Monday, October 20, 2008

Why Health Plans Should Have Ethics Programs

On Thursday I'll be speaking about "Ethics, Health Plans, and State Health Plan Associations" at the AHIP (America's Health Insurance Plans) state issues conference in Chicago. I'll be urging health plans - both not for profit and for profit - to create meaningful ethics functions/ethics committees, using Harvard Pilgrim Health Care's 12 year experience as an example.

Here, in italics, are some questions I hope I'm challenged with, followed by my answers:

1. "What do we need an ethics program or ethics committee for? Are you saying we're not ethical people?" "No, I'm not saying you are unethical. I believe our major health insurance companies and the individuals who work for them want to do the right thing. But health care poses exceptionally complex ethical questions that often involve trade-offs among our deepest values. Health plans operate at the intersection of business (health care is the largest single sector of the U.S. economy) and calling (the origins of the care taking role go back to early religious roots). Our shared human nature, alas, finds it easier to react in either/or terms ('either we're a business or we're a calling...') rather than both/and ('we have to make a margin to serve our mission - we can't be true to our calling unless we run our business well').

The Harvard Pilgrim Ethics Advisory Group (EAG) includes HPHC staff, who understand the business realities of the health plan, employers, who understand the impact of the ever rising premiums, physicians who practice in the network, who understand how insurance affects their ability to care for their patients, and consumers, whose health is what the whole enterprise is about. This kind of gathering of perspectives brings a broad spectrum of values and perspectives into its deliberations and broadens the organization's understanding of the ethical dimensions of its work."

2. "Big deal! What does an ethics committee offer that a smart management group doesn't already have?" "Well functioning hospital ethics committees are valued for the consultation they offer to the patient, family and clinical team. In hospitals the clinical team is like the management team at a health plan. The team only consults the ethics committee when it feels that additional perspectives might help it meet its objectives better. Harvard Pilgrim operates the same way. No issues have to come to the Ethics Advisory Group. The EAG only enters in when the responsible manager asks for its advice."

3. "What evidence do you have that what you describe is worthwhile? What's the bottom line on this?" "I was hoping you'd push me on this, so I asked two leaders at Harvard Pilgrim. Here's what one said:
'The industry we are in addresses issues of critical importance to patients, providers and the public. We are involved with allocation decisions that are often fraught with tension and difficult to figure out. Just as there are ways of working out other business processes, there are ways of working through the ethical dimensions of what we do. The value of the program comes from teasing out the ethical issues and helping to design processes to deal with them in new and better ways.'
The other person I spoke to said:
'We can't do an economic analysis of the value of the ethics program, so I evaluate it by asking five practical questions: (1) Is the EAG membership broad based? (2) If it is, do the members attend and participate? (3) Do I hear complaints from my staff about the time it takes? (4) Is there a shortage of topics? and, (5) Do the consultees get what they are looking for?'
An ethics program isn't free, but it won't cost much. The key ingredients are support for the idea from the top, and the right kind of leadership."

I'll hope to have something interesting to say about all of this when I'm back from the conference.


Alex said...

Great Post

Jim Sabin said...

Hi Alex -

Thanks for the encouragement. I've felt a bit like Don Quixote in my efforts to encourage health insurance companies to develop ethics programs/ethics committees. The three programs I'm aware of are at Harvard Pilgrim, Kaiser Permanente, and Group Health Cooperative. All three have (KP & GHC) or recently had (HP) delivery systems as part of the organization, and so were familiar with the constructive role that ethics committees can play at hospitals. Many years ago United Behavioral Health had an ethics committee, driven by a physician employee with a special interest. But to the best of my knowledge we don't yet have any robust programs at insurers that haven't also been care proviers.



Anonymous said...

I hardly know where to begin, sir. Your post was revelatory, even though long overdue. I did read in your bio that you worked with an insurer, My initial response was honestly, "oh no"! That was until I read your blogs, especially this one. It is evident how passionate you are regarding this plausible marriage of professional healthcare and medical ethics. How positively our healthcare environments [albeit overtaxed] have greatly evolved. If I am correctly understanding that there is an inclusion in the national bailout package regarding parity for mental health care/coverage, then I am joyful. More accurately, I am indeed thrilled, yet puzzled. Puzzled as to why, after passage of the ADA, it has taken so long for private insurers to accept and/or sympathetically acknowledge. The Act which did address the credibility that a disability not be only physical in nature, but mental as well. I don't believe I just told YOU that! haha
Your work is impressive. I commend you.
Cannot find any comment, or returned note from you, that is in Wordpress. I was notified one was sent. It has been some time since I've had a posting, [The election fills my time, and can Nov 4 please come!]
I'm Donna. If I get inspired with wisdom worth sharing, and post it, if you want, e-mail is
Keep up the good works!!

Jim Sabin said...

Hi Donna -

Thank you for this posting. And, I'm sorry about the delay in responding.

Your initial "oh no!" reaction to seeing that I am associated with an insurance company is important. Health insurance is in the middle of (1) patients who need insurance to access care, (2) physicians, hospitals and others who provide care and need to be paid, and (3)those who pay for care - employers, government (via tax revenues), and individuals themselves.

When providers raise prices and manufacturers market new, costly products, those who pay for care blame insurers and ask them to do something. When insurers tried to "manage care" in the 1990s, physicians and the public blamed them for intruding into the doctor-patient relationship.

The company at which I direct the ethics program is not for profit. That means that while we can't spend more than we receive from employers, individuals and public payers, we don't have the complication of equity ownership and the executive compensation that has been characteristic of the for profit sector. Our ethics program tries to bring the different stakeholders into dialogue to find constructive resulution to the conflicting values that are at the heart of modern health care.

Re the move towards parity - the fact that experience has shown that when mental health care is prudently managed the costs are predictable and controllable has been key. In the past employers feared that mental health would be a "black hole" for ever increasing costs.

And, great that you have been working on the election!



Anonymous said...

Much thanks for the reply. Knowing what your schedule must be, it was timely enough!
So very glad to hear about not for profit company. I honestly didn't realize they where around. Perhaps I haven't paid close enough attention.
Non the less, the approach to ethically based healthcare, from bed to home and beyond, is a lofty one which I greatly respect.
That is why my fears for the future are fraught with angst. People lost jobs, healthcare management on the table, the overall economy ominous, will make things harder for you. The climate will probably change greatly, just when you had a solid forecast!
Well, time insists I close. Cannot tell you how please I am to hear from you. Keep up the good work.
Funny you mentioned the election. My doorbell just rang. It was the postman with my better late than never Obama yardsign. Yes, I admit my allegiance, do hope not inappropriately so.
As with medical ethics, my belief in right to privacy over one's body is paramount and maybe where medical ethics begins.

Anonymous said...

Jim, Didn't tell you I have ADD. hahaha. Was a jump ahead of myself.
So in closing, alas,yours,