Ethics Roundtable: When the Healthcare Plan Limits Care

Response by John La Puma

John La Puma, M.D., F.A.C.P.
Robert Wood Johnson/EDC Task Force on End of Life Care in Managed Care
Chicago, Illinois
Author, Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics (Hatherleigh Press, New York, 1998) ( or

To refer or not to refer--that is still the question. Whether it is nobler to send Mrs. Morgan for further testing or to come in under cap occupies the physician's thoughts long enough, and much longer than he or she wants.

Why did the physician not order further testing? Many reasons are possible:

  • medical indication: a diagnosis of hearing loss was made, an appropriate treatment was available, and a trial of therapy accepted;
  • patient preference: the patient had a financial incentive to use a therapy she knew about, and wanted to use it first; or perhaps she refused further workup;
  • contextual factors: the HMO physician may have a financial incentive to use fewer consultants; may fear loss of the patient to a specialist; may not know the audiologist or trust her judgement; or, Mrs. Morgan may have been discouraged by family, who think that she has always been dizzy and deaf;
  • quality of life factors: the patient wanted a chance to improve her hearing before investigating something that might require surgery;

Primary physicians are legally culpable for a consultant's recommendations: at the very least, discussing and documenting that discussion is owed to the patient. If it's within the audiologist's expertise to interpret her findings, she should suggest a second opinion to both physician and patient, and document, document, document.

If she suggests an appeal to Mrs. Morgan, she should make sure that the patient wants an appeal. She should review the reasons for treatment, payment alternatives and other choices. She should be realistic about the benefits of treatment and the risks of non-treatment. She should consider a time-limited trial of treatment, if feