General hospital psychiatry and the ethics of managed care

El SEVIFR

General Hospital Managed Care

Psychiatrv

and the Ethics of

James E. Sabin, M.D. AbstraCf: Managed care programs come in many stripes, and the field is evolving with bewildering rapidity. In order to be effective adzxxates and critics, clinicians needa vision of ethical managed care practice, to use as a standard for judgment and quality improvement. This paper presents four principles that 1 believe capture the essential stance of an ethical clinician in managed cure. The central challenge for creatingethicalmanagedcaresystemsis integratingstewardship(communitarian) and fiduciary (patient centered)values.Because generalhospital psychiatriststreat individual patientsin a “communal” (institutional) settingin which issues of resource usestandout with great clarity, they will play a central role in developing ethicalguidelinesfor managedcarepractice.This paper considers issuesin general hospital psychiatric practicedetermininghospitallength of stay, decidinghow muchsuicidalrisk is tolerablein a treatmentplan, and theproblems that arisewhen patientsprefer valid but lesscost-effectivetreatments-as examplesof the kindsof questionsa clinically relevant setof ethicsmustaddress.

Introduction

ductive. It confuses the question of whether managed care puts money ahead of patient care values, which would be unethical, with the question of whether managed care puts appropriate concern about money alongside of patient care values, which I believe is mandatory for. ethical practice. The erroneous conclusion that managed care by its inherent structure cannot be ethical distracts those who hold it from the difficult, vital, but relatively unexplored issue of how to conduct managed care in an ethical manner. In this paper, after presenting what I regard as the overall framework for ethical managed care practice, I briefly consider some examples of ethical issues that arise at the interface of general hospital psychiatry and managed care.

An Ethical Framework Managed Care

for

At virtually every workshop and lecture 1 have presented on the ethics of managed care, at least one participant-generally with the approbation of much of the audience--argues that the topic itself is an oxymoron. Managed care, the argument goes, is inherently unethical because its concern about the financial bottom line subverts health care’s fundamental commitment to the welfare of the patient. This perspective on managed care, though understandable as an affectively driven response to disruptive, wrenching, and chaotic change, is fundamentally confused and therefore counterpro-

I have argued elsewhere that ethical clinicians practicing in managed care settings espouse four principles to supplement the codes of ethics already established by the mental health professions [l]. These principles, presented (adapted slightly) as assertions but which need to be debated, improved, and-l believe-adopted, have significant implications for general hospital psychiatry.

Harvard Community Health Plan, Boston, Massachusetts Address reprint requests to: James E. Sabin, M.D., Harvard Community Health Plan, 126 Brookline Avenue, Boston, MA 02215.

When health care is structured between patient and clinician,

General Hospital Psychiatry 17, 293-298, 1995 Q 1995 Elsevier Science Inc. 6.55 Avenue of the Americas, New York, NY 10010

Principle #I: Ethical Clinicians Should Dedicate ThemseZvesto Caring for Their Patients in a Relationship of Fidelity, and at the Same Time to Acting as Stewards of Society’s Resources

