Managed care does not involve an entity, rather a wider category that involves various healthcare delivery practices and structures, physician incentives as well as the developed relationship with physicians. Even though managed care structure undergoes the challenge of avoiding conflicts of interest hence leading to under-treatment, others are more challenged compared to some. Whether the MCO minimizes physician conflicts of interest depends on the manner in which they are organized and financed, the degree of physician involvement in managing patient care quality as well as the nature of the incentives used in controlling costs. The structure of managed care that currently works best in preventing understatement is one that is nonprofit and has a large salaried physician group that manages the clinical aspect of the provision of healthcare services.
Most authors have suggested that traditional clinical ethics structure does not fully accomplish organizational situations that are formed by the managed care system. Managed care controls healthcare access for both individuals as well as groups. Due to this power, it has a responsibility of using resources appropriately, protecting the interest of the community, and assuring the quality of clinical practices. The Ethical Force Program (EFP) realized five core qualities of clinical practices that mark an ethically sensitive “benefits package” (Nembhard, & Edmondson, 2006). Such a package has to be considered transparent, consistent, equitable and sensitive to value as well as compassionate in its formation.
Using this as a point of beginning DeCamp, Farber, Torke, George, Berger, Keirns, & Kaldjian, (2014) conducted an additional survey on the improvement of fairness in covering decisions. In a similar context, Allen Buchanan provides discussion on the core elements of procedural justice in the context of managed care that uses techniques of rationing to serve best the interest of controlled society and population while avoiding injustice to people. The core competencies include publicity of regulations; accessible, fair and timely protocols; nondiscrimination; impalpability and publicity of justifications of those rules for appeals of denials of coverage.
While countries with national health services may be better in controlling financial conflicts of interest for physicians, in the USA free-for-service medicine has been placed by management care and both models provide opportunities for conflicts of interest. Free for service medicine can provide an incentive for over-treatment and managed care risks providing incentives to under-treatment. One of the primary criticisms aimed towards the risk-sharing financial incentive in reducing utilization introduced by some managed care contracts involves creating a conflict of interties for the contracting providers, between their professional concerns for the bests of interest of the patient and their financial advantage. Conflicts of interests need to be identified, disclosed to all the affected parties and in other cases may as well lead to the need of withdrawing from events.
Organizations face a conflict of interest and conflicts of commitment as well. One of the criticism most frequently made of for-profit managed care is that the obligation to serve the patient, conductive and defamatory of the social institutions of the care, is in possible conflict with the necessity of ensuring profits for investors. Current legal structure in the United States creates an additional complication. Managed care organizations have a purposeful commitment to their financial survival as well as the care of patients of the providers with whom they contract. However, unlike individual physicians, most structures are sheltered in the provision of various procedures.
The goal-orientation of healthcare systems accounts for their normative dimensions. As has been argued extensively, organizations, as well as individuals, are challenged with the purpose as well as aims of carrying with them moral obligations (Werhane, 2003). While it is less transparent that structures too are moral agents of some sort, there is the fact that the structure, interrelationship, and goals of particular structure system reduce results that have normative consequences. An alteration of a particular system or part of that system will often produce different kinds of outcome. A system is comprised of an asset of network relations that involve patients. Therefore, a system is developed from relationships between people. The way that the system is formed and is an operation, however, affects and is affected by individuals. The operations and characters of particular systems or set of systems affected by people who come into contact with the system either patients, the community, professional, managers or insurers. Systematic arrangements, however, crate roles and responsibilities, rights, and opportunities that affect activities and performance.
Traditionally, managed care goals have been based on improving access, preventing diseases, promoting health and containing costs. MCO goals, however, should not be focused mainly on controlling provider’s practices and on return costs. Without consideration of the ethical underpinnings, managed care may not resolve policy dilemmas of justice may adversely affect the quality and may not reduce costs in the long run. The ethical constraints in managed care result in specific benefits and burdens to all parties in the relationship. The benefits of patients in MCOs are considered substantial. Even though MCOs differ in structure as well as function, the philosophy of managed care discourages overtreatment, encourages general preventive care and attempts to promote both cost containment and quality health care delivery. MCOs combine the financing and delivery of health services, provide service at a discount and minimize paperwork. In one study, the quantity and quality if ambulatory care of the HMO patients was judged equally to or better than that of fee-for-service patients.
There are, however, specific burdens for managed care patients. Given the traditional focus on the individual patient, MCO emphasis on group benefit may seem utilitarian and even impersonal. Some patients receive incomplete or incomprehensible information when an MCO plan is provided or advertised. Restrictions on care are de-emphasized, and patients must at least consider scrutinizing both payer and physician. Patients may no longer be in a position to trust a physician to have their best interests at heart, as physicians do not serve just one master. These and other practical access particular questions arise about autonomy and the patient’s ability to access providers and services that might not be covered by MCO structure.
In conclusion, it is apparent however that managed care as a subjective study, is a rapid moving target. Patients, however, or members of the MCO have the responsibility of ensuring operation of an organization is conducted at various levels. Subscribers have their opportunity of receiving full discloser from the health plan concerning incentives in limiting treatment and any restriction on coverage. MCOs, on the other hand, are faced with the responsibility of ensuring a mechanism to include health plan members in a discussion of benefit coverage as well as conflict resolution issues. In the same line, authors suggest that education and communication are essential elements of both ethical structure and increase in patient understanding, participation and satisfaction in a beneficially managed healthcare system.
References
DeCamp, M., Farber, N. J., Torke, A. M., George, M., Berger, Z., Keirns, C. C., & Kaldjian, L. C. (2014). Ethical challenges for accountable care organizations: A structured review. Journal of general internal medicine,29(10), 1392-1399.
Werhane, P. H. (2003). Business Ethics, Organization Ethics and Systems Ethics for Health Care. Philosophy and Medicine, 79, 73-98.
Nembhard, I. M., & Edmondson, A. C. (2006). Making it safe: The effects of leader inclusiveness and professional status on psychological safety and improvement efforts in health care teams. Journal of Organizational Behavior, 27(7), 941-966.
