PALO ALTO -- With the patient-physician relationship and medical professionalism facing pressures from competing demands and cost concerns in today's health care environment, all stakeholders in the system need to understand the ethical issues involved in this changing environment.
     The references contained in this bibliography are intended to assist these parties in their understanding. This bibliography does not reflect a comprehensive assessment of all issues in this area inasmuch as it is intended to provide the reader a general overview of the issues in a readily accessible form.
     In developing this bibliography, we first identified articles on medical ethics and managed care using BIOETHICSLINE and Internet searches. We selected articles based on their quality and availability, omitting articles that are difficult to obtain.
     Finally, we selected articles that represent a balance of viewpoints in the literature, with the specific focus on the changing practice environment, and the impact of such on patients and physicians.

Codes of Ethics by Health Professional Associations and Health Plan Organizations
Health Professional Associations

American College of Physicians — American Society of Internal Medicine. Ethics Manual. Fourth Edition. Ann Intern Med. 1998;128(7):576-594.

Summary of ethical guidelines for internists, with particular attention to ethics in the changing practice environment under The Ethics of Practice and The Physician and Society.

American Medical Association. Principles of Managed Care. Fourth Edition. 1999.

Summary of ethics principles in the managed care environment for physicians based on AMA policy and ethical opinions.

American College of Healthcare Executives. Code of Ethics. 1995. Available at:

Summary of standards of conduct for healthcare executives.

Health Plans

American Association of Health Plans. Code of Conduct.

Code of ethical conduct for health plans to achieve three key objectives: (1) to communicate facts about benefits of plans to patients; (2) to emphasize how member plans are responsive to needs of patients, physicians, and health professionals and are adaptive; and (3) to provide a platform for plans to demonstrate commitment to high levels of accountability.

General Ethical Issues

American Medical Association Council on Ethical and Judicial Affairs. Ethical issues in managed care. JAMA. 1995;273(4):330-335.

Discusses manner in which rise in managed care model of health care delivery and financing places stress on the patient-physician relationship, and offers ways to mitigate these pressures. Provides steps for patients, physicians, and health care organizations to take to foster an ethical environment, and ends with general guidelines.

Appleby C. True values. Hospitals & Health Networks. 1996 Jul 5;70(13):20-22, 26.

Summarizes ways in which health care system decision-makers are struggling to incorporate ethics principles into the changing environment in which they provide care. A companion piece includes commentary from several ethicists on the ethics of the emerging care delivery system.

Chin MH. Health outcomes and managed care: discussing the hidden issues. Am J Man Care 1997;3:756-762.

Argues that to best optimize health, must consider the underlying ethical, social, and political values and judgments that influence attempts at improvement, an exercise that will require accepting uncertainty, allocation decisions, and opportunity costs. Argues for greater attention to public preferences (and not simply scientific data), and for creation of clinical guidelines that are locally developed, routinely updated, and open to exemption.

*Davidoff F. Changing the subject: ethical principles for everyone in health care. Ann Intern Med. 2000;133:386-389.

Provides the most recent version of the ethical principles proposed by the Tavistock Group to guide all parties within the healthcare system. Contends that the "next step" after formulation of such a statement is to engage the public to move the principles into practice, employing legal, aspirational, and rhetorical means. Concludes that there is much value derived from simply getting parties together to discuss a subject other than the influence of money in health care, namely how to fashion an ethical system out of limited resources and based on the rights and responsibilities of the multiple parties.

Gervais KG, Priester R, Vawter DE, Otte KK, Solberg MM, editors. Ethical Challenges in Managed Care. A Casebook. Washington, D.C.: Georgetown Univ Press, 1999.

Explores twenty detailed case studies that provide glimpses of the ethical uncertainties raised by current managed care arrangements and methods. The case studies are followed by questions for consideration and commentaries from noted individuals in the field of bioethics, health policy, clinical practice, health care administration, law, and medical sociology. The six general sections cover rationing, cost-containment and quality-improvement incentives, providing quality care in a competitive market, responsibilities to patients, care for vulnerable populations, and responsibilities to the community.

Kassirer JP. Managed care and the morality of the marketplace. [Editorial.] N Engl J Med. 1995;333:50-52.

Urges physicians to be leaders, for patients and for quality care, and also ensure that the care offered is medically necessary and cost-effective.