tient with

no involvement

as a 1:l transactian paid for by the paof collective

(third

293 ISSN0163-8X3/95/$9.50

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J. E. Sabin party) funds, as is often the case in outpatient psychotherapy, the clinician can closely approximate a position of unalloyed fiduciary devotion to the patient. General hospital psychiatry, however, unlike outpatient psychotherapy, virtually always involves third party funds. When third parties pay for treatment, clinicians are at one and the same time 1) caring for patients and 2) spending the money of all those who have pooled their funds through taxes or insurance premiums to provide for care. In Hippocrates’ era, health care consisted of a series of 1:l contracts between individuals and their doctors, and the Hippocratic ethic appropriately focused on that dyad. A system funded by third-party resources, however, requires a different social compact for clinicians, patients, and health care organizations. The Preamble to the American Medical Association Principles of Medical Ethics, which form the basis of the American Psychiatric Association (APA) ethical code [2], provides the potential basis for a moral vision that would include some form of balance between patient-centered (fidelity) and communitarian (stewardship) ethics: As a member of this profession, a physician must recognize responsibility not only to patients, but also to society (emphasis added), to other health professionals, and to self. Unfortunately, although Morreim [3] has offered an excellent book-length discussion of how medical ethics can incorporate stewardship as well as fiduciary values, neither the APA code nor the associated opinions of the APA Ethics Committee [4] provide any clarification of the responsibility that the psychiatrist--qua psychiatrist-bears towards society. Though I have elsewhere tried to explicate some of the practical implications of a communitarian medical ethic for psychiatric education [5] and clinical care [6], the major work remains to be done. Because general hospital psychiatrists work in settings in which the reality of limited resourcesin the form of DRGs, competition for intensivecare beds, and so forth-is easy to see and understand, they generally recognize that by practicing in a cost-attentive manner they enhance the total benefit that can be rendered to identifiable patients and programs. Thus, general hospital psychiatrists are likely to agree that they cannot care about patients without caring about money as well [q. In all areas of health care there are many clinical situations in which individual clinicians have

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strong beliefs about the “right” way to practice, but for which panels of experienced clinicians and health service researchers would see a range of equally plausible paths to the desired clinical outcome. The ethics of managed care gives very clear guidance for how to proceed in these circumstances, discussed under the next heading.

Principle #2: Ethical Clinicians Should Recommend the Least Costly Treatment Alternative Unless They Have Substantial Evidence That a More Costly intervention IS Likely to Yield a Superior Outcome When an intervention is very costly and the likelihood that it will provide significantly more benefit than a less expensive alternative is small (e.g., five times a week psychoanalysis instead of more focal but responsible psychotherapy), it is easy to defend the less costly approach as the ethical choice. In the United Kingdom, where citizens levy taxes on themselves to support a national health service for the entire population, the relationship among societal resources, parsimonious practice patterns, and patient welfare is much clearer than in the United States. Interestingly, the British Medical Association uses examples from hospital practice to explain why physicians have a positive “ethical duty” to use the least costly option that can be expected to achieve the clinical objectives: Finite resources can never match potentially infinite demands or expectations. The inevitable consequence is that a decision to allocate a particular sum to a particular service will produce underfunding of another service. This will result in a number of possible outcomes (e.g., ward closure/staff reductions/ increased waiting lists) all of which may increase morbidity . . . [consequently] it is the doctor’sethical duty to usethe mosteconomicand efficacioustreatment available[8] (emphasis added).

The third principle reflects the fact that the checks and balances of our complex system need clinicians to influence the ethical quality of organizations and managed care programs, by acting as advocates for “health system and organization ethics” [9] as well as “individual patient ethics.” General hospital psychiatrists will see this need because their practice can only occur within and through complex organizations and systems. In many hospitals, ethics committees take an active role in developing clinical and administrative pol-

Psychiatry and the Ethics of Managed C’are icies, and provide cacy.

an important

venue for advo-

Principle #3: In Their Stewardship Role Ethical Clinicians Need to Advocate for Justice in Their

Organizations and the Health Care System, Just As in Their Clinical Role They Need to Advocate for the Welfare of Their Patients Finally, although rationing is still a taboo subject in American political dialogue, most thoughtful observers of health care acknowledge that rationing is inevitable, and the truly honest admit that rationing already occurs, largely on the basis of limited access to health care for segments of the population. A realistic ethic for managed care needs to anticipate the possibility of rationing as official national policy.

Principle #4: Ethical Clinicians Insist That Potentially Beneficial Interventions Should Only Be Withheld on the Basis of Fair and Explicit Guidelines Which Have Been Established With Participation of the Affected Populations and Which are Acknowledged with lndividual Patients or Their Surrogates If and when rationing becomes an acknowledged national policy, general hospital psychiatrists will encounter rationing issues every day because hospital-based treatment is the costliest component of health care and would represent an obvious focus for rationing. Principle #4 acknowledges that rationing is not inherently unethical if it is based on explicit guidelines, has been agreed to by the affected population, is distributed fairly within that population, and is acknowledged with the patient in the clinical situation itself.

