Introduce the issue.

This paper addresses many ethical and legal issues in the managed care. This paper checks managed care ethical implications along with offers recommendations, which would contribute towards the improved cost, quality along with access within the health care as per the ethical principles.

Managed care has been maligned because of the perceptions corning from the suspect business practices utilized to include costs along with weaknesses, which jeopardize patient privacy. Inherent competing goals of the containing costs, maintaining as well as promoting health, generating profit, making sure quality and also giving access have been the tangible problems directly impacting patient care. Intangible ethical issues, heart of health care delivery system, underlie those tangibles and also have been of paramount concern. Aligning managed care ethics having the biomedical ethics would reestablish the trust dependent physician patient relationship.

Like market dictates cost containment needs to set the system, it should be balanced against the patient welfare. Failure would outcome in the unstable health care system within 21st century. Managed care industry, dependent on the corporate principles focusing the cost reduction as well as profit maximization should develop the equally firm ethical foundation.

System provides several advantages in the health promotion as well as disease prevention, efficient delivery by the evidence dependent medicine and also providing the affordable care. Such advantages would be overshadowed through the unethical business practices.

Define the problem.

Ethics link goals of the quality, access along with cost within health care's iron triangle.

Like United States health care system redefines itself, ethical implications corning from competing goals of the cost containment, access as well as quality care delivery should be addressed. Managed care has huge potential for improving population's health by the clinical practice guidelines, making sure practice of the evidence dependent medicine, fostering research programs along with promoting health and also prevention programs. Those positive characteristics have been over shadowed through the concentration on bottom line vice patient welfare.

Search the literature.

Americans asked solutions to both curtail enhancing the health care costs along with diminish barriers towards access. Outcome has been managed care. Like business entities, managed care organizations (MCOs) make sure that effective use of the limited resources within concert having quality along with access imperatives. Theoretically, resources have been rationed as per the principle of the distributive justice. Whereas rationing has not been the ethical problem unto itself, ethics pertain towards value judgments utilized for setting the restrictions on the physician choice, authorized treatments along with diagnostics and also accessibility of the care [Har23] Disturbingly, providers and also patients perceive that industry focuses on profit motive vice patient motive within the health care delivery [Orr95].

Managed care organizations position themselves like the important links in continuum of care, 4 principle approaches towards the biomedical ethics [Bea94] has been germane towards the managed care: respect for the autonomy, non-maleficence, beneficence and also justice.

Patient physician relationship, heart of the medical ethics has usually been undercut through the managed care business practices [Deg99]. In the current American Medical Association (AMA) survey, 3 of 5 physicians described that the managed care negatively effects patient care quality. Number of plan enrollees enhanced substantially within last decade, prompting managed care organizations towards aggressively control costs through denying payment for the services, which both the patients along with their providers deemed compulsory. Public criticism about managed care intensifies like the media reports patient horror stories daily.

In American Hospital Association's (AHA) 1996 to 1998 study about the public's perception about hospitals, respondents described that patients may not have advocates, cost enhances have inversely been associated to the quality declines, along with health system corporatization conflicts with the health care being personal human service [Lar99]. Myriad public opinion polls show that America's faith within health care system has been eroding. Predominant trust has been that managed care organizations control physician decisions solely dependent on the profit motives, apart from of the patient impact.

Analyze problem.

Ethical Implications

Relationship within the provider's ethical nature along with decision makers' business nature has been highly divisive. Accusations abound that the care decisions have been dependent on bottom line when patient requirements have been secondary. Torn Atchison, Midwestern consulting company president, feels that providers have often been ethical. Closer we get to business side, which has been where problem of trust comes in decision makers have not often been motivated towards place patients first in similar manner [Lar99].

Providers have been forced to assume conflicting roles, patient advocate along with business manager, towards the bigger extent. Faced with competing goals of the patient welfare vs. bottom line, providers confront has increasingly been general ethical dilemma: must they expend the precious resources on the uninsured patients who have lesser hope of the survival. In shrinking fee for service market, treating sickest patients generated greater physician compensation.

Medically complicated patients drain resources having lesser recompense in capitulations [Slo98]. Providers along with administrators should consider many problems: allocation of the scarce resources on the patients having lower probability of the survival; evaluation of the treatments like financially justifiable; perceived main concern about the medical community having the bottom line. Physicians would not sacrifice our brand of heroism for sake of the economics.