La Puma J, Schiedermayer D, Seigler M. Ethical issues in managed care. Trends in Health Care, Law Ethics. [Special Issue.] 1995;10(1/2):73-77.

Discusses ethical assumptions of managed care and managed competition, namely that the patient-physician relationship is characterized by its fiduciary and non-adversarial nature and that equality of access is a proper ethical concept to resolve allocation dilemmas. Identifies the benefits and burdens of managed care for patients, physicians, and payers. Lists new ethical responsibilities for patients and physicians in the changing practice environment.

McCullough LB. A basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients. J Med Phil. 1999;24:77-97.

Analyzes recent professional associations’ statements on ethical issues in the managed care environment, and their thematic focus on the primacy of patient needs, disclosure of conflicts of interests, and opposition to gag orders. An alternative to the "my patient first" approach in clinical ethics would rest on a foundation where physicians and plans share moral obligation to populations of patients and to individual patients. An assumed by-product of this renewed commitment to intellectual and moral excellence and scientific rigor in clinical judgment would be morally responsible cost controls.

Povar G, Moreno J. Hippocrates and health maintenance organizations. Ann Intern Med. 1988;109:419-424.

Argues that health maintenance organizations (HMOs) are moral agents with ethical duties, and offers suggestions to prevent abuse.

Smith R., Hiatt H, Berwick D. A shared statement of ethical principles for those who shape and give health care: a working draft from the Tavistock Group. Ann Intern Med. 1999;130:143-147.

Statement of five ethical principles to guide all health care professionals in the face of increasing resource consumption, financial pressures, allocation decisions, complexity and cost, and poor system design. It is hoped that health care organizations will work for greater consistency between their missions and the principles; that payers will ensure that their policies are coordinated with ethical care; and that the public will use these principles to understand how health care should work.

Snyder L, Tooker J. Obligations and opportunities: the role of clinical societies in the ethics of managed care. J Am Geriatr Soc. 1998;46:378-80.

Argues that putting the individual patient first should be the goal and obligation of every physician, notwithstanding the particular practice environment — a professional standard that clinical societies should set, promote, and maintain at their core.

The Patient-Physician Relationship

General

Dorr Goold S, Lipkin M. The doctor-patient relationship. J Gen Intern Med. 1999 (Supp. 1);14:S26-S33.

Examines the foundation and features of the patient-physician relationship and the effects of managed care on this relationship, offering suggestions for what physicians and health care plans might do to preserve the relationship. Incorporates both encounter data (empirical studies) and moral features of the relationship, concluding with practical tips.

Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273(4):323-329.

Describes the fundamental elements of the patient-physician relationship as six C’s: choice, competence, communication, compassion, continuity, and (no) conflict of interest. Highlights potential improvements on and threats to the six C’s by managed care.

Hall MA, Berenson RA. Ethical practice in managed care: a dose of realism. Ann Intern Med. 1998;128:395-402.

Develops a set of pragmatic ethical principles for physicians’ use in managed care environment, arguing that adherence to absolutist ideals results in principles readily contradicted in current practice. The three central principles offered are that: (1) medical ethics derives from physicians’ roles as healers; (2) ethical statements are purely aspirational; and (3) preserving patient trust is the primary objective.

Holleman WL, Holleman MC, Moy JG. Continuity of care, informed consent, and fiduciary responsibilities in for-profit managed care systems. Arch Fam Med. 2000; 9:21-25.

Discusses what health care organizations should do internally to foster cost-effective, quality, and ethical care, with a focus on the patient-physician relationship. Utilizes case studies to touch upon the key issues of beneficence, disclosure, "proportional advocacy," and rationing.

Morreim EH. Balancing Act. The New Medical Ethics of Medicine’s New Economics. Washington, D.C.: Georgetown Univ Press, 1995.

Evaluates, in light of changing practice environment and the entry of new players into the traditional dyadic patient-physician relationship, what obligations physicians do, and do not, owe patients, and what responsibilities patients themselves have. Physicians owe traditional obligations, such as professional competence, compassion, and honesty; new duties include economic advocacy, economic disclosure, and a close scrutiny of institutions with which they affiliate. However, physicians are not obligated to circumvent legitimate contracts or program limits, to ignore other patients’ competing interests, or to deny personal interests completely.

