Recently we caught up with James V. Springrose, M.D., medical director of CIGNA HealthCare Mid-Atlantic in Hartford, Conn., to gauge his thoughts on how the managed care balancing act should weigh in on healthcare ethics vs. company profits.
Q. There seems to be a buzz in healthcare circles these days about ethics. How come?
A
. The healthcare industry is in upheaval. There has been a shift away from a hospital-centric world to one of integrated delivery systems throughout the country. Employers are adjusting to working with managed care companies to deliver their employees' care.
Physicians used to providing care under an indemnity, fee-for-service system are now being asked to be more cost-conscious about their services, and to practice within accepted quality standards. Patients are also adjusting to a new world of taking more responsibility -- fiscal and otherwise -- for their health status.
While all these changes are for the better, I believe they are also unsettling and raise some ethical concerns. That, in turn, has caused people to look for some guiding principles upon which they can rely.
Q. What are some of the ethical dilemmas facing managed care today?
A
. We are asking ourselves a number of ethical questions: how do we deliver care in a cost-effective way without compromising on quality?; how do we make certain that patients are neither under- nor over-treated?; what is our responsibility when we are faced with major illnesses not covered by the plan?; how do we ensure that both providers and patients have sufficient information with which to make informed medical decisions?
Q. Isn't there an inevitable conflict between what a managed care organization is expected to do (make profits) and what it should do (put the patient's welfare first)?
A
. It has been suggested that managed care creates financial incentives which encourage physicians to undertreat patients. In fact, our system helps ensure that cost and efficiency are considered without undermining our overriding commitment to providing appropriate medical care. We do this through practice guidelines, quality assurance audits, peer review, outcome measurements based on reliable data, and patient satisfaction surveys.
Remember too, that managed care is replacing a fee-for-service system with built-in incentives to overtreat and which contributed to the high cost of healthcare, but not necessarily to better medical outcomes.
Q. Why do managed care companies seem particularly vulnerable to these ethical quandaries?
A
. They're not. Discussions of ethics and managed care should recognize that profit-making and balancing conflicts of interest are not unique to the healthcare business. Nearly all industries have to weigh "human" issues -- such as worker safety or keeping the environment clean -- against improving the bottom line and keeping shareholders happy.
Q. What is CIGNA HealthCare doing to ensure that ethical considerations are a part of the decision making process?
A
. We're addressing ethical issues on several fronts. We retained ethics consultant Michael Rion, Ph.D., a nationally recognized specialist in the ethics of management, to run our ethics program. Dr. Rion is training our senior managers and medical executives to recognize and resolve challenging ethical issues that arise in specific cases. Additionally, we've developed an internal decision-making process which is designed to help our doctors and nurses make medically and ethically sound judgments in their daily practices. This process has been introduced to all of our health services personnel throughout the country. We've also established an Ethics Council that identifies and develops resources to support our providers in making ethically responsible decisions.
Q. Why the big push for ethics at CIGNA?
A
. First, ethics is the right thing to do. We are in the "business of caring" and we want to treat our patients, providers and employers with respect and fairness. Our members need to be confident that our medical decisions are formally guided by sound ethical standards that are consistently applied
Second, ethics is good business. Companies that demonstrate a serious commitment to ethics in managing patient care will ultimately be the most successful. Employers, doctors and patients will, in the long run, choose the most responsible companies.
Ethically responsible actions translates into competitive advantage, I believe, by earning the confidence and long-term trust of patients and providers. Lastly, an ethical corporate culture can help keep a business out of trouble by minimizing insensitive actions and careless mistakes which can lead to public embarrassments damaging to its reputation.
Q. What are some specific areas your ethics program will address?
A
. At this point, in the early phase of our ethics initiative, we are beginning to identify particular issues to focus on. We expect to assess the ethical challenges in marketing managed care plans and determine what policies, training and support are in place to ensure responsible marketing practices. We'll also address how clinical medical ethical issues are handled, such as coverage determinations. We will also examine the relationship between provider financial incentives and our commitment to providing proper patient care.
Q. How do you plan on integrating your ethics efforts into your marketing and public relations efforts?
A
. I've noticed recently that some healthcare companies have issued press releases to publicize their hiring of an ethics director or the issuance of ethical guidelines. They recognize that ethics is a good thing to be seen as doing. That's not our style. We believe that ethics should first be promoted where it really matters -- in the care management decision making process.
A strong ethics approach internally will become evident to members, employers and providers. That will become our ethics "selling" point. We take ethics very seriously, and we are integrating ethical considerations into everything we do, from underwriting to marketing our products.
Q. Ultimately, what do you hope your ethics program will achieve?
A
. In examining ethical issues, we want to ensure that: patient health remainsthe highest priority in medical management decisions; procedures and policies won't compromise the ethical responsibilities of physicians to their patients; consistency in care management will be maintained; effective appeal mechanisms for members and confidentiality of member records will be preserved; and clear, honest communications with purchasers of our services will be sustained.
I believe that having an appropriate set of ethical goals is important, but not enough, in today's health care environment. What's also needed is the establishment of real life, practical processes that will ensure ethical considerations are a part of our every day medical decisions.
Dr. Springrose can be reached at 860/726-8340.