Ethics in managed care.

The current era of managed costs and care create ethical dilemmas based on economic constraints and incorporation of principles of distributive justice. Traditional ethical concerns related to confidentiality, conflicts of interest, double agentry, and honesty are complicated by interference in the doctor-patient relationship caused by intrusive utilization management. National health reform must take these issues seriously to ensure that the "cure" promised by such reform efforts is not worse than the disease. The challenge for psychiatrists is to adapt to these constraints without losing site of traditional medical ethical positions. Once the ethics become diseased, no cure may exist at all.     

Ethics in managed care.

The current era of managed costs and care create ethical dilemmas based on economic constraints and incorporation of principles of distributive justice. Traditional ethical concerns related to confidentiality, conflicts of interest, double agentry, and honesty are complicated by interference in the doctor-patient relationship caused by intrusive utilization management. National health reform must take these issues seriously to ensure that the cure promised by such reform efforts is not worse than the disease. The challenge for psychiatrists is to adapt to these constraints without losing sight of traditional ethical medical positions. If the ethics become diseased, then no cure may exist at all.     

Corporatization of pain medicine: implications for widening pain care disparities

The current health care system in the United States is structured in a way that ensures that more opportunity and resources flow to the wealthy and socially advantaged. The values intrinsic to the current profit-oriented culture are directly antithetical to the idea of equitable access. A large body of literature points to disparities in pain treatment and pain outcomes among vulnerable groups. These disparities range from the presence of disproportionately higher numbers and magnitude of risk factors for developing disabling pain, lack of access to primary care providers, analgesics and interventions, lack of referral to pain specialists, longer wait times to receive care, receipt of poor quality of pain care, and lack of geographical access to pharmacies that carry opioids. This article examines the manner in which the profit-oriented culture in medicine has directly and indirectly structured access to pain care, thereby widening pain treatment disparities among vulnerable groups. Specifically, the author argues that the corporatization of pain medicine amplifies disparities in pain outcomes in two ways: 1) directly through driving up the cost of pain care, rendering it inaccessible to the financially vulnerable; and 2) indirectly through an interface with corporate loss-aversion/risk management culture that draws upon irrelevant social characteristics, thus worsening disparities for certain populations. Thus, while financial vulnerability is the core reason for lack of access, it does not fully explain the implications of corporate microculture regarding access. The effect of corporatization on pain medicine must be conceptualized in terms of overt access to facilities, providers, pharmaceuticals, specialty services, and interventions, but also in terms of the indirect or covert effect of corporate culture in shaping clinical interactions and outcomes.     

Psychiatric nursing positions in managed care

Career Perspectives discusses alternative careers for psychiatric nurses. This column explains the variety of roles for nurses in a managed care organization, and outlines two of the more common and important roles of precertification nurse and case manager.     

Geriatric psychiatry and managed care.

A wide gap exists in the American health care system between what we know good geriatric mental health care services should look like and the types of services generally available. Cost effective treatment requires a continuum of care in which geriatric psychiatry and primary care geriatric services are integrated in an aggressively case managed model. MCOs have the infrastructure and tools at their disposal to make this work, but they must incorporate into their programs and approaches expert knowledge of the unique clinical problems of the frail elderly.     

Myths and mystifications of managed care

This paper reviews some of the major conceptual "myths" that have been propagated to support the cost containment activity referred to as "managed care." It discusses the facts and logic inherent in these myths and examines the implications such myths have for compromising the integrity of clinical care.     

Medical necessity and psychiatric managed care.

The concept of medical necessity is a provision of commercial insurance contracts and federal government Medicaid requirements that limits the payment to only those services that are essential for treating a person's sickness, injury, or condition. The concept of medical necessity is one tool used by third-party payers to contain their financial risk in a seemingly nonarbitrary manner. Also, the definitions of medical necessity used by commercial insurers or by the federal government reflect their product's or program's philosophies. Expanding commercial insurance or Medicaid psychiatric coverage would require changing those philosophies. As long as society is faced with a greater demand for health-related service than resources to meet them, such systems of rationing will be used. Even with full parity for psychiatric benefits, mechanisms will be used by payers to limit or control demand, thereby controlling financial risk. The short-term challenge for psychiatric advocates is to secure the most acceptable definitions of medical necessity from third-party payers. The long-term challenge for MH/SA advocates and for all health care advocates, is to develop a system that pays for the greatest number of quality services for the greatest number of people in need, in an affordable manner, regardless of diagnosis.