*Pearson SD. Caring and cost: the challenge for physician advocacy. Ann Intern Med. 2000;133:148-153.

Argues that "care" and "cost" can be joined at the bedside in a way that preserves the trust that is critical to the patient-physician relationship. Uses a hypothetical case to analyze how "proportional" patient advocacy allows physicians to continue their roles as patient advocates while also acting as responsible stewards of health care resources.

Pellegrino ED. Managed care at the bedside. How do we look in the moral mirror? Kennedy Institute J Ethics. 1997;7(4):321-330.

Argues that ethical duties should trump economic ones in the managed care environment, although financial concerns do merit some consideration. Physicians face numerous ethical conflicts, of particular strain on the duty of loyalty, and also suffer from non-dollar costs of managed care.

Communication

Levinson W, Gorawara-Bhat R, Dueck R, et al. Resolving disagreements in the patient-physician relationship. JAMA. 1999;282(15):1477-1483.

Suggests communication strategies for physicians to use to decrease potential communication conflicts, derived from a discussion of various case scenarios by a representative sample of patients, health care organization leaders, practicing physicians, communication experts, and medical ethicists. Concludes with thoughts on how health care organizations might enhance and support these communication strategies.

Loyalty

Bloche MG. Clinical loyalties and the social purposes of medicine. JAMA. 1999; 281:268-274.

Addresses the tension the physician faces between an ethical duty of undivided loyalty to the patient and expectations of use of medicine for social purposes and on behalf of third parties. The stated goal is not to resolve tension, but to provide more modest ways to mediate between tensions in clinical setting on case-by-case basis, focusing on interpersonal relationships and not "disembodied principles."

Bloche MG. Fidelity and deceit at the bedside. JAMA. 2000;283:1881-1884.

Responds to the question of the scope and limits of physician advocacy to gain access to health care resources for patients in a pluralistic society with multiple sources of social control. Fidelity should be conceived as requiring allegiance to patients when they are at their most vulnerable, which would entail advocating for patients’ interests to the limits of what is possible without making false statements or upsetting contractual justice. This style of professional advocacy would decrease "gaming" by health plans and also lead the general public to consider the tension between its desire for cost-effectiveness generally and uncompromising advocacy individually.

Trust

*Buchanan A. Trust in managed care organizations. Kennedy Institute J Ethics. 2000;10(3):189-212.

Argues that there are two different types of patient trust in physicians — status trust and merit trust — and that it is not necessarily detrimental if managed care lessens status trust if at the same time it increases well-founded merit trust. Contends that the most appropriate foundation for securing merit trust in managed care is not traditional medical ethics, but rather organizational legitimacy (e.g., procedural justice, empowerment of constructive criticism within the organization, and a commitment to professionalism’s service orientation toward patient well-being). Illustrates how this organizational-based merit trust can accommodate professional obligations while not succumbing to the notion that a physician’s fiduciary obligation requires providing all care that might be of net benefit to the patient.

*Dorr Goold S. Money and trust: relationships between patients, physicians, and health plans. J Hlth Politics Policy Law. 1998;23(4):687-695.

Discusses patient-physician and health plan organization-member trust and the moral obligations in each relationship. Analyzes how the trust placed in organizations by members differs from the trust placed in physicians by patients. Explains how trust in managed care organizations is affected by financial reimbursement schemes, and how restrictions on or regulation of these incentives would best be accomplished at the national level.

*Mechanic D. The functions and limitations of trust in the provision of medical care. J Hlth Politics Policy Law. 1998;23(4):661-686.

Examines important aspects of trust, and in each instance how the changing practice environment threatens the trust. Suggests ways for physicians within the system to enhance trust, and how managed care organizations can foster this environment, while also arguing that these measures are necessary to avoid excessive regulation of medical care decision-making. Contends that physicians must accept the notion of limited resources, must participate in allocation decisions, and must also advocate for patients.

Shortell SM, Waters TM, Clarke KWB, Budetti PP. Physicians as double agents. JAMA. 1998;280(12):1102-1108.

Develops five properties as a framework for a discussion of how physicians can maintain trust when faced with multiple accountabilities. The five properties (population-based medicine, incentive alignment, governing and managing physician groups, developing effective care management practices, and outcomes management and reporting systems) will assist in revising the patient-physician relationship based on a model of mutual learning and shared information and expertise.

