Philosophic Ruminations and Personal Interviews

[By Render S. Davis; MHA, CHE]

Crawford Long Hospital at Emory University

Atlanta Georgia USA

For more than 2000 years, the principle of beneficence, the profession’s obligation to be of service to others, was the foundation of the practice of medicine.

In taking the Hippocratic Oath, physicians swore that they would “perform their art solely for the cure of patients,” and patients viewed their doctors as wise, caring, and paternalistic healers unwaveringly committed to their welfare.

Until the era of modern medicine dawned in the early Twentieth Century, sincere caring and compassionate service probably were the most effective instruments in the physician’s meager armamentarium.

Post WWII Period

World War II and the decades that followed saw an unprecedented explosion in medical knowledge and technology. As a direct consequence, physicians were called upon to become increasingly sophisticated technicians and specialists, demands that pulled them farther from the bedside and diminished the close, personal relationship with patients they once enjoyed.

This increasingly impersonal relationship, combined with the starkness and technically intimidating nature of hospitals, led to a dramatic shift in the traditional patient-physician relationship. No longer did the patient see the family doctor as the caring paternalistic figure that held his or her interests foremost.  Instead, an overwhelming array of specialists appeared before the patient to explore illness etiology or examine a particular body part – too often appearing more interested in the malady than in the person afflicted with it.

The Lost Covenant

The covenant of trust that once bonded the physician and patient was rapidly eroding and, amid the social turmoil of the 1960s, patients began to demand that physicians treat them as equal partners, both informing them of the nature of their disease and seeking their permission to initiate treatment. After all patients reasoned, they should have the final say regarding what was done to their own bodies. 

Consequently, the principle of respect for autonomy, an acknowledgment of an individual’s right to self determination, slowly took precedence over, but did not eclipse, beneficence. Physicians still cared for their patients, only now they were obligated to take extra steps to bring patients directly into the decision-making process by explaining treatment options and requesting “informed consent” on the plan of care from the patient

Impending Economic Disaster

Both principles were supported in the prevailing system of fee-for-service, private-practice medicine.  There were few constraints on physicians’ clinical autonomy and their professional judgment remained, for the most part, unquestioned. In this climate, physicians reasoned that patients would likely benefit from more tests and procedures; patients, especially the well insured, demanded almost unregulated autonomy over their health care choices. For those with the means to pay, access to nearly all that medicine had to offer was considered an unquestioned right.

This proved to be a formula for potential economic disaster. There was an explosion in new and expanded facilities and unwavering demand for the latest technological innovations, much of it supported by the government as vital to a healthy economy. Nonetheless, a fundamental problem existed because health care was being delivered in a financial vacuum, where both physicians and patients had only a vague understanding of, or interest in, the economic consequences of the services they felt either obligated to provide or entitled to receive.

Beneficence and Autonomy

Both beneficence and respect for autonomy could be invoked to support this nearly unbridled use of health care resources in the care and treatment of individual patients. 

Insurers, both private and governmental, paid “reasonable, usual and customary” charges, almost without argument; while as patients’ advocates, physicians could garner six-figure incomes from fees generated in providing virtually unlimited care.  

Inevitable Financial Fallout

Yet, the inevitable financial fallout from medicine guided by these laissez-faire rules eventually led to an unsustainable inflationary spiral in medical costs.

In the forty plus years following the passage of the Medicare Act in 1965, the health care sector of the American economy soared from 4% of Gross Domestic Product (GDP) to over 15-16% in 2008, and there is no clear end in sight to the upward rise.

Nevertheless, a growing number of Americans actually saw their access to medical care diminish due to rising costs of employer-paid insurance (when it was offered at all) and tightening restrictions in eligibility requirements for Medicaid and other government safety-net programs.  Even as the nation increased overall spending for medical care, many Americans were losing access to the system. 

This trend has continued, and even accelerated, during the recessionary period that has just begun. An especially troubling characteristic of the increasing number of Americans now without health insurance is that, for the first time, it includes expanding segments of the middle class – white collar executives, middle managers, and skilled workers who had, historically, been immune from such cutbacks. 

Today, lack of access to affordable medical care is no longer just the domain of the working poor. It is the purview of the middle class.

Sounding the Alarm

Alarm over rising health care costs began to spread in the 1970s, as both private and government payers sought any means possible to stem the hemorrhaging outflow of dollars.  President Richard Nixon tried unsuccessfully to implement wage and price controls to slow it; a few years later, President Jimmy Carter attempted to cap Medicare expenditures. Both efforts failed for two primary reasons.

First was a fundamental misunderstanding of the nature of healthcare competition. Health care providers did not compete directly for patients, but rather for physicians who held the legal authority to admit patients. As independent contractors, physicians could, for the most part choose to join the staff of institutions that provided the latest technology, the most-up-do-date facilities, and even the most luxurious amenities. Consequently, hospitals competed fiercely for doctors, a process that actually caused prices to rise, not fall.

Second, the dominant, indemnity-based, fee-for-service approach to medical care remained fundamentally intact, continuing to insulate both physicians (the consumer’s agent) and patients (consumers of care) from the true costs of the services provided. But economic concerns arising from double-digit inflation and business downturns in the late 1970s assured that fundamental and inevitable changes in the financing and practice of medicine were on the horizon. 

Cost Constraint Initiatives

The first major initiative to have a significant cost constraining effect occurred in the early 1980s with the implementation of the Medicare Prospective Payment System (PPS) and its healthcare provider payments pegged to Diagnosis Related Groups (DRGs); now Medical Severity-DRGs. This system ushered in a new era of controlled, predetermined prices for health care services. The inflationary spiral of government payments for health care slowed and soon private payers also were considering adopting alternatives to traditional insurance.  Slowly, the concept of prepaid, fixed or capitated managed health care provided by health maintenance organizations (HMOs), a concept developed by the Kaiser Foundation and other organizations on the West Coast in the 1940s (and first strongly opposed by organized medicine) began to spread nationwide as a possible answer to the country’s healthcare ills.

Enter the HMOs

By the 1990s, HMOs and other types of managed care organizations that provided integrated healthcare services and financing through insurance or other means, had gained a serious foothold and were in positions of dominance in American medical care.  The growth in the popularity of managed care signaled the next evolutionary change in the predominance of the key ethical principles.

Severing the Link 

Just as respect for autonomy super-ceded beneficence, the principle of justice, representing a new approach of balancing the health needs of an individual with the availability of finite resources for the larger population, rose to take its place as the primary principle, becoming the vanguard force driving the movement toward managed care. 

Physician-ethicist, John LaPuma M.D., in his book Managed Care Ethics, writes that managed care has gone so far as to “sever the link between autonomy and justice that once existed to support the care of individuals.”

Fairer Distribution       

Embedded within this drive toward a fairer distribution of healthcare resources was the urgent, but highly controversial desire to rein in costs. Despite years of active suppression and condemnation by health professionals and providers, the hard economic realities of American society’s love-hate (love to have it, hate to pay for it) relationship with health care had finally reached the bedside. The result has been an irrevocable sea-change in the landscape of American medicine.

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Developing Healthcare Delivery Skills for Modernity

As we have seen, medical practice today is vastly different from a generation ago, and physicians need new skills to be successful.  In order to balance their obligations to both individual patients and to larger groups of plan enrollees, physicians now must become more than competent clinicians.

