Ethical Considerations in Disease Management

Managed care, with its restrictions on patient and provider autonomy, has dominated the delivery of healthcare in the US over the last decade. The latest model of managed care has focused on disease management programs, which outline optimal cost-effective processes for care, built on evidence-based guidelines. Patients and providers seem to be more accepting of these programs than of the restrictive managed care practices, but ethical dilemmas remain for both patients and providers when participating in such programs. The basic ethical tenets of beneficence (to do good), autonomy (to make one’s own decisions) and non-maleficence (to do no harm), have been well accepted by the medical community. Under managed care these basic tenets have been challenged, with a notable impact on the principle of autonomy; patients lose their choices in selecting care providers, while healthcare providers face restrictions on what pharmaceutical agents they can prescribe and how to care for patients.Additionally, the changing nature of managing care has highlighted conflicts of interest between: patients and the providers of healthcare; patients and the implementers of health plans; and providers and health plans. Conflicts of interest between various parties involved in healthcare challenge the fundamentals of ethical principles, particularly autonomy and beneficence.Recently, there has been greater recognition of the ethical notion of social justice (including the competing concepts of distributive and contributive justice), in terms of the provision of healthcare, partly due to the development of concerns over the expense of, and access to, healthcare. Distributive justice reflects the broader societal concerns over the provision of scarce resources for all citizens, and argues for universal coverage schemes. The concept of contributive justice recognizes that principles of equity demand that we allocate commonly collective funds fairly to those who have contributed to the pool of funds; in the realm of healthcare in the US this is particularly relevant for those who have insurance coverage.Disease management programs offer great potential to improve healthcare. Programs that are developed with attention paid to the principles of beneficence and social justice as well as to concerns regarding patient and provider autonomy can limit conflicts of self-interest.     

Calendar of Meeting

Growing public interest in the operations of managed care plans has fueled a variety of activities to collect and analyze their performance. These activities include studies of financial performance, analysis of enrollment decisions, and, more recently, the development of systems for measuring healthcare quality to improve accountability to consumers. In this study, the authors focus on the activities of managed care plans that may frustrate patients and providers and, subsequently, motivate patients to file complaints. Using data from three sources, they evaluate the relationships between complaints against managed care plans and two metrics of performance: (a) the financial performance of the plan, and (b) the quality of care provided. Their findings indicate that complaints against health maintenance organizations are significantly related to the plans' levels of quality and to actions that may impede access to care.     

Health maintenance organization (HMO) performance and consumer complaints: an empirical study of frustrating HMO activities

Growing public interest in the operations of managed care plans has fueled a variety of activities to collect and analyze their performance. These activities include studies of financial performance, analysis of enrollment decisions, and, more recently, the development of systems for measuring healthcare quality to improve accountability to consumers. In this study, the authors focus on the activities of managed care plans that may frustrate patients and providers and, subsequently, motivate patients to file complaints. Using data from three sources, they evaluate the relationships between complaints against managed care plans and two metrics of performance: (a) the financial performance of the plan, and (b) the quality of care provided. Their findings indicate that complaints against health maintenance organizations are significantly related to the plans' levels of quality and to actions that may impede access to care.     

The relation between selective contracting and healthcare expenditures in private health insurance plans in the United States

Many healthcare systems, including The Netherlands, Germany and Switzerland, have incorporated elements of managed competition, whereby insurers compete for enrollees in a marketplace organized or facilitated by a government or governing entity. In these countries, managed competition was introduced with the idea that the system would contain cost growth while maximizing value for consumers and employers. An important mechanism to control costs is selective contracting: the process of contracting providers into a network and offer insurance packages with varying levels of provider coverage. In these systems, enrollees are expected to choose lower cost plans which offer access to only contracted providers in the network. The questions is, however, if restricting provider choice leads to reduced healthcare expenditures.In the United States, enrollees often have a choice between plans with restricted networks of providers and plans that offer more provider choice, where care outside the contracted network of providers is (partly) covered. The purpose of this study is to understand whether insurance plans with restrictions on provider access in the United States have reduced healthcare expenditures and to identify the mechanism by which that reduction occurred. We used data from the Medical Expenditure Panel Survey (MEPS), a nationally representative sample of families and individuals. We estimated expenditures for enrollees in restricted network plans using two-part models and generalized linear models. We found that restricted network plans, on average, save $761 per enrollee.Our results suggest that cost savings due to restricted network plans are largely a result of price reductions rather than utilization reductions, although both play a role in cost savings. When introducing reforms shifting from a supply‐oriented to a demand‐oriented health care system, these findings might be worth considering by other countries.     