Privacy/Confidentiality

Mitka M. Do-it-yourself report on patient privacy. [News.] JAMA. 1998; 280(22):1897.

Discusses a JCAHO and NCQA joint report, released in November of 1998, which offered recommendations on how to meet demands for information by health care organizations and other players in the managed care context. The report addressed the need for ensuring accountability; dealing with consent in an evolving health care delivery and financing system; educating individuals about policies, practices, rights, and responsibilities; using technology as a solution; providing legislative support; and guiding research.

Empathy

Nadelson CC. Ethics and empathy in a changing health care system. Pharos. 1996 Fall;59(4):29-32.

Argues that compassion and empathy are critical ingredients of quality (ethical) care. Physicians and patients must do more to advocate for the individual voice in a growing bureaucracy.

The Physician in Society
Professionalism

American Board of Internal Medicine. Professionalism in medicine: issues and opportunities in the educational environment. I. Definitions and objectives.

Summarizes the key elements of professionalism, noting the physician’s obligations to the patient, to society, and to others in the profession. The key elements described are altruism, accountability, excellence, duty, honor and integrity, and respect for others.

*Benson JA. The burdens of professionalism: patient’s rights and social justice. Pharos. 2000 Winter;63(1):4-9.

Argues that professionalism is best response to current climate in which patients seek rights, purchasers pursue strategies to reduce costs in an era of limited resources, population-based medicine is advocated, and physicians find themselves caught in the middle between a patient-centered ethic and community need. Emphasizes, as a central tenet, that medicine is a moral enterprise grounded in a covenant of trust, and that it is up to physicians to uphold this sacred trust.

*Cruess RL, Cruess SR, Johnston SE. Professionalism: an ideal to be sustained. [Viewpoint.] Lancet. 2000;356:156-59.

Argues that physicians must take role in shaping profession’s future and also educate themselves about the principles and obligations inherent in their role as professionals. In the future, physicians must engage in more rigorous self-regulation, develop further guidelines that are prudently applied, and accept new levels of accountability. In turn, society must recognize the demoralization among many physicians in the changing practice environment, and endeavor to ease the demands placed on physicians as all parties work together to renew the concept of professionalism in the 21st century.

Rothman DJ. Medical professionalism — focusing on the real issues. N Engl J Med. 2000;342(17):1284-1286.

Suggests ways to strengthen the commitment to professionalism and enhance its relevance in daily lives of physicians. Comments that these deeper issues, concerning whether professionalism needs to be revived or even created, are masked by a focus on perceived threats from managed care.

Snyder L, Povar GJ. Medical ethics, professionalism and the changing practice environment. Position Paper. ACP-ASIM. 1999. [In press.]

Analyzes the strains placed on professionalism by a changing practice environment, particularly in the era of managed care. Suggests that the key issue is not whether systems and incentives influence care, but rather if an appropriate ethical balance can be reached between an individual patient’s needs, societal concerns for resource allocation, and other competing interests. Argues that, no matter what the system or incentive, all parties should recognize and respect the physician’s primary professional and ethical role as patient advocate.

Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med. 1999;341:1612-1616.

Provides an overview of their three core elements of an "ideal archetypal model" of medical professionalism (devotion, public profession of values, and negotiation between professional and societal values), and discusses models for professional activism in the health care quality debate. Reliance on professionalism is needed when a market-driven or legislative approach, alone, cannot ensure quality care.

Conflicts of Interest - Physician Incentives

Asch DA, Ubel PA. Rationing by any other name. N Engl J Med. 1997;336:1668-1671.

Argues that rather than ask if rationing is acceptable, the more constructive question to ask would be what compromises are justified. In so doing, the focus would shift from an endless debate over the language chosen to what is, and should be, actually occurring in clinical care.

Lo B. Incentives for physicians to decrease medical services. In: Lo B, ed. Resolving Ethical Dilemmas: A Guide for Clinicians. Baltimore: Williams & Wilkins, 1995. p. 293-300.

Discusses types of incentives common to managed care contracts, and suggests ways for physicians to practice ethically within the various reimbursement schemes.

Miller TE, Sage WM. Disclosing physician financial incentives. JAMA. 1999; 281(15):1424-1430.