Ethical Issues in Determining Length of Stay

Hospital

Because hospital costs form such a substantial percentage of total health care expenditures, reducing length of stay is perhaps the single most popular cost containment strategy. Not surprisingly, the commonest complaint psychiatrists bring to the APA managed care hotline is conflict with managed care companies about length of stay. Taking the role of the hospital for patients with whom suicidality is a major issue as a case example for considering ethical issues in determining length of

stay, it is useful to distinguish three ethical concerns that arise in these determinations

Risk Though hospitalization does not eliminate suicide risk, acutely suicidal patients are safer in the hospital under observation, monitoring, and active treatment. No managed care program would deny hospital coverage for patients with acute suicidal intent accompanied by a plan, available means, clinical depression, and a history of suicidal acts. On the other hand, hospitalizing all patients who entertain the idea of suicide might 1) cause harmful regression for some patients, 2) produce little or no benefit for many, perhaps the vast majority, and 3) create unacceptable levels of expenditure. How do we chart an ethical course between excessive risk and excessive cost? In insurance language, the standard answer to this question is that length of stay should be determined by “medical necessity.” Unfortunately, this answer obfuscates more than it clarifies. Calling a treatment “medically necessary” is a shorthand way of saying that it is a necessary means for achieving an agreed upon end [lo]. In our example, determining the degree of suicidal risk that is actually present and the degree to which it will be reduced by continued hospital treatment (means) is a judgment about clinical facts. Determining how much risk is acceptable (ends), by contrast, is a judgment about value. Values cannot be derived from facts. In principle, the values that guide this kind of decision should be set by the population that pools its collective funds to pay for care. As a nation, however, we have barely begun a process of public dialogue about the limits we as a people are prepared to accept wtih regard to health care outcomes and the priorities we want to apply. Thus, neither general hospital psychiatrists nor the utili-zation managers they encounter at the other end of an 800 number have publicly sanctioned guidelines regarding the framework of values within which to interpret the clinical facts regarding suicidal@ and make the judgment about length of stay. In the long run we clinicians need society to help us establish a framework of values for decisions that involve questions such as how much risk is acceptable. To anyone who tells us that no suicidal risk whatsoever can knowingly be allowed, we might choose to reply, “Then we will have to put

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the entire population into four-point restraints, since that is the only way to eliminate absolutely all risk of suicide.” For the present, as individual clinicians we need to make sensible decisions on a day-to-day basis, but collegially we need to encourage a form of open consideration of values our political leadership has largely avoided. In the absence of an explicit ethical framework for considering risk in determining length of stay, I have applied some common sense precepts in my own managed care practice. I am prepared to discharge patients who may still be considering suicide as a probable event in their lives if that “probability” does not include immediate urgency, which in practical terms means that the potentially dischargable patient has no suicidal intent within the next 64%week period. I anticipate and plan for intensive treatment during that period and include explicit discussion of risk, how we will monitor it and how we will respond. In conducting the treatment, I pay special attention to the important recommendation of Gutheil et al. [ll] that we find clinically appropriate ways of sharing the uncertainties inevitably present in the treatment plan with patient and family.

