Response by Dennis deLeon

Ethics Roundtable: When the Healthcare Plan Limits Care

Dennis deLeon, M.D.
Clinical Ethicist Department of Family Medicine
Loma Linda University and Medical Center

The case of Mrs. Morgan's hearing problems, and her audiologist's dilemma, represent a completely realistic, plausible, and increasingly common scenario. Providing health care to people is today such a complex undertaking that for almost any diagnosis or disease condition, including Mrs. Morgan's hearing loss, many different professionals and multiple services and treatments are provided. The rising cost associated with these professionals and services, of course, is what the managed care organization or HMO is seeking to "manage". The HMO collects a fixed premium dollar amount from Mr. Morgan's employer. With this dollar amount, how does the HMO go about "managing" Mrs. Morgan's health care and paying her bills? Through a variety of controversial methods: by using its clout to drive down the price of audiometry and hearing aids; by negotiating for discounts for its enrollees from ENT doctors, audiologists, primary physicians, and hospitals; and (perhaps most controversially) by trying to make treatment decisions conform to certain standardized guidelines or protocols. The treatment protocol might involve requiring a primary care physician's approval first, prior to treatment by specialists like audiologists or ENT doctors (an increasingly unpopular policy). Or the HMO's protocol might require the professionals to try cheaper treatments and tests first, before more expensive ones. In this case, instead of simply following the audiologist's recommendation to schedule a follow-up ABR and MRI plus amplification and aural rehabilitation, the managed care company only approves hearing aids, and denies the other tests. What the HMO really is saying: "We don't think that the tests you are recommending, are necessary under the guidelines you should be following for this hearing complaint."

What should the audiologist, with sincere doubts about the appropriateness of this denial, do about this situation? Isn't Mrs. Morgan being cheated, denied appropriate care? Some large-scale efforts are currently underway in society to address these concerns. For example, it's recognized that treatment guidelines and protocols for many conditions either don't exist yet, or they're simplistic and rudimentary, sometimes being crafted by HMO's and groups who don't have sufficient multi-disciplinary clinical sophistication, or who are motivated more by economic than patient concerns. As a result, almost all professional groups in health care are working on guidelines. For example, if the audiologist had been able to refer the HMO to an authoritative guideline from the professional literature, suggesting that an MRI and ABR are mandatory in this situation, it's more likely that the treatment would be approved.

Also, at the state and national level, legislators are seriously considering various "Patient Bills of Rights". These laws would enforce standard grievance and appeals processes for people like Mrs. Morgan who feel like the HMO has denied them appropriate care to which they are contractually obligated. And finally, some believe that health care professionals should in fact carry out the HMO function of "managing" care themselves, contracting with employers, patients and government and accepting the financial and clinical risks of patient care, without the HMO intermediary. These are the proponents of so-called Provider-Sponsored Organizations, or PSO's. Only time will tell whether PSO's will become large and efficient enough to do a better job than HMO's at providing care at reasonable cost, and winning public and professional support.

But all of this still doesn't help here and now! What should the audiologist do about the denial of Mrs. Morgan's tests? Like almost all health care professionals, the audiologist's primary responsibility is to the patient's welfare. Of course, the audiologist should also be a cost-effective professional. If he or she is a member of a professional practice or clinic, then the financial viability of the group is also a concern. Referral sources have to be cultivated, and it may be important to remain eligible for HMO referral panels. But these concerns, though legitimate, should still be secondary to the patient's welfare. The audiologist, if convinced of the necessity for these tests, should first win allies: perhaps the referring physician, if convinced of the clinical necessity, will help the audiologist make an conscientious appeal to the HMO to get the tests approved. (Don't forget that sometimes, unfortunately, the HMO's policy might actually "reward" the physician with incentives to also deny care. In this case, sadly, the physician might be an obstacle rather than an ally.) Perhaps Mrs. Morgan herself could help by registering a request or grievance with the managed care organization. As a good citizen and with the special knowledge of a health care professional, the audiologist should strive along with others to help improve the health care system as a whole, and work toward a system where the incentives appropriately reward good care. But meanwhile, though it might be a lonely battle, the audiologist's duty is to negotiate for appropriate care in Mrs. Morgan's best interests.

Related Readings

  1. Brett AS. Relationships between primary care physicians and consultants in managed care. Journal of Clinical Ethics 1997; 8(1): 60-65.
  2. Friedman E. Managed care, rationing and quality: a tangled relationship. Health Affairs 1997; 16(3):174-182.
  3. Hillman AL, Ripley K. Physician financial incentives in managed care: their impact on healthcare for the elderly. American Journal of Managed Care 1995; 1(2): 199-204.
  4. La Puma J. Anticipated changes in the doctor-patient relationship in the managed care and managed competition of the Health Security Act of 1993. Archives of Family Medicine 1994; 3:665-671.
  5. Morreim EH. To tell the truth: disclosing the incentives and limits of managed care. American Journal of Managed Care 1997; 3(2):35-43.

To submit cases or to be added to the list of respondents please contact: Helen Sharp Department of Speech Pathology and Audiology, 307 WJSHC University of Iowa, Iowa City, IA 52242. Phone: 319-335-6596, fax 319-335-8851, e-mail: [email protected]

ASHA Corporate Partners