Ethical Aspects of Addiction Treatment in a Managed Care Environment

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Ethical Aspects of Addiction Treatmentin a
Managed Care Environment
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What is Ethics?
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Ethics(Websters New Collegiate Dictionary)

• 1.The discipline dealing
• with what is good and
• bad and with moral
• duty and obligation.

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Ethics(Websters New Collegiate Dictionary)

• 2a. A set of moral
• principles or values
• 2b. A theory or system
• of moral values
• 2c. The principles of
• conduct governing
• an individual or a
• group

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• What is
• Managed Care?

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Managed Care

• A system or process of organization or control
  which determines the arrangements by which health
  care services are provided to individuals and
  populations,

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• by directing patients within a population to
  specific providers, determining whether care will
  be provided, by which provider, in which
  location, over what span of time, and under
  specific financial terms.

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• What
• Gets
• Managed?

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What Gets Managed in Managed Care?

• The scope of the population to be served (the
  covered lives, the enrollees, the members)
• The scope of the providers who could be
  authorized to provide service (the provider
  network)
• Whether an episode of care is approved to occur

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What Gets Managed in Managed Care?

• Whether an episode of care is approved to be paid
  for
• The scope of the care provided (which procedure,
  how many encounters)
• The content of the clinical activity transpiring
  between patient and provider

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Functions of Managed Care

• Sales/Marketing/Underwriting
• Network Development and Management (Contracting)
• Utilization Management
• (Criteria, Algorithms)
• Medical Management Guidelines
• Customer Service (Patients)
• Provider Relations
• Administration

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Financial Arrangements in Managed Care

• Contracts with Customers (employees)
• Contracts with Providers - Inpatient
• Contracts with Providers - Professional Services
• Contracts with Pharmacies
• Contracts with DME, HHC, etc.
• Contracts with Carve-Outs

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Financial Components in Managed Care

• Medical Loss
• Administration
• Profit

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What Can Be Managed?
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What Can Be Managed?

• Units of service
• Price per unit of service
• Patients selection of providers
• Providers selection of procedures

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What Can Be Managed?

• The care process
• The disease state of the individual served
• The health status of the individual served
• The health status of the population served

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Is It All About Money?

• No, its also about
• Care paradigms
• (practice guidelines)
• Professional standards
• (standards of practice)
• Public health
• (population medicine)
• Health Systems Planning

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Beyond Managing Money

• Managed care manages the content of care and
  the health status of populations

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Professionalism(Websters New Collegiate
Dictionary)

• The conduct, aims, or qualities that
  characterize or mark a profession or a
  professional person

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Professionalism(Websters New Collegiate
Dictionary)

• adj Characterized by or
• conforming to the
• technical or ethical
• standards of a
• profession

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Profession(Websters New Collegiate Dictionary)

• n A calling requiring specialized knowledge
  and often long and intensive academic
  preparation a principal call, vocation or
  employment

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• A profession generally is distinguished from a
  trade in that

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• The body of knowledge and practical expertise is
  defined by the members of the profession, not by
  those outside the profession

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• The standards of practice are defined by the
  members of the profession, not by those outside
  the profession and

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• Review of performance (to assure adherence to
  these standards of practice) is conducted by
  members of the profession, not by those outside
  the profession

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In the analysis of the ethical aspects of
addiction treatment, one should
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• 1. Examine the ethical aspects of addiction
  treatment that may or may not have a direct
  connection to the managed care arrangements

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• 2. Be sure that ones critiques are on an ethical
  basis versus another basis of evaluation or
  preference

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• 3. Determine that ethical defects, if identified,
  reside with managed care structures or with other
  design flaws, e.g., benefit design

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What should we discuss about the ethical aspects
of addiction treatment in any environment?
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• 1. The Right to Refuse Treatment
• 2. Informed Consent
• 3. Medical Futility

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Should we withhold treatment for non-patients
simply because they dont complain about
addiction?
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Duty to Treat

• Is it ethical to refuse to treat a patient?

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Informed Consent

• Is it ethical to initiate treatment without
  describing its content, benefits, risks, and
  alternatives to the patient?

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Should we continue treatment in cases of medical
futility?
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Is it unethical to let a patient leave treatment
when their capacity is limited by their medical
status?
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Should we allow patients to leave treatment
without designating their exit as Against
Medical Advice?
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Should We Inform Third Parties of Potential Harm?