Examines the practical questions concerning how to implement disclosure mandates, including, for example, the proper content, scope and timing of disclosure, the relationship of disclosure to patients’ substantive rights, and the impact of disclosure on patient trust in physicians.

Pearson SD, Sabin JE, Emanuel EJ. Ethical guidelines for physician compensation based on capitation. N Engl J Med. 1998;339:689-693.

Outlines a framework and a set of principles for use in discussions of balance between cost- and quality-effective compensation methods and the ethical obligations of physicians.

Snyder L, Hillman AL. Financial incentives and physician decision making. In: Snyder L, ed. Ethical Choices. Case Studies for Medical Practice. Philadelphia: American College of Physicians, 1996. p. 105-112.

Contrasts a case involving two twin brothers — one in a traditional indemnity fee-for-service plan and one in an HMO — and their different treatment by their physicians when deciding to join a gym. The commentary argues that a "patient first" professional obligation would caution against over-testing (the "more is better" philosophy) in a fee-for-service setting, or under-treating in a managed care setting. It would also require that physicians be able to provide to patients, in an understandable fashion, coherent and complete explanations — based on concern for the individual, science, and cost-efficiency.

Sulmasy DP. Physicians, cost control, and ethics. Ann Intern Med. 1992;116:920-926.

Examines health care financing and the "moral stress test" certain forms of managed care create. What is needed is a system of "cost-control" that does not require unilateral bedside rationing by physicians or restrictive gatekeeping.

Special Topics
Access to Health Care and Allocation of Health Care Resources

*Buchanan A. Managed care: rationing without justice, but not unjustly. J Hlth Politics Policy Law. 1998;23(4):617-634.

Argues that the common criticisms of managed care — that it "skims the cream" of the patient population; that is rations by withholding beneficial care for some patients, reducing the quality of care; and that it pressures physicians to ration care and thus interferes w/ physicians’ fiduciary obligation of patient advocacy — are misconceived. Managed care cannot solve the problems of a system that has not (1) reached a social consensus or political determination on what health care entitlements exist (the "adequate level" of care); and has not (2) developed institutional mechanisms to ensure that resources saved through cost-containment are utilized to ensure equal access to that entitlement. Ethical theory alone cannot determine the proper content of a right to health care; we also need societal commitment to define a concrete conception, and the political will and political procedures to make it effective.

Daniels N, Sabin JE. Last chance therapies and managed care: pluralism, fair procedures, and legitimacy. Hastings Cent Rep. 1998;28(2):27-41.

Argues for greater transparency in managed care plans’ reasoning processes behind coverage decisions vis-à-vis unproven, but promising, last chance therapies. Offers four conditions that should be met for deliberative process to be "legitimate," with the focus on openness and publicity, the reasonableness of justifications, due process, and public accountability. In the end, a fair, legitimate process, and not a mandated result, is the only way to manage last chance therapies in a pluralistic society.

Emanuel EJ. Justice and managed care: four principles for the just allocation of health care resources. Hastings Cent Rep. 2000;30(3):8-16.

Delineates four principles to enhance the justice of a managed care organization’s allocation of resources, with the primary goal to improve health. Discusses certain implications raised by these principles, and how an ethical organization might respond.

Paris JJ, Post SG. Managed care, cost control, and the common good. Camb Q Healthc Ethics. 2000;9(2):182-188.

Discusses the influence of managed care on health care, what brought about medicine’s transformation, and how to define the ethical contours of the new environment. Analyzes how to balance between patients’ wants and social considerations.

Ubel P. Physicians’ duties in an era of cost containment: advocacy or betrayal? JAMA. 1999;282(17):1675.

A cautionary note about the societal and personal consequences of bending third-party payer rules.

*Zoloth-Dorfman L, Rubin SB. Medical futility: managed care and the powerful new vocabulary for clinical and public policy discourse. Healthcare Forum J. 1997; 40(2):28, 30-33.

Contends that "futility" is not an objective medical or scientific fact, but rather an evaluative judgment influenced by the goals of treatment and decisions regarding which goals are worth pursuing. The definition thus depends on the goals chosen, who selects such goals, and how the goals gain context within a culture. Argues for greater public discussion about these goals and how to allocate options within a climate of scare health care resources.