Family Responsibility Judgment about readiness for discharge involves assessment of the patient’s environment as well as assessment of the patient. Some families are highly skillful at handling a suicidal family member and eager to have the patient at home. Other families might be comparably skillful but reluctant to facilitate discharge by taking time away from work or cancelling a previously planned vacation. When family members prevent an otherwise potentially prudent discharge by their reluctance to extend themselves to make the home environment safe, the managed care company, representing those whose insurance premiums create the pool of funds available for care, will often not want to “subsidize” the family’s position by paying for an extended hospital stay. Situations like this put the hospital psychiatrist squarely in the middle of a conflict between family and communal interests. The best approach to the ethical dilemma of adjudicating among reasonable expectations of the family, of the insurance program, and of the hospital is early and vigorous work with the family around attitudes, family and insurer expectations, and plans for the discharge process. On occasion, psychiatrists will find them-

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selves in the uncomfortable position of having to articulate values regarding family responsibilities that should ideally be part of a wider public dialogue about our shared expectations regarding individual, family, and societal responsibility in health care. An example of locutions on the subject is: “There is a wide range of opinion about how much responsibility families should have for participating in the treatment of family members, but insurance expects that when a patient is otherwise ready to leave the hospital, the family will help make the discharge possible . . . .” As the issue of family responsibility and participation needs to be addressed with every hospitalized patient with a family, it should not emerge as an unanticipated crisis when a utilization reviewer refuses to certify further hospital care.

Responsibility for Providing a Spectrum of Care Utilization reviewers and hospital-based psychiatrists can come into conflict when a patient could have prudently been discharged from the hospital if resources such as intensive outpatient treatment, day hospital care, or clinical home visits had been available. Who should pay for hospital care made “medically necessary” by the absence of resources that would otherwise make discharge feasible? When systems that combine clinical and financial responsibility-e.g., staff and group model HMOs or the national health service in Englandrecognize an opportunity to maintain or increase quality while decreasing cost, as by creating good alternatives to hospital care, they do so. When clinical and financial responsibility is split, as in systems that rely on third-party utilization review, insurers and clinical providers need to develop ways of collaborating. Thus, a wise managed care insurer coming to a new area in which it believes hospital length of stay has been longer than needed will meet with potential network providers to plan for an improved spectrum of care before its reviewers start to deny coverage for hospital care on the basis of potentially feasible discharge. In the same situation, comparably wise general hospital psychiatry programs will initiate similar discussions to explore the fit between their clinical philosophy and spectrum of services and the payer’s expectations. Fiduciary and stewardship values obligate insurance managers and care providers to collaborate in creating a responsible, cost-effective spectrum of care. When these conditions prevail, responsible in-

Psychiatry

surers will not refuse to certify further hospital care when a specific component of a spectrum is not yet available. Likewise, responsible general hospital clinicians will participate actively in creating the needed spectrum.

Ethical Issues Involving Patient Preferences By the mid-1990s a strong clinical, ethical, and legal consensus has emerged that says competent patients are entitled to decline treatment recommendations in accord with their own preferences. Managed care supports this consensus, since “treatment” given against the wishes of a competent patient is doubly unethical; it disrespects the patient as a person and it wastes resources that could be used for the benefit of others by covering an unwanted “treatment.” But what about situations where the patient’s preference is for a mode of treatment judged to be less cost-effective than the recommended alternative? When the alternatives are similar in terms of characteristics such as intrusiveness on the patient’s body and side effects-as would be the case, for example, with cognitive-behavioral as opposed to psychodynamic psychotherapy for depression or anxiety--clinicians may not experience significant ethical strain if one is covered and the other is not. But what if the mode judged to be cost-effective is electroconvulsive therapy (ECT) but the patient strongly prefers potentially effective but more costly and less likely to succeed psychotherapy? Here the clinician is likelier to feel disturbed on ethical grounds. On the one hand, insisting that insurance will only cover a physically intrusive and (for many) frightening treatment such as ECT goes against the dominant values of our consumer and choice-oriented society. However, expecting third parties to subsidize more expensive preferences, especially when those preferences have less likelihood of producing the desired result, would appear to give sanction to the patient to “hijack” collective resources. This dilemma is solvable in principle by allowing the patient to apply the payment that would have been available for the recommended, less costly approach to a mode the patient prefers, but expecting the patient to be responsible for the differential cost. Here the evolution of managed care programs to allow more consumer choice, as by pointof-service plans in which the patients can choose

and the Ethics of Managed Care

to go outside of the network at an incremental cost to themselves, can help the clinician resolve the ethical dilemma. The fact that less affluent patients will have fewer choices raises a series of different ethical issues as does the same circumstance with regard to choices about education and housing. Society might choose to increase individual choice by providing additional resources to needy individuals, as might occur with scholarships at private colleges. Unless the employees who pay insurance premiums or the taxpayers who pay for public programs elect to subsidize more expensive preferences, it is ethical for insurers to pay no more than required for the most cost-effective alternative as long as forms of flexibility such as going outside of the network at one‘s expense for incremental costs are also available.

