Monday, September 3, 2007

Harvard Pilgrim Health Care’s Approach to Organizational Ethics

Since 1996 Harvard Pilgrim Health Care (HPHC), a not-for-profit health insurance company serving 1,000,000 members in Massachusetts, New Hampshire and Maine has supported an ethics program that provides an important decision support function to the company. The program advises on clinical policies, insurance product development, and the full range of issues that contemporary health plans address. I have been responsible for the program since 2000.

Before HPHC launched the ethics program one of its two precursor organizations – Harvard Community Health Plan – had tip toed up to starting one several times but kept backing off. A major reason for the back pedaling was that a task force on “humanistic health care” in the 1970s had been perceived as a forum for grousing, and management was afraid that an ethics program might go down the same path. Management also feared that an ethics program might inadvertently take accountability for grappling with ethical problems away from program managers.

In 1995 Harvard Community Health Plan, a not-for-profit physician-governed HMO, and Pilgrim Health Care, a not-for-profit physician-governed IPA, merged to form HPHC. Despite their similarities, the cultures of the two organizations were different enough so that each felt the other might contain “unethical” components. HPHC started the ethics program to address these tensions.

The heart of the program is an ethics advisory group (EAG), composed of HPHC staff, consumers, physicians from the network, purchasers and brokers, and external ethics and health systems leaders. The group advises about issues brought to it by HPHC leaders (referred to as the “customer”) who are responsible for the area in question. Consultation with the EAG is always voluntary – it has no “must approve” role, and its opinions are advisory, not binding.

The every two month EAG meetings typically have twenty to twenty-five participants and last for two hours. I prepare and circulate a “case” in advance that gives background, identifies the customer’s questions, and summarizes relevant precedents. After the meeting I write a consultation report presenting the key perspectives that emerge from the deliberations. The report is posted on the HPHC intranet site and the Web site for affiliated providers. As of this summer the EAG has held 85 meetings.

The key question to ask about an organizational ethics program is – so what? What difference does the program make? There is no measuring rod for answering this question, but the leaders who bring questions to the EAG have been very positive about the experience and many have brought several issues to the group over the years. The meetings are open to HPHC staff and close to 10% have attended at least once, which the organization sees as a contribution to an organizational culture concerned with values and doing the right thing. Harvard Pilgrim has supported the program for eleven years, including during a financial crisis in 1999-2000 that required many cutbacks.

In this posting I want to give an example of how one organization has structured an ethics program. The question of whether and how ethics activities contribute to organizational effectiveness is the central focus of this blog, and I will speak to that topic recurrently in the future. I hope that over time readers will contribute observations from their own organizations.

The July/August issue of Health Affairs has a more extended article on the HPHC program: “Confronting Trade-Offs in Health Care: Harvard Pilgrim Health Care’s Organizational Ethics Program," written with David Cochran. If you would like a paper copy for educational purposes (Health Affairs does not provide a free pdf of the article yet) write to me at


Anonymous said...

I am a provider and my experience with Harvard Pilgrim Health Care is one that leads me to believe that they are highly unethical. I deal with many insurers and this one takes the lead in poor business practices.

Jim Sabin said...

Dear Anonymous
I'm sorry for whatever your unhappy experiences have been. I can say with confidence that the organization is highly ethical as an overall entity. I hope you've brought your particular concerns to the attention of the relevant part(s) of the organization or person(s).