Accountability

*Daniels N, Sabin JE. The ethics of accountability in managed care reform. Health Affairs. 1998;17(5):50-64.

Managed care reforms invoke two versions of accountability: market accountability and accountability for reasonableness. The former version would require health plans to inform purchasers and consumers about performance and coverage/price options, elevating consumer choice over a discussion of proper limits to care. Alternatively, the latter — accountability for appropriateness — would require that rationales behind limits to care be public and subject to agreement by "fair-minded" individuals. Argues that the latter model fosters a more educated clinical and patient population, and invokes democratic processes to legitimize decisions limiting care.

Emanuel EJ, Emanuel LL. Preserving community in health care. J Hlth Politics Policy Law. 1997;22(1):147-184.

Analyzes three models of accountability in health care (professional, economic, and political), arguing that the patient-physician relationship belongs, and only it belongs, within professional model. The emphasis in managed care on an economic model is fraught with many shortcomings and should therefore be supplanted by greater emphasis on a political model that gives voice to patients and physicians.

Morreim EH. Moral justice and legal justice in managed care: the ascent of contributive justice. J Law Med Ethics. 1995;23(3):247-265.

Examines the broadening conception of justice, which now includes contractual and contributive justice. An ensuing focus on patient accountability in health care contracts will require providing patients with a greater range of options, and a fuller disclosure of limitations on benefits within each option.

Coverage Decisions
The "What" and "Who"

Mansheim BJ. What care should be covered? Kennedy Institute J Ethics. 1997;7(4):331-336.

Managed care organizations make coverage decisions based on what the consumer, or more typically the purchaser, is willing to pay.

Sharpe VA. The politics, economics, and ethics of "appropriateness." Kennedy Institute J Ethics. 1997;7(4):337-343.

Coverage decisions based on what is "medically necessary" and "appropriate" necessarily involve normative judgments; such value judgements must therefore be addressed in managed care plan coverage decisions.

Stobo, J. Who should manage care? The case for providers. Kennedy Institute J Ethics. 1997;7(4):387-389.

Health care professionals are preferable to payers and patients in allocation decisions.

Veatch RM. Who should manage care? The case for patients. Kennedy Institute J Ethics. 1997;7(4):391-401.

Patients are preferable to providers and payers in allocation decisions.

Cultural Competency

Lavizzo-Mourey R, Mackenzie ER. Cultural competence: essential measurements of quality for managed care organizations. Ann Intern Med. 1996;124:919-921.

Argues that attention to cultural sensitivity and cultural appropriateness should infuse all areas of ethical guidelines in the changing practice environment.

Mediation

Dubler NN. Mediation and managed care. J Am Geriatr Soc. 1998;46:359-364.

Meditation of disputes between the multiple stakeholders in the managed care health system is more ethically appropriate than reliance on arbitration or litigation.

Organizational Ethics

Agich GJ, Forster H. Conflicts of interest and management in managed care. Camb Q Healthc Ethics. 2000 (April);9(2):189-204.

Discusses three major types of conflicts (economic incentives, patient and physician autonomy, and fiduciary character of patient-physician relationship) and three levels of management (administrative, clinical, and resource) infusing managed care. Emphasizes that the debate over ethical practice within a managed care system must first acknowledge the conceptual changes that managed care’s organization and management have brought to health care, which will require looking beyond individual relationships and clinical decisions to accountability for resource use.

Blake DC. Organizational ethics: creating structural and cultural change in healthcare organizations. J Clin Ethics. 1999 (Fall);10(3):187-193.

Ethicists should pay more attention to practical "small steps" to make health care organizations somewhat "better," rather than be stifled by arguments over the big picture or a moral conception of a "good" organization.

Emanuel LL. Ethics and the structures of healthcare. Camb Q Healthc Ethics. 2000 (April);9(2):151-168.

Analyzes the purposes and moral obligations of medicine and healthcare organizations (such purposes determinant of the structural design that fosters ethical performance), mechanisms for accountability, and how to implement structural ethics in medicine.

Hirsch NJ. All in the family—siblings but not twins: the relationship of clinical and organizational ethics analysis. J Clin Ethics. 1999 (Fall);10(3):210-215.

Analyzes similarities and differences between clinical and organizational ethics, and emphasizes that organizational ethics are aided, but not completely guided, by the experiences of clinical ethics. Organizations must commit internally to an ethical environment at each managerial level.