Traditionally, the physician was viewed as the “captain of the ship,” in charge of nearly all the medical decisions, but this changed with the new dynamics of managed care.  Now, as noted previously, the physician’s role may be more akin to the ship’s navigator – or health economist allocator – utilizing his or her clinical skills and knowledge of the health care environment to chart the patient’s course through a confusing morass of insurance requirements, care choices, and regulations to achieve the best attainable outcome.  Some of these new skills include:  

• Negotiation – working to optimize the patient’s access to services and facilities beneficial to their treatment;
• Team Play – working in concert with other care givers, from generalist and specialist physicians to nurses and therapists, to coordinate the delivery of care within a clinically appropriate and cost-effective framework;
• Working within the limits of professional competence – avoiding the pitfalls of payer arrangements that may restrict access to specialty physicians and facilities, by clearly acknowledging when the symptoms or manifestations of a patient’s illness require this higher degree of service, then working on behalf of the patient to seek access to them.
• Respecting different cultures and values – inherent in the support of the Principle of Autonomy is acceptance of values that may differ from one’s own.  As the United States becomes a more culturally heterogeneous nation, health care providers are called upon to work within and respect the socio-cultural framework of patients and their families;
• Seeking clarity on what constitutes marginal care – within a system of finite resources, physicians will be called upon to carefully and openly communicate with patients regarding access to marginal and/or futile treatments.  Addressing the many needs of patients and families at the end of life will be an increasingly important challenge in both communications and delivery of appropriate, yet compassionate care. 
• Exercising decision-making flexibility – treatment algorithms and clinical pathways are extremely useful tools when used within their scope, but physicians must follow the case managed patient closely and have the authority to adjust the plan if clinical circumstances warrant. 

Re-Fostering Social Responsibility

The erosion of trust expressed by the public for the health care industry may only be reversed if those charged with working within or managing the system place community and patient interests before their own.

We must foster an ethical corporate culture within health care that rewards leaders with integrity and vision; leaders who encourage and expect ethical excellence from themselves and others; and who recognize that ethics establishes the moral framework for all organizational decision making.

Healthcare Ethics

In a presentation to the Health Care Ethics Consortium of Georgia, Dr. Paul Hoffman, vice president of Provenance Health Partners, spoke of the importance of nurturing and sustaining an “ethical organizational culture” where high standards of ethics and morality govern the behavior of all participants, from senior management and physicians, to nurses and technical staff. 

In such cultures, the ethical dimensions of decisions are weighed as heavily as the financial or operational factors and actions are not taken if the outcome would conflict with the organization’s stated values and mission.

To assess the climate of an organization, Hoffman recommends conducting an “ethics audit” that would reveal real and perceived problems within the system; provide insights into ethical deficits that may exist; identify opportunities for education; and provide feedback from staff on their support for the organization’s ethical culture.

Enterprise Wide Integration

Most importantly, Hoffman stressed that ethics must be integrated into every aspect of organizational work, calling for “a systems-oriented, proactive approach to improving an institution’s health care practices, including both administrative and clinical practices.” 

He went on to say that this “integrated ethics approach anticipates and responds to recurring ethical situations and applies a continuous quality improvement philosophy. This approach unites ethics activities throughout the organization.”  

Whether your workplace is a 500-bed academic medical center or a small internal medicine practice, the purpose is the same – to foster and maintain an organization that is grounded in ethical behavior and dedicated to providing the highest quality of patient care.  

Assessment

In an article published in the Journal of the American Medical Association [JAMA], authors Ezekiel Emanual, M.D. and Nancy Dubler, L.L.B. cited what they call the “Six C’s” of the ideal physician-patient relationship: Choice, Competence, Communications, Compassion, Continuity, and [no] Conflict of interest.  Physicians who accept a seventh and eighth “C” – the Challenge and Collaboration, and are imbued with the moral sensitivity embodied in their solemn oath, have an obligation to serve as the conscience of this new system dedicated toward caring for all Americans.

Writer and ethicist Emily Friedman said it best when she wrote,  

“There are many communities in health care. 

But three to which I hope we all belong are the communities devoted to improving the health of all around us, to achieving access to care for all, and to providing our services at a price that society can afford. 

These interests are, of course, expressions of the deeper community of values that states that healing, justice, and equality must guide what we believe and do”. 

Conclusion

While the above may not solve the current philosophical and economic crisis, or provided needed answers to the domestic health insurance quagmire, we believed the problem has been reframed for further discussion and frank discourse.