• Should we inform public authorities about
  patients who pose risks to public safety?

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Should we inform the primary care physician of a
patient encounter?
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Should we inform the utilization management or
case management staff without the patients
consent?
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Should the willingness to offer treatment be
affected by the presence of a co-morbid Axis II
condition?
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What do I do in the clinical setting with
information gleaned from AA attendance?
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Should liver transplant programs use addiction
status as a criterion for patient selection?
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• In a recent article, Agich and Forster explore
  two major domains of conflict of interest

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• Conflicts in the fiduciary character of the
  physician-patient relationship linked to
  conflicts of economic incentives and ethical
  obligations

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• Conflicts with patient and physician autonomy

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• Are holdbacks unethical?
• Are bonuses unethical?

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• Are first dollar coverages unethical?
• Are co-pays and deductibles unethical?

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Are capitation payment systems unethical?
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Is it unethical to spend a shorter time in a
patient visit because one knows that ones
personal financial return will be enhanced by
shorter appointment times?
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Is it unethical to spend a longer time in a
patient visit because one knows that ones
personal financial return will be enhanced by
longer appointment times?
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Is it unethical to let financial incentives
override professional obligations?
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Is it unethical for managed care organizations to
select or retain providers to panel membership
based on practice patterns, e.g.,
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• appointment times
• use of consultants
• utilization of tests
• prescribing patterns
• formulary compliance
• practice guideline compliance
• cost efficiency?

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Are there ethical aspects to managed care
organizations changing panel composition or
employers changing managed care plans such that
patients are unable to maintain doctor/patient
relationships with established providers?
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Is there data to show that continuity of provider
versus change of provider - in and of itself -
affects health care outcomes?
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Is it unethical to transfer a patient to a
substandard facility if continued stay in your
own facility would produce financial hardship?
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Is it unethical for a PCP to serve simultaneously
in the role of gatekeeper for his/her patients
service utilization?
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Whose interests am I serving?

• The patient?
• The family?
• The employer?
• The society at large?
• The managed care organization and its
  stockholders?
• The managed care company which I own?

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Is it possible to retain professionalism within
managed care?
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Is it unethical to conduct oneself as if
professionalism is impossible within managed care?
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Is the problem the management of the care or the
structure of the benefit?
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Is it unethical to disparage the entity managing
care when the wrong resides with the purchaser
of the coverage - or the marketplace which,
affected by stigma, has ascribed a value to
addiction services?
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Is medical treatment the only legitimate form
of health care service delivery?
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Are carve-outs inherently unethical?
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Is it unethical to fail to inform patients about
consultants not covered by the plan?
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Is there any ethical obligation to purchasers of
health care services?

• Is it ethical to give the patient the treatment
  the patient wants if the provider believes the
  treatment is ultimately not in the patients best
  interest?

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Is it ethical to be a consultant with a managed
care organization?
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Is it ethical to avoid being a consultant for a
managed care organization?
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Is it unethical for for-profit entities to be
components of the health care delivery and
financing systems of America?
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Is it unethical to squander national resources on
a wasteful health care system with ineffective
systems of accountability?
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Is it unethical to not manage resources in our
health care delivery system?
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Can medical ethics develop beyond the narrow
parameters of the individual doctor/patient
relationship?
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Ethical Challenges Due to Managed Care

• Conflicted Economic Incentives
• Conflicted Primary Loyalties
• the patient, the payor, the population under
  contract
• Disruptions in Continuity of Care Based on
  Managed Care
• Ethical Aspects of Carve-Outs
• Limitations on Provider Panel Access for
  Addiction Clinicians

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Conflicts

• ... between having the individual and the
  population as the most appropriate focus of
  physician attention

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Conflicts

• ... between the professional service
  relationships and the fiduciary relationships
  that the provider may experience

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Conflicts

• ... between providing more care for the
  individual (even if that means less for the rest
  of the population) and providing less for the
  individual (even if that means more for the
  provider)

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Conflicts

• ... between the interests of the general medical
  MCO and the MBHO carve-out firm)

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Michael M. Miller, M.D. FASAM

• mmiller_at_meriter.com
• Secretary ASAM
• Medical Director,
• NewStart Program
• Meriter Hospital
• Madison, WI