Conclusion American culture, for better and for worse, worships technical solutions to problems and prefers quick fixes. Rather than confronting the painful, difficult, but unavoidable question of what principles to apply in allocating our substantial but limited resources, politicians prefer to pretend that by managing care prudently “we can have it all as long as we get the flow charts and systems theory right” [ 121. General hospital psychiatrists, like other clinicians, know from daily experience that society cannot have it all. Managed care companies have been asked to bear this message to the population. Clinicians are and should be highly concerned with the relationship between treatment planned with realistic recognition of limited resources and the malpractice system. It is all too easy to imagine a plaintiff’s att orney asking-in a tone of stunned incredulity-“Doctor, are you telling us that you discharged your patient even though you knew that letting him leave the hospital increased the risk that he would die by suicide?” But recognizing the inevitable impact of the liability system on clinician behavior has no bearing on defining the right or ethical course of action. When our society engages more openly with the question of how to manage a health care system that cannot do all things for all people in the most ethical manner, we will be more able to insist that our liability system be changed to support ethical conduct. Because mental health clinicians are especially well trained in understanding complex systems issues, confronting denial, and articulating unstated

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J. E. Sabin conflicts in ways that foster constructive problem solving, we can play an important role in helping individuals, organizations, and our society come to grips with the ethical issues that arise in applying an ethics that respects both fiduciary and stewardship values. Because their location in the health care system puts them close to many of the most difficult ethical issues-such as how much risk we are prepared to tolerate, what kinds of responsibility families can be expected to take, and how much scope to give an individual preference for valid but less cost-effective modes of treatmentgeneral hospital psychiatrists can expect to be at the center of clinical-ethical inquiry for the rest of the century and beyond. 7’he author Foundation

wishes to thank the Harvard for its generous support.

Community

Health

Plan

References 1. Sabin JE: A credo for ethical managed care in mental health practice. Hosp Commun Psychiatry 45859 860, 1994 2. American Psychiatric Association: The Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association Press, 1993

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3. Morreim EH: Balancing Act: The New Medical Ethics of Medicine’s New Economics. Dordrecht, Kluwer Academic Publishers, 1991 4. American Psychiatric Association: Opinions of the Ethics Committee on the Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry. Washington, DC, American Psychiatric Association Press, 1993 5. Sabin JE: The moral myopia of academic psychiatry: a response to Glen 0. Gabbard’s “The Big Chill.” Acad Psychiatry 17:175-179, 1993 6. Sabin JE: The therapeutic alliance in managed care mental health practice. J Psychother Pratt Res 1:2936, 1992 7. Sabin JE: Caring about patients and caring about money: the American Psychiatric Association code of ethics meets managed care. Behav Sci Law 12: 317-330, 1994 8. British Medical Association: Philosophy and Practice of Medical Ethics. London, British Medical Association Press, 1988 9. Reiser SJ: The ethical life of health care organizations. Hastings Cent Rep 24(6):2835, 1994 10. Sabin JE, Daniels N: Determining “medical necessity” in mental health practice. Hastings Cent Rep 24(6):5-13, 1994 11. Gutheil TG, Bursztajn H, Brodsky A: Malpractice prevention through the sharing of uncertainty: informed consent and the therapeutic alliance. N Engl J Med 311:49-51, 1985 12. Gaylin W: Faulty Diagnosis. New York Times, June 12, 1994, p A41