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.