And so, please add to the needed debate with your informed thoughts, opinions and comments. All are greatly appreciated?

Acknowledgements

Partial excerpt, updated from the best selling book, with permission.

The Business of Medical Practice [Profit Maximizing Skills for Savvy Physicians]

© Springer Publishing, New York, NY 2005

http://www.springerpub.com/prod.aspx?prod_id=23759

Citations:

Back to Reform: Values, Markets, and the Healthcare System.  Dougherty, Charles J., Ph.D.  Oxford University Press, New York, 1989.

“Beyond Ethics Committees,” Hoffman, Paul, Dr. P.H. Presentation at the Annual Conference of the Health Care Ethics Consortium of Georgia, April 2, 2003.

“The Doctor as Double Agent”: Angell, Marcia, M.D.  Kennedy Institute of Ethics Journal, Vol. 3, No. 3, September 1993.

“Ethical Issues in Managed Care”:  Report from the American Medical Association’s Council on Ethical and Judicial Affairs.  JAMA, Vol. 273, No. 4, January 25, 1995.

“Ethical Issues in Managed Care”: Wicclair, Mark R., Ph.D.  Remarks at Fifth Annual Retreat of the Consortium Ethics Program, October 1995.

“Ethics of Managed Care”: Philip, Donald J., FACMPE.  Medical Group Management Journal, November – December 1997.

Ethics, Trust, and the Professions: Philosophical and Cultural Aspects.  Pelligrino, Edmund D., M.D., Veatch, Robert M., Ph.D., Langan, John P., S.J.  Georgetown University Press, Washington, D.C., 1991

“The End of Health Insurance – Part II” Brody, William R., M.D., Ph.D. Crossroads: Essays on Health Care in America, Johns Hopkins University School of Medicine, June 5, 2002.

“ER’s Cut Back as Patient Loads Rise,” Kellerman, Arthur, M.D. The Atlanta Journal-Constitution, June 5, 2003.

Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics, LaPuma, John, M.D.  Hatherleigh Press, New York, 1998.

“Managed Health Care: A Brief Glossary,” Integrated Healthcare Association, Pleasonton, CA, 1997.  Website: www.iha.org.

Medical Management Signature Series, Managed Care Resources, Inc. 1997.  Website: www.mcres.com).  Carefoote, Roberta L., R.N.:http://www.mcres.com.

Medicine At The Crossroads.  Konnor, Melvin, M.D., Vintage Books, New York, 1994.

“Poll: Health Advice Ignored,” Duffy, James A.  The Atlanta Journal-Constitution, November 20, 1998.

“Outside the Box”: Zwolak, Judith.  Tulane Medicine, September 1995.

“Preserving the Physician-Patient Relationship in the Era of Managed Care,” Emanual, Ezekiel J. M.D., Dubler, Nancy N., LL.B.  JAMA, Vol. 273, No. 4, January 25, 1995.

Principles of Biomedical Ethics:  Beauchamp, Thomas L., Ph.D., Childress, James F., Ph.D.  Oxford University Press, New York, 1989.

“Principles of Managed Healthcare”: Integrated Healthcare Association, 1997.  www.iha.org.

The Right Thing: Ten Years of Ethics Columns from The Healthcare Forum Journal.  Friedman, Emily.  Jossey-Bass Publishers, San Francisco, 1996

“Understand Guiding Principles When Mixing Business, Medicine,” LaPuma, John, M.D.  Managed Care Magazine, July 1998

“What Could Have Saved John Worthy?” The Hastings Center Report, Special Supplement, Vol. 28, No. 4, July-August 1998.

Personal Interviews:

Frank Brescia, M.D: Professor, Medical University of South Carolina, Charleston, SC.

Joseph DeGross, M.D: Professor, Mercer University School of Medicine, Macon, GA.

David DeRuyter, M.D: Pulmonologist, Atlanta, GA.

Daniel Russler, M.D: Vice President, HBOC, Inc., Atlanta, GA.

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