Good ethics have been good business. There has been no reason why making best ethical decisions may not equal to best financial decisions describes, of Midwest Bioethics Center [Lar99]. Medical decisions should consider along with evaluate all the specific costs starting from the tangible financial costs towards the intangible ethical costs. Focusing on bottom line and also neglecting human dimension can generate the profit in shorter term.

Longer term cost has been tremendous: potential loss about patient trust, whereas inherent in both the fee for service along with prospective payment systems, financial conflicts about interests assumed potentially deadly dimensions [Fin97]. In fee for service, issues abounded while physicians ordered the unnecessary tests for generating the revenue. Conversely, in capitation, physicians retain revenue, which have not been spent treating patients.

Legal Implications

In the year 1999 Patients' Bill about Rights debate, ethical principle of non-maleficence catalyzed the intensified scrutiny about federal law's provision, which shields managed care organizations from the tort liability. When patient can to sue the physician who does something towards endanger his health, why has been patient barred to sue the managed care organizations while this does nothing through delaying care or the denying payment [Goo99].

Preemption provisions within Employment Retirement Income Security Act (ERISA) about year 1974 give such protective shield. Proposed legislation includes language, which would majorly abrogate ERISA preemption about state laws [Jor99], allowing patients to sue managed care organizations for the negligent along with wrongfully denied care.

Charrow and Greenlees describes that laws suffer from disease of the language. Managed care reform favors contend, which ERISA suffers from similar disease [Cha99]. ERISA safeguards employee advantages in the employer sponsored self-funded pension advantage plans. ERISA's provisions in regard to health advantages plans have been ambiguous along with offer sparse substantive information for the ethical management.

Health advantages have been grouped with the pension plans even if needs have been distinctly separate. Disregarding those differences, ERISA's preemption provision has been construed towards preempting the state tort law within malpractice claims filed against the health advantages plans [Jor99]. Capitalizing on the ambiguous language so as to what constitutes the health benefits plan, managed care organizations maintain immunity from the liability through discussing that they have extensions/components  of benefits plans.

United States Supreme Court's decisions in regard to the health care liability have failed to term the scope of preemption [Cha99]. As the outcome, low courts have been barred from awarding the remedies within the cases including delay of care/payment denial, which outcome in the patient injury or the death. Legal problems along with considerations abound beyond the tort liability. Enhanced issue for the medical record privacy would develop the fertile ground for upcoming litigation.

Offer possible solutions.

Ethical dilemma to preserve the right of the patients towards privacy when making sure medical information access has been about paramount issue. Right to privacy permeates soul of the American society. Even of Unites States Constitution may not include the particular privacy provision, Americans feels that the right towards privacy has not been only legally protected however fundamental. Apart from the medical records along with information, privacy has been the multidimensional, encompassing diverse legitimate and also ethical dimensions. United States Supreme Court Justice L.D. Brandeis eloquently described that right towards privacy has been right to be let alone.

In the managed care, right to privacy has been becoming obscure. Access towards the medical information has been justified for preserving common good along with health objectives being it contributes towards the cost containment as well as increase the medical research. But, emergent authorized abuse about the medical information should be countered. Like needs for the medical information enhances, agencies authorized to access the medical records have been expanding scope of the retrieval.

Managed care system needs the considerable details for making authorization decisions as well as advantages determinations, thus allowing agencies for accessing the patient's whole medical record. Information has been consolidated in the comprehensive profiles along with has been stored within the databases having the substantial links. As the outcome, patient information would no longer be maintained, accessed/originate having one institution. Apart from that, this would travel within agencies, additional compromising the patient privacy.

While medical information has been combined with the financial along with customer information for developing the aggregate profile, this develops potential for the substantial privacy intrusion. Profile has been lucrative towards marketers, who straightly advertise the products along with services to customers and also may be appreciably detrimental while employers utilize that in the adverse hiring/promotion processes. Whereas managed care organizations along with health agencies need medical information to make sure both access towards care and also expeditious reimbursement, they have been ethically obligated to safeguard the patient privacy.

Propose one solution.

Competing factors within the medical technology involve cost, necessity, ethics, and physician autonomy along with patient welfare. Like assumption in regard to the technology development has been that like technology evolves, costs diminishes because of the enhanced efficiencies. Medical technology, conversely, dispels theory. Like medical technology evolves, costs enhance. This, providers would continue towards confronting the competing needs for the state of the art diagnostic evaluation as well as cost containment.