Patient Advocacy - Voice, Education, and Protection
Voice

Rodwin MA. Consumer voice, participation, and representation in managed health care. A white paper prepared for the Consumer Federation of America. May 1998.

Argues for greater consumer voice, rather than reliance on an exit option, while highlighting the variety of mechanisms (e.g., grievance committee and governance board representation) available to accomplish this goal.

Swankin D. Consumer advocacy committees. Healthplan. May/June 1999, pp.19-22.

Discusses how consumers can play an enhanced role in managed care policy and process by formation of consumer/member advisory committees. Analyzes the challenges for these committees (and enhanced consumer input generally), and includes a checklist for use by health plans to increase consumer involvement.

Education

Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research). Your guide to choosing quality health care. http://www.ahcpr.gov.

A consumer guide developed by AHRQ in cooperation with the U.S. Department of Health and Human Services and other public and private sector health care organizations. The goal of the guide is to help consumers choose quality care, and also to provide tools for these individuals to measure quality based on factors of particular importance to them.

Health Insurance Association of America. Guide to Managed Care: Choosing and Using a Health Plan (updated December 28, 1999). http://www.hiaa.org/cons/choosing.html.

A consumer guide developed by AHRQ in cooperation with the HIAA. The goal is to help consumers make sense of the various health plan options that exist, by providing a set of commonly-asked questions and answers and tips on how to get the most out of health plans.

Protection

President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry: Appendix A — Consumer Bill of Rights and Responsibilities. July 17, 1998 (last revised).

Final report of executive advisory committee, charged with assuring quality and value in health care, focusing on information disclosure, choice of providers and plans, access to emergency services, participation in treatment decisions, respect and nondiscrimination, confidentiality of health information, complaints and appeals, and consumer responsibilities.

Quality of Care/Consumerism

*Casalino LP. The unintended consequences of measuring quality on the quality of medical care. [Sounding Board.] N Engl J Med. 1999;341(15):1147-50.

Argues that, since most of what physicians do when caring for patients is not measured, efforts to reward only limited numbers of activities based on quality measurements might have the unintended consequence of lowering the quality of care in certain areas that may be as, or more, important. Quality measures might also reduce attachment to professional principles and the "art" (vs. "science") of medicine, in part by raising the costs of adhering to them. Suggests ways to minimize these unintended consequences, by, for example, fostering research that looks also to the "quality of agents" (e.g., their adherence to professionalism), and not simply the quality of outcomes.

*Coalition for Affordable Quality Healthcare. Progress Report. July 12, 2000.

Summarizes first 6 months of work by CAQH — a coalition of 22 health plans, serving a combined total of over 100 million Americans — to improve health care coverage, quality, and service for clinicians and consumers.

Surveys
Patient/Consumer:

Grumbach K, Selby JV, Damberg C, et al. Resolving the gatekeeper conundrum. JAMA. 1999;282:261-266.

Emphasizing a "gatekeeper" role too much in managed care plans undermines patient trust and confidence in their primary care physicians.

Reschovsky JD, Kemper P, Tu HT, Lake T, Wong HJ. Do HMOs make a difference? Comparing access, service use and satisfaction between consumers in HMOs and non-HMOs. [Issue Brief.] Center for Studying Health System Change. Number 28, March 2000. http://www.hschange.com/issuebriefs/issue28.html.

Patients in managed care plans experience less satisfaction with their HMOs, less trust in physicians, and lower ratings of physician visits, than patients in fee-for-service plans.

Physician:

Feldman DS, Novack DH, Gracely E. Effects of managed care on physician-patient relationships, quality of care, and the ethical practice of medicine. Arch Intern Med. 1998;158:1626-1632.

Many physicians believe that managed care negatively affects the patient-physician relationship, physicians’ ability to carry out ethical obligations, and the quality of care.

*Lepore P, Tooker J. The influence of organizational structure on physician satisfaction: findings from a national survey. Eff Clin Pract. 2000;3(2):62-68.

Internal medicine physicians who are salaried employees of a staff- or group-model HMO report highest levels of satisfaction; the most dissatisfied are physicians with multiple contracts with health plans. The top two reasons given for dissatisfaction are loss of autonomy (interference with clinical decision-making) and increased administrative burdens imposed by managed care organizations.

