimal care for each of

their patients and for the entire group at the same time? In agreeing to

a distributive ethic, are physicians tacitly becoming agents of the plan

instead of agents for their patients? How sturdy are our traditional

medical ethics? Can we preserve them, or must we modify them to suit our

modern delivery system?

Some believe that we can and should adopt a new ethical formulation. In a

1995 report, the Council on Ethical and Judicial Affairs of the American

Medical Association maintained that physicians, no matter what their plan

structure, must remain primarily dedicated to the care of their

individual patients. (2) In a critique of that report, Miles and Koepp

put forth a population-based system of ethics, (3) recently embraced and

expanded on by Hall and Berenson. (4) To optimize care for all patients

within a group, they urge physicians to distribute care among all the

members of the group, with the aim of achieving the best overall results

within the limitations of the particular plan. Some patients could

receive " minimally acceptable " care, whereas others would

receive optimal care. ating physicians would be considered to have

exhibited ethical behavior as long as they met the minimally acceptable

standard, even if they were unable to deliver optimal care to all of

their patients. According to this view, it is acceptable for physicians

to make differential medical judgments on the basis of patients'

insurance coverage as long as they acknowledge the basis for their

recommendations. Hall and Berenson argue that an important test of the

unacceptability of an incentive to limit treatment is whether the

arrangement would be embarrassing if disclosed, although they do not

think that physicians need to make such disclosures. They believe that

physicians are well suited to make allocation decisions and to decide how

much profit they can reasonably " drop to the bottom line "

without compromising the quality of their patients' care. They believe

that monitoring doctors' performance, introducing protections, and

punishing abuses are effective means of ensuring acceptable care and

preserving patients' trust. (4)

Should we accept a new ethic that is population-based? Given the current

structure of the health care system, I think not. I believe that

intentionally providing minimally acceptable care to some for the benefit

of others in an arbitrary group -- let alone for the benefit of the

bottom line -- is wrong. Customizing care on the basis of a patient's

insurance coverage is also wrong. When patients are sick and vulnerable,

they expect their physicians to be their advocates for optimal care, not

for some minimalist standard. Benefits vary substantially between plans.

If physicians unwittingly become proxies of the plans, they may

deliberately be providing poorer care for some patients than for others.

True, there is already considerable injustice in the distribution of

care, but why should physicians collude to exacerbate the problem?

Should physicians feel comfortable defining the amount of money that

should flow to the bottom line or simply disclosing all incentives? I

don't think so. Much of the discontent among physicians today is the

consequence of the requirement that the kind of care be balanced against

the cost of care. Many physicians are uneasy making choices that pit

their own financial well-being against their patients' physical and

mental well-being. Although I believe that physicians should disclose to

patients the financial incentives under which they are operating,

disclosure is not sufficient to allay ethical concerns. Those who receive

the information may not know how to use it or may have no other choices.

(5,6) Disclosing a financial conflict of interest only reveals a problem;

it does not give any guidance for solving it. (5) Whether a physician is

embarrassed by the disclosure of a financial arrangement is also a poor

criterion: some people are a lot less easily embarrassed than others, and

what people find embarrassing can change not only with time but also with

conditioning. Finally, disclosure that a physician's income is closely

tied to providing less care can backfire: even physicians who are

providing superb care may come to be seen by their patients as agents for

the insurance plan. (6)

Financial considerations have a profound influence on the behavior of

physicians within a plan. In the effort to limit the cost of care,

capitation is rapidly becoming the preferred method of payment. (7,8,9)

Financial incentives, such as the bonuses and " withholds " that

are widely used under capitation, influence the use of resources most

when they are immediate and substantial, when base pay is not generous,

and when the risk pool consists of individual physicians' panels of

patients. Incentives spread over large physician groups may have less

effect on use. At present, the decisions of physicians in an IPA are not

influenced much if they receive only a small fraction of their income

from any single plan. However, if capitation spreads and if payers

attempt to reduce capitation payments (which seems likely), physicians

will be under great pressure to provide even less than minimally

acceptable care. (10,11,12,13) Our current methods of monitoring and

auditing the quality of care are simply too crude to prevent

undertreatment. (14)

The fundamental flaw in any universal ethic of medical care in this

country is the structure of our health care system. Some patients are

still in fee-for-service plans with virtually no limit on coverage, some

are in capitated plans with generous benefits, some are in plans with

limited coverage or large deductibles, and many, of course, have no

coverage at all. A system in which there is no equity is, in fact,

already unethical. We gave up the idea of having an equitable system when

we decided several years ago to give up on a proposed national health

system with consistent coverage for the entire population. Although the

chance of rekindling such a proposal seems remote now, we should not stop

trying.

The pressures on physicians will undoubtedly increase as capitation

spreads as a prime method of cost containment. What can doctors do within

the current structure of the health care system? For each patient, they

should provide efficient but effective diagnosis and treatment. They

should review their patterns of care and those of their groups with the

aim of improving quality and eliminating waste. Physicians will have to

accept that capitation and its potentially perverse incentives are here

to stay, but they should refuse to participate in plans in which the

financial risk is so great that they may be tempted to provide suboptimal

care. They should refuse to sign contracts that prevent full disclosure

of financial incentives or of beneficial options not covered by a plan.

Some may have to accept lower incomes or less satisfactory working hours

as the price of maintaining their moral commitment to each patient and to

the integrity of the profession. (13,15) They should work to reform plans

that keep the level of resources for patient care artificially low while

spending large amounts of the health care dollar on administration,

advertising, and stockholders' profits. Above all, when physicians are

forced to choose between their personal finances and the welfare of their

patients, they should reject a distributive ethical construct that serves

as an excuse for abandoning the patient-centered ethic that has grounded

the medical profession since the time of Hippocrates. (1,16,17,18)

If we capitulate to an ethic of the group rather than the individual, and

if we allow market forces to distort our ethical standards, we risk

becoming economic agents instead of health care professionals.

Inevitably, patients will suffer, and so will a noble profession.

Jerome P. Kassirer, M.D.

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