The Ethics of the Appeals Process

From time to time (here and here) I write about tools that organizations can use to strengthen the ethics of their enterprise. For medical ethics to be more than an engaging classroom exercise, we need to connect deliberation to effective action.

Yesterday I conducted a seminar at a large pharmacy benefits management company, focused on their experience handling appeals about drug coverage. My “assignment” was to help the group put the appeals work into an ethical framework.

I used a framework developed by the American Medical Association Institute for Ethics Ethical Force Program. The Ethical Force Program convenes multi-stakeholder working groups to develop consensus-based frameworks of values for central areas of health care and to derive measurable performance expectations. The framework I used with the PBM group comes from “Ensuring Fairness in Health Care Coverage Decisions.” It performed superbly.

The Ethical Force Work Group (I was a member) identified five key values for designing and administering health benefits:

• Transparent: The processes for designing and administering health benefits should be fully transparent to those affected by these processes.
• Participatory: Stakeholders should be involved in a meaningful way in creating and overseeing health benefits.
• Equitable and Consistent: Design and administration of health benefits should result in similar decisions under similar circumstances.
• Sensitive to Value: Design and administration of health benefits should consider the relationship between health outcomes and resource use.
• Compassionate: Design and administration of health benefits should be flexible, responsive to individual values and priorities, and attentive to the most vulnerable individuals and those with critical needs.

I confess to feeling bored when I see lists of values. On first glance a list can look like a compendium of platitudes. Yawn.

But in yesterday's seminar the framework came to life. Everyone who had participated in the actual process of addressing appeals about drug coverage had experienced the pull of each of the five values and the conflict among them.

The Ethical Force framework proposes no algorithm for weighing the five values or adjudicating among them. Its usefulness for the group came from the encouragement it gives for accepting the tension among values and deliberating about alternative options. There is a natural tendency to avoid conflict, either by rigid adherence to rules ("bean counters") or rigid commitment to the desires of the individual appellant ("bleeding hearts").

Organizations have to give lip service to the importance of ethics. Even Enron had a well worded ethics code! But even at the best organizations “ethics” has negative connotations – either self righteous preaching or wishy-washy “on the one hand/on the other hand” inconclusiveness. In other words, tunnel vision adherence to single values or paralysis among multiple values.

But if those of us concerned with the ethics of organizations can link skillful ethical deliberation with skillful organizational leadership, we will have a powerful combination. As Muhammad Ali taught us: "float like a butterfly, sting like a bee."