Strategic integration of hospitals and physicians

A striking development in the healthcare market place has been the formation of strategic relationships between hospitals and physicians. Hospital-physician integration appears to be a response to rapidly expanding managed care health insurance. We examine whether integration lead to efficiency gains from transaction cost economies thereby allowing providers to offer managed care insurance plans lower prices or whether integration is really a strategy to improve bargaining power and thereby increase prices. We find that integration has little effect on efficiency, but is associated with an increase in prices, especially when the integrated organization is exclusive and occurs in less competitive markets.     

The characteristics of highly effective therapists in managed behavioral provider networks

As managed behavioral healthcare plans experience increasing requirements to measure outcomes, create report cards and adopt other quantifiable approaches to quality management, rating the effectiveness of behavioral healthcare providers is essential. The authors describe one aspect of their company's quality management program, which uses standardized assessments of client satisfaction, problem resolution and appropriateness of care to identify highly effective therapists. This process has yielded useful results that indicate some of the characteristics of highly effective therapists in such areas as experience, gender and personality type.     

Quality & access in the managed behavioral healthcare industry

Building on a study of the costs of behavioral healthcare under managed care first released in the March/April, 1994 issue of this journal, the American Managed Behavioral Healthcare Association has now turned its attention to two other fundamental issues in healthcare reform: access and quality. The following study presents data indicating how managed behavioral healthcare plans assure quality and access in such areas as response time, accreditation, provider credentialing, patient satisfaction and outcomes measurement.     

Dual diagnosis care for severe and persistent disorders. A comparison of three methods

People with severe and persistent mental illnesses frequently suffer from addictive disorders as well. Managed care plans and at-risk providers who care for people with these conditions must understand, authorize, and provide evidence-based and cost-effective care. The authors of this article evaluated three specialized interventions for treating people with co-occurring severe mental illness and substance abuse. Treatment of both disorders was found to be essential. In addition, a behavioral skills training was found to improve outcomes and reduce total healthcare costs when compared with intensive case management and 12-Step recovery interventions. Supplemental supportive services further increase the overall value of care. Implications for managed care and at-risk providers are discussed.     

Clinicians as advocates: An exploratory study of responses to managed care by mental health professionals

Utilization review and other managed care techniques require that health care professionals assume new responsibilities as patient advocates. This article explores the extent to which characteristics of providers or their experiences with managed care practices predict the nature and extent of advocacy behavior. Interviews of 142 mental health providers revealed that experiences of harmful utilization review and norms of professionalism significantly predicted advocacy behavior. However, providers who were concerned about disaffiliation were less likely to challenge the plan directly but more likely to alter their presentation of the case to reviewers. Providers who believe that managed care plans retaliate against advocacy behavior appear to substitute covert advocacy for direct advocacy. These results are preliminary but suggest that providers condition their advocacy behavior in response to their experiences with and perceptions of managed care plans.     

Measuring Healthcare Providers' Performances Within Managed Competition Using Multidimensional Quality and Cost Indicators

Background and objectives: The Dutch healthcare system is in transition towards managed competition. In theory, a system of managed competition involves incentives for quality and efficiency of provided care. This is mainly because health insurers contract on behalf of their clients with healthcare providers on, potentially, quality and costs. The paper develops a strategy to comprehensively analyse available multidimensional data on quality and costs to assess and report on the relative performance of healthcare providers within managed competition. Data and methods: We had access to individual information on 2409 clients of 19 Dutch diabetes care groups on a broad range of (outcome and process related) quality and cost indicators. We carried out a cost‐consequences analysis and corrected for differences in case mix to reduce incentives for risk selection by healthcare providers. Results and conclusion: There is substantial heterogeneity between diabetes care groups' performances as measured using multidimensional indicators on quality and costs. Better quality diabetes care can be achieved with lower or higher costs. Routine monitoring using multidimensional data on quality and costs merged at the individual level would allow a systematic and comprehensive analysis of healthcare providers' performances within managed competition. Copyright © 2015 John Wiley & Sons, Ltd.     

