On Thursday I’ll be speaking at the Geisinger Clinic in Danville, PA on Comparative Effectiveness; the Payer’s ethical dilemma.
This is one of those ‘honored to be asked’, followed almost immediately by ‘I’ve a lot of work to do’ things. And a lot of work it indeed has been, but the deeper I’ve gotten into this, the more…gratifying it has become.
One example. In my research I came across Jim Sabin, MD. Dr Sabin, clinical professor in the departments of Population Medicine and Psychiatry at Harvard Medical School; he also directs the ethics program at Harvard Pilgrim Health Care and writes an excellent blog, Health Care Organizational Ethics.
Here’s a few of the things I’ve learned from Dr Sabin.
1. Harvard Pilgrim may be the only health insurer in the country that has an inhouse ethics program that includes members, employers, brokers, community members, administrators and physicians. (If there are others out there I’d love to hear about them)
2, This isn’t a program set up merely for PR; rather it has studied significant issues, taken tough stands, and been public about its role and results.
3. The issue of ethics in medical research on effectiveness has another dimension, one that I hadn’t thought thru or explored in enough detail – health plans and health systems can be and in many cases are ‘sites’ for research; there are several ethical issues inherent in that role, issues that involve informed consent, public involvement and education, funding sources and use of those funds, the balance of cost and effectiveness, and the potential impact on the physician-patient relationship inherent in many research efforts.
4. Perhaps the most helpful discussion was around the not for profit status of HPHC. As a not for profit, Harvard Pilgrim doesn’t have to deal with the primacy of stockholder returns inherent in the for profit world; that’s not to say it doesn’t have to ensure financial stability and long-term viability. The difference is in what’s most important – profits or patients.
The primacy of stockholder returns influences ethical and business decisions, or rather should. For profit companies must consider shareholder returns first and foremost; to do otherwise would be an ethical problem. There are for-profit health plans and insurers that work diligently to deliver services ethically and responsibly, bending over backwards to do the right thing. Aetna is one that comes first to mind. And there are others that don’t bend at all.
Which is ‘right’? A compelling argument could be made for either position.
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13
I would bet that hardly any insurance companies/ managed care organizations have ethics departments, or well-developed organizational ethics policies (see: http://hcrenewal.blogspot.com/2009/10/organisational-ethics-policies-primer.html).
I would also bet that few other health care organizations of many types (e.g., pharmaceutical companies, biotech companies, device companies, health care IT companies, etc) have such departments or policies.
I would further argue that most of the organizations that have ethics departments really have bioethics departments that deal with certain kinds of difficult clinical decisions (e.g., around end of life care), but not with the sorts of issues you discuss.
The big question is why?
One possible answer is that too many leaders in too many of these organizations might be made very uncomfortable by the sorts of discussions these departments might have.
An interesting question: why don’t non-profits, without the “constraint” of profitability, drive for-profits out of business? Of course, this question is interesting in all sectors. And, of course, the usual theory is that the profit motive drives innovation and efficiency better than philanthropic motives.
Personally, I have worked about equally for both not for profit and for profit organizations and didn’t notice any obvious difference in how concerned each one was about making a profit. I don’t recall the Blue Cross plans, for example, being vastly more ethical before they all converted to for profit status.
While on the for profit side of health care, we preferred to think of the distinction as being between ‘tax paying’ and ‘non tax paying’ organizations rather than for profit and not for profit.
Hamilton – welcome to MCM.
The issue – as I’ve come to understand it – is not so much about concern about making a profit or a plan becoming more or less ‘ethical’. There’s a good argument that for-profit status places an ethical requirement on management to consider profits first, as a corporation exists primarily to generate profits for shareholders.
To your point, there are plenty of examples of not for profit plans exhibiting what some would think of less than ethical behavior – Kaiser’s transplant fiasco springs to mind, as does the VA’s issue with incompetent surgeons.
not for profits aren’t ‘better’ or ‘worse’ than for profits; they should have different priorities.
Paduda
Ken – welcome to MCM.
I’d suggest one reason may be not for profits’ mission isn’t to dominate a space or market, but rather to serve their societal mission. There’s no question a for-profit mentality drives innovation, just as there’s no question the Veteran’s Administration has done a better job developing and implementing electronic health records than any for-profit entity.
I don’t think it’s that simple; there are many examples of not for profits driving innovation – from cooking and water projects in the third world to development of physical therapy guidelines in the Netherlands by a governmental body to Velcro to the NIH’s core role in pharmaceutical development.
Paduda
Thanks for the welcome! I’m eager to learn from your blog.
I agree that innovation comes from non-profits too.
But why, without having to worry about the profit motive, don’t they drive out the for-profit operators? Your suggestion is an interesting one: perhaps there aren’t enough people that want to run non-profits and those that do don’t want to “dominate a space”.
My guess is that the traditional explanation is the largest factor, but I certainly can’t prove that!