Ethical decision making should be attained to reestablish America's trust within their health care system along with managed care. Making sure patient welfare, whereas pursuing the cost containment may be attained through applying the physician directed managed care.

Whereas administrators as well as businessmen have been the integral players in attaining the corporate objectives, clinicians, dependent on their oaths, owe primary loyalty towards patient.

The chief executive officer, who possesses the MD vice the MBA, provides the clinically dependent point of view that would facilitate the effective demand as well as disease management program design, patient compliance programs as well as effective use programs.

Cost cutting measures should be dependent on the ethical principles. Thus, managed care organizations should develop along with apply ethics policies same to medical profession. Ethics training programs should be applied in the entire industry, not only on clinical side.

Medicine has been the business. Same as rest of the industries, human being has been the product. Ethically dependent business practices should be in concert with biomedical principles, which focuses human aspect about health care: respect for the autonomy, non-maleficence, beneficence as well as justice.

Develop the implementation plan.

Several managed care plan executives focus on hiring just currently graduated physicians who have been more willing towards accepting newer corporate managed care culture as well as who fast become dependent on that. However culture of minimums usually conflicts with striving for the excellence. The optimal health delivery system should be patient responsive, give sufficient and also compassionate care, motivate physician excellence, being accessible, and diminish bureaucracy to the minimum, give humane treatment dependent on the scientific merit along with being accountable to patient.

1. Initially, like our patient's physician do right thing as well as do no harm.

2. Keeping our patient's rights as well as interests foremost.

3. Treating our patient like we could wish our family be treated.

4. Remember that we have been clinically responsible party. We would be held responsible for our decisions. When there has been the conflict within our patient's interest along with that of the 3rct party intermediary committed towards diminishing the costs, for instance, of tests, referrals, hospital days and many more being sure that course we choose has been medically appropriate proper and also defensible. There has been nothing wrong in safeguarding our patient's rights in most prudent along with cost efficient way. Danger lies within distortions about judgment, which have been caused through financial considerations. Where feasible, attempt towards working amicably and also effecting managed care organizations and when their constraints have been reasonable, complying with them. On the contrary, when we feel that they have not been reasonable, we must represent our patient's interests.

5. When conflict must happen within you along with managed care company or their intermediary like that our patient can be put at risk, appeal those decisions vigorously as well as repetitively. Discuss our dilemma with our patient describing advantages and disadvantages of every perspective and also eliciting feedback from him or her. When our patient rejects our advice favoring of managed care organization, ask managed care company to give another physician to care for patient. Document those facts carefully along with send proper confirmatory letters towards both patient as well as managed care company. Ask patient to sign the Against Medical Advice form that clearly describes our recommendations for the continued or rest of the treatment along with feasible consequences of the failure to gather treatment, which we recommend. Document managed care organizations role in affecting decision of our patient.

Justify why and how your solution will solve the identified problem.

Physicians have ultimately been responsible for its behavior with the patients. Like community standards remain yardstick through that care would be measured, clinicians have been very well advised, in which there has been disagreement, for seeking consultation with the peers, particularly requesting for its opinion of what treatment has been required and whether recommended treatment meets the community standards. Physicians many not follow the protocols that they believe might potentially injure its patients without risk towards their licenses.

References

• Beauchamp, T., & Childress, J. (1994). Morality and Moral Justification. In T.L. Beauchamp & J.F. Childress (Eds.) Principles of Biomedical Ethics, (p. 25-38). New York, NY: Oxford University Press.
• Charrow, R. P., & Greenlees, L. T. (1999). ERISA preemption: A law in search of a doctrine. Health Law Digest, 7(3), 3-16.
• Degnin, F. (1999). Between a rock and a hard place: Ethics in managed care and the physician- patient relationship. Managed Care Quarterly 1999; 7(2), 15-22.
• Finnerty, J. (1997). Ethical issues in managed care for the obstetrician and gynecologist. American Journal of Obstetrics and Gynecology, 308-315.
• Goodman, E. (1999). Patient's bill is excluding too many. San Antonio Express News.
• Harding, J. (1997). The ethics of managed care: Doing the right thing might take more than instinct. Postgraduate Medicine, 102(3), 15-17.
• Jordan, K. A. (1999). Tort liability for managed care: The weakening of ERISA's protective shield. Journal of Law, Medicine & Ethics, 25 , 160-179.
• Larson, L. (1999). The right thing to do: An ethical framework helps trustees lead the way. Trustee , 9-12.