Participation of plans and providers in Medicaid and SCHIP managed care. State Children's Health Insurance Program

For Medicaid and SCHIP managed care programs to succeed, they must attract enough and the right kinds of plans and providers to meet access and care goals. In 2001 we analyzed practices and perceptions that bear on these goals by surveying managed care plans participating in Medicaid or SCHIP, or both, in eleven states. Participating plans appear supportive of both programs and are largely able to secure providers to participate, too. To date, SCHIP has not attracted many plans not already participating in Medicaid. While perceptions were positive in 2001, maintaining current plan and provider relationships in an environment that has become much more budget constrained will be challenging.     

Managed care: past evidence and potential trends

Enrollment in network-based managed care plans has grown rapidly, raising important questions about the actual impact of different types of managed care plans on health care use, expenditure, and quality of care. In this article, we analyze the literature on the performance of managed care plans relative to fee-for-service plans. We find strong evidence that staff- and group-model HMOs have lowered utilization and expenditure relative to fee-for-service while maintaining quality of care. The relatively sparse evidence is more mixed on the performance of newer forms of managed care organizations (MCOs). We also speculate on future trends in network-based managed care. It is likely that employers will increase their economic leverage with managed care firms, accelerating processes that are leading to greater concentration of marketshare among managed care firms. In turn, newer forms of MCOs will increase their economic leverage with providers, which will help MCOs contain costs and monitor quality. Some of the newer MCOs will adapt important features of staff- and group-model HMOs, including increased emphasis on provider selection and reselection.     

Dialogue. Quality and the bottom line. How can shareholder interests be prevented from interfering with quality care?

Market-driven, for-profit behavioral health systems put patients and investors in the same financial equation. Do shareholder profits depend on preventing patients from receiving appropriate care? Does investor greed directly increase consumer pain and suffering? Or, does the marketplace work the way one hopes: providing profits to investors in proportion to improvements in healthcare quality and affordability? Well-intentioned providers find themselves walking right through the middle of this high-stakes minefield. Should the government and the marketplace allow clinicians--and their standards of ethics and social values--to be swept away in the name of efficiency? Or does the marketplace for behavioral healthcare require government intervention through legislation and regulation to protect the interests of both patients and providers? This debate is far from over. Every reader of this journal has a vital stake in the outcome. In the following dialogue, leaders representing employers, clinicians, and managed care plans argue different positions in this debate and propose compelling solutions.     

ERISA preemption and its impact on behavioral health services

Recently, mental health parity provisions were passed and incorporated retroactively into the Health Insurance Portability and Accountability Act (PL 104-191). Although limited, these provisions were instrumental in focusing national attention and debate on people's need for and right to behavioral health services. A handful of states have also passed parity provisions, but their full impact on the insurance market cannot be assessed. This is because a majority of plans are preempted from compliance with many state insurance mandates by the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the primary obstacle to state behavioral health mandates, and it threatens the inclusion of behavioral health providers and settings in managed care plans integrating public and private healthcare systems. This article provides basic information on ERISA, its preemption clauses, and its impact on behavioral healthcare services.     

To what degree are health insurance enrollees in the Netherlands aware of the restrictive conditions attached to their policies?

BackgroundWithin the Dutch healthcare system of managed competition, health insurers can contract healthcare providers selectively. Enrollees who choose a health insurance policy with restrictive conditions will have to make a co-payment if they consult a non-contracted provider. This study aims to gain insight into enrollees' awareness of the conditions of such health insurance policies.MethodsIn August 2020, an online questionnaire was sent out via health insurers to their enrollees with restrictive health plans. In total 13,588 enrollees responded.ResultsOne fifth of the respondents appeared to be totally unfamiliar with the policy conditions. Men, younger people, people with a low level of education, a lower income, a poorer health status and non-care users were found to be less familiar with the conditions. Of those who have been in the situation that they wanted to visit a healthcare provider whose care was not fully reimbursed, 62% went to that provider. Of those who had to pay extra because hospital care was not fully reimbursed, 62% did not know this in advance and 30% indicated that paying extra was a serious problem.ConclusionsNot all enrollees who choose a policy with restrictive conditions are aware of the consequences of receiving care from non-contracted providers. Increased awareness among enrollees will benefit the functioning of the healthcare system based on managed competition.     