Simon SR, Pan RJD, Sullivan AM, et al. Views of managed care: a survey of students, residents, faculty, and deans at medical schools in the United States. N Engl J Med. 1999;340:928-936.

Medical students, residents, faculty members, and medical school deans hold negative views of managed care. There exists a need for greater education (system-wide) in academic health centers about managed care and practicing in such a climate.

Sulmasy DP, Bloche MG, Mitchell JM, Hadley J. Physicians’ ethical beliefs about cost-control arrangements. Arch Intern Med. 2000;160:649-657.

Most midcareer physicians find many methods used by health care plans to influence medical decision making ethically objectionable.

Wynia MK, Cummings DS, VanGeest JB, Wilson IB. Physician manipulation of reimbursement rules for patients: between a rock and a hard place. JAMA. 2000; 283(14):1858-1865.

A significant number of physicians manipulate reimbursement rules, and many who do so believe it is necessary to provide high-quality patient care.

Health Plan:

American Association of Health Plans. Health care quality: outcomes and satisfaction. Managed Care Facts. October 1999. http://www.aahp.org/menus/index1.cfm.

Research studies since 1997 generally demonstrate that HMOs provide their members with care that is comparable to, or better than, care provided in traditional indemnity plans. Many surveys also indicate high consumer satisfaction with managed care health plans.

American Association of Health Plans. Health care quality: utilization of health services. Managed Care Facts. October 1999.

Many studies show that managed health care plans are providing better quality of care than fee-for-service plans; are providing high levels of preventive health services; and are providing enrollees with similar levels of health services.

American Association of Health Plans. Access to specialty care: The experience of health plan enrollees with chronic and acute illnesses. Facts in Brief. August 1998.

In health plans, patients with chronic and acute illnesses are offered an affordable, high-quality alternative to fragmented, expensive fee-for-service care. These health plans also provide access to high-quality specialty care through innovative, streamlined referral and preauthorization initiatives.

Sources for Additional References
General Issues

Bioethicsline.

On-line database of interdisciplinary articles on medical ethics and health policy, allowing for specialized searches under managed care. Can be accessed through Internet Grateful Med, a service of the National Library of Medicine.

Darragh M. Ethical issues in managed care. A selected bibliography. Kennedy Institute J Ethics. 1997;7(4):421-426.

Contains annotated references to major additions to literature on managed care ethics in 1996-1997.

Confidentiality

Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research). Health Confidentiality Bibliography.

Identifies basic key documents in healthcare confidentiality, drawn from the government, books, articles and studies, international materials, and other bibliographies.

Organizational Ethics

Bishop LJ, Cherry MN, Darragh M. Organizational ethics and health care: expanding bioethics to the institutional arena. Kennedy Institute J Ethics. 1999;9(2):189-208.

Scope Note containing annotated references to literature on organizational ethics for health care organizations.

CQ Sources/Bibliography. Camb Q Healthc Ethics. 2000;9(2): 239-241.Contains suggested references for further reading on organizational ethics and healthcare.

    [Editor's Note: The highest professional standards are thoiught to require health care staff to demonstrate the following standards and practices in patient contacts and records: Altruism as the essence of professionalism. The best interest of patients, not self-interest, is the rule.
     Accountability as required at many levels -- individual patients, society and the profession. Health Cre staff as accountable to their patients for fulfilling the implied contract governing the patient/physician relationship.
   They are also accountable to society for addressing the health needs of the public and to time-honored ethical precepts.
     Excellence entails the conscientious effort to exceed ordinary expectations and to make a commitment to life-long learning.     
     Commitment to excellence is an acknowledged goal as well as to duty and a commitment ro being available and responsive to a patient's welfare, advocating the best possible care regardless of ability to pay, seeking honor and integrity in the consistent regard for the highest standards of behavior and the refusal to violate one's personal and professional codes.
     Honor and integrity imply being fair, being truthful, keeping one's word, meeting commitments, and being straightforward. They also require recognition of the possibility of conflict of interest and avoidance of relationships that allow personal gain to supersede the best interest of the patient.
    Respect for others is the essence of humanism, and humanism is both central to professionalism. The ability to affect attitudes, behavior patterns and ethical conduct in patient care must be recognized and used during residency and fellowship training.]

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