Patient fear of managed care grows; who’ll lead the way to harmony?

Committees need to redefine roles to become managed care maestros

(Editor’s note: This is the last in a three-part series on ethics and managed care. Last month, Medical Ethics Advisor examined building truthful and open relationships with managed care organizations. This month, we will focus on reaching contract agreements between hospitals and managed care organizations that benefit patients most.)

Denied coverage. Physician deselection. Nondisclosure agreements. It seems the headline-grabbing cases involving patients who were denied treatment or — worse yet — died as a result of battles with managed care organizations (MCOs) are mounting these days. And because November is an election month, chances are that winners of local and federal races will report to their offices in January with renewed vigor to remedy current patient dissatisfaction with managed care.

Generally, Americans seem satisfied with their managed care plans. The dissatisfied minorities’ horror stories, however, give most health care consumers cause to call on tougher government regulation of MCOs, including the power to sue a health care provider. An ABC News/Washington Post poll conducted last summer, for example, found 80% of MCO members satisfied with the quality of care provided through the MCO.

There’s no doubt that physician and patient advocacy groups alike are turning up the heat for legislators to enact stricter laws on what MCOs can and cannot do for plan members. But what happened to the health care delivery system in the United States to arrive at such a critical mass in the first place? Consider the following instances resulting in increased frustration with today’s health care delivery system:

• A majority (53%) of Americans think veterinarians spend more time with animals than MCO physicians do with patients, according to a survey conducted by Washington, DC-based Luntz Research Companies.

• Of the 850 people polled, 60% expressed little or no confidence that their MCO would provide the best medical care available for them or a family member.

• Only 28% said legislation would improve the health care system, while 60% said personal initiative by patients was more effective.

Perhaps more important, say experts on both sides of the debate, is whether or not anything can be done to remedy the situation.

"Absolutely," says Steve O’Dell, vice president of Long Beach, CA-based First Consulting Group. O’Dell also is chairman of the board of the Rocky Mountain Center for Healthcare Ethics in Denver. He previously worked for MCOs, including as chief executive officer of PacifiCare’s Colorado region. (For information on the Rocky Mountain Cen ter’s Code of Ethics, see Medical Ethics Advisor, October 1998, p. 112.)

Lots of followers, but no leaders

There still is disagreement, however, on who — providers, payers, or physicians — will take the lead in fixing the problem. "There will be a radical change in the health care system within the next two to five years," O’Dell predicts. "I think [members of] hospital ethics committees will have to look at themselves differently as a result of the changes and determine how broadly it defines itself."

For a more effective ethics committee, he suggests, hospitals should allow the committee to deal with issues such as a physician who is unhappy with an MCO contract he is considering signing. "The physician should be able to go to the group and ask if there is an ethical problem with the contract. The group should then tell the physician that it’s not appropriate to complain or vent’ to the patients about the contract. Individ ual patients shouldn’t be subjected to the limits of his or her contract. The patient should be encouraged to go directly to the ethics committee with any concerns. I think a committee would be stunned if that were to happen now," he adds.

To reach a point where that occurs, O’Dell says, might require an ethics committee to revise its charter. "This hasn’t been the typical definition of the role of the ethics committee, but if hospitals are involved in MCO contracts, then the ethics committee should be authorized to deal with issues that concern the MCO." (For more suggestions for ethics committees, see story, below right.)

Current system won’t last

The current managed care system — while inevitable — will not last, agrees Arnold Relman, MD, professor of medicine and social medicine at Harvard Medical School in Cambridge, MA. During a recent summit on health care reform sponsored by the Illinois Ad Hoc Committee to Defend Health Care in Chicago, Relman asked who will do the managing and who ultimately will benefit from changes.

One thing Relman is certain of, however, is that physicians will be a critical component of creating change. Relman supports a plan involving the public and private sector working together to create a not-for-profit system. Caregivers would receive support, he says, through local, nonprofit medical institutions and state and federal government assistance.

One component of negotiating MCO contracts that benefit patients optimally is viewing patients as consumers, experts say. "The question for ethics committees is, How do we, in every component of health care delivery, build the confidence and trust back for the patients?’ And that shouldn’t be done through a procedural mentality, but [by looking] at how to address the patient’s problems. Give consumers the belief that they have made a difference in the way health care is delivered," notes O’Dell.

"As health care continues to evolve into a marketplace where consumers are the driving force, it only makes sense for them to be informed," adds John D. Banja, PhD, associate professor in the department of rehabilitation medicine at Emory University in Atlanta. Plus, informed consumers help hold MCOs accountable by asking for disclosures, such as what prescriptions are included in the drug formulary, he adds.

Changing the health care delivery system doesn’t completely fall in the lap of the hospital, either, O’Dell says. "The hospital doesn’t have to smooth over the problems patients have with their MCO. Instead, give the patient the information to solve the problem. Refer them to the MCO ethics committee. Tell them to inquire about the MCO’s grievance procedure."

"The ethics committee needs to help patients take on the role of consumer. They don’t know how to do that in health care because we haven’t given them the information to be empowered consumers," he explains.

The ethics committee should expand its scope, advises O’Dell. "Traditionally, the ethics committee has dealt with individual patient problems, but that should be expanded. The committee needs to move from being a compliance-based, tradition driven function to an integrity-based, consumer driven group."

Ultimately, how a hospital responds to the challenges and changes from managed care depends on whether the ethics committee is prepared, says O’Dell. "It all depends on which scenario the ethics committee would rather be in: responding when patients come pounding the door down or waiting for them with an open door."