Materiel managers: survival under managed care

Managed care by healthcare providers is becoming the method of choice for controlling costs. Insurance companies, employers, employees as well as healthcare providers are all doing what they can to understand and practice economical managed care. With financial systems that reimburse healthcare providers now moving to a capitated approach, providers need to get away from a cost-plus mentality. More than ever materiel managers need to realize that providers are moving from revenue to expense accounting. Under capitation many, if not all, of management philosophy must change to compete in the new healthcare delivery environment.     

Managed Care and Gender Disparities in Problematic Health Care Experiences

Objective. To determine whether gender differences in reports of problematic health care experiences are associated with characteristics of managed care.
Data Sources. The 2002 Yale Consumer Experiences Survey ( N =5,000), a nationally representative sample of persons over 18 years of age with private health insurance, Interstudy Competitive Edge HMO Industry Report 2001, Area Resource File 2002, and the American Hospital Association Annual Survey of Hospitals 2002.
Study Design. Independent and interactive effects of gender and managed care on reports of problematic health care experiences were modeled using weighted multivariate logistic regression.
Principal Findings. Women were significantly more likely to report problems with their health care compared with men, even after controlling for gendered differences in expectations about medical care. Gender disparities in problem reporting were larger in plans that used certain managed care techniques, but smaller in plans using other methods. Some health plan managed care practices, including closed networks of providers and gatekeepers to specialty care, were associated with greater problem reporting among women, while others, such as requirements for primary care providers, were associated with greater problem reporting among men. Markets with higher HMO competition and penetration were associated with greater problem reporting among women, but reduced problem reporting among men. Women reported more problems in states that had enacted regulations governing access to OB/GYNs, while men reported more problems in states with regulations allowing specialists to act as primary care providers in health plans.
Conclusions. There are nontrivial gender disparities in reports of problematic health care experiences. The differential consequences of managed care at both the plan and market levels explain a portion of these gender disparities in problem reporting.     

Effects of decentralisation and health system reform on health workforce and quality‐of‐care in Indonesia, 1993–2007

The impact of decentralisation, socioeconomic changes and healthcare reforms in Indonesia on type and distribution of healthcare providers and quality‐of‐care has been unclear. We examined workforce trends for healthcare facilities from 1993 to 2007 using the Indonesian Family Life Surveys. Each included a sample of public and private healthcare facilities, used standardised interviews for numbers and composition of staffing, and quality‐of‐care vignettes. There was an increase in multiprovider facilities and shift in profile of solo providers—increasing proportions of midwives and drop in doctors in rural areas (including facilities with doctors) and nurses in urban areas. Quality‐of‐care scores were low, particularly for nurses as solo providers. Despite increased numbers of healthcare workers and growth of the private sector, outer Java‐Bali and rural areas continued to be disadvantaged in workforce capacity and quality‐of‐care. The results have implications for accreditation and in‐service training requirements, the legal status of nurses and private sector regulation. Copyright © 2014 John Wiley & Sons, Ltd.     

On the "efficiency" of managed care plans.

The claim that managed care plans are more efficient than fee-for-service plans has been made so often that it has reached the status of folklore, but the evidence is inconclusive. The claim is usually based on one or both of the following errors: (1) lower medical care costs mean lower total costs (medical plus administrative costs) and (2) lower HMO premiums mean HMOs are more efficient than fee-for-service plans. The first assertion ignores evidence indicating that managed care has driven up administrative costs for both insurers and providers. The second ignores evidence that managed care plans have numerous methods of shifting costs that are unavailable or less available to fee-for-service plans. The lull in health care inflation during the mid-1990s is often cited as evidence that managed care is efficient. But the lull may have been caused not by the spread of managed care but by the near-simultaneous occurrence of four events: a downturn in the insurance underwriting cycle, the 1990-1991 recession, endorsement of managed competition by numerous politicians, and the merger fever triggered by those endorsements.