- Physician response to utilization review study
- Appeals of adverse utilization review decisions
- Physician capitation survey
- Physician survey response rates study
- Codes of ethics and ethics policies: consensus and conflict
- Focus groups of health plan purchasers
- Organizational ethics
PRESSURES Study: Physicians' responses to utilization review pressures
Physicians face increasing ethical pressure from utilization review processes
in managed care. When patients need a service for which payment has been or
is likely to be denied, physicians may respond in several ways. Among the potential
options, a few are particularly ethically troublesome: the physician may not
tell the patient about the service, may ask the patient to pay for the service
personally, or may alter the patient's record to justify payment for the service.
This 1998 national physician survey documents the frequency of each of these
occurrences and explores correlates for each.
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Appeals of adverse utilization review decisions: Physicians' experiences
One ethically appropriate response to an adverse utilization review decision
may be to mount an appeal. Yet the frequency and success rates of such appeals
are largely unknown. As part of the 1997 AMA Socioeconomic Monitoring Survey,
several questions were added to determine how often physicians challenge adverse
utilization decisions, and what the outcomes of these challenges are in specific
managed care plans.
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Physician capitation: A national survey of primary care physicians
Increasingly, physicians' income is being placed at risk for the costs of their
patients' care, especially through capitated payment. This national physician
survey, conducted throughout 1997, explored primary care physicians' experiences
with, views on, and responses to capitated payment for medical care. The survey
answered several questions, including: how often do physicians discuss with
patients how they are compensated for patient care; whether physicians recommend
to certain patients that they avoid or join capitated managed care plans; and
whether greater experience with capitation alters physician views on this form
of payment for medical care.
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Physician survey response rates: The effect of monetary incentives
Survey researchers commonly include a monetary inducement with mailed surveys
to encourage higher survey return rates. The precise effect of these monetary
incentives for physician surveys today is not known. This randomized trial -
conducted as a sub study of another physician survey project - compared different
cash incentives for their effect on survey response rates.
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Codes of ethics and ethics-related policies: consensus and conflicts
The contents of the codes of ethics of medical professional associations have
never been systematically compared with each other, or with the actual ethics-related
policies of care delivery organizations. Where are there areas of broad professional
consensus on ethical policies? Where do the policies of managed care plans and
medical groups facilitate professional ethics, and where might conflicts arise?
To answer these questions, samples of medical professional association codes
were systematically abstracted and compared with each other and with abstracted
ethics-related policies from a randomly drawn sample of managed care organizations
and medical group practices.
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Focus groups of influential parties in health plan purchasing
Employers frequently make decisions about health plan purchasing that affect
numerous employees. What information do these decisionmakers find useful? What
information would they like to have, but do not? And who else is involved in
these critical decisions? In preparation for work on the Ethical Force Program
we performed a series of 6 focus groups of employee benefits managers from diverse
sizes and types of organizations, followed by 4 focus groups of insurance brokers
and consultants. Each focus group discussed health care quality, where information
on quality is available, and how issues of ethics might affect health care purchasing
and delivery.
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Health care organizational ethics
Changes in the health care system have raised the importance of the roles of organizations in how the health care system functions. Today, organizations profoundly influence the way patients pay for, access, and experience health care delivery. These changes necessitate greater consideration of organizational accountability in the health care system. But what is the appropriate framework for assessing organizational accountability in health care delivery?
There is a well-developed literature on professional ethics, which focuses primarily on individual patient-physician encounters. Unfortunately, professionalism — while arguably an adequate basis for accountability of individual physicians — has not yet taken into account the multitude of parties and organizational structures now involved in the provision of health care. Although this does not mean that professionalism should be abandoned, there is a need to seek an expanded view in order to understand the ethical obligations of health care organizations.
The field of business ethics provides another potential starting point for organizational ethics, but there has been little discussion in this literature that focuses specifically on health care organizations and whether they have unique obligations. Yet these entities do present unique issues, in part because they must integrate business, professional, and patient concerns. In addition, although some similar concerns may be shared by any organization dealing with multiple stakeholders, the fact that these organizations provide health care (a basic need) to ill people (a vulnerable population) is of particular importance. Thus, general theories of institutional morality or institutional obligations (eg, stakeholder theory) may not provide a full theory for the ethics of health care organizations.
The Institute for Ethics National Working Group on Organizational Ethics
in Health Care was appointed to study the interactions between professional
and business ethics and to begin the development of a coherent theory of health
care organizational ethics. Participants included representatives from clinical
ethics, business ethics, institutional ethics, health care organization administration,
and government regulatory agencies. A white paper outlining the Working Group's
theory was developed and is now available on the Web
(PDF, 158KB).
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Content provided by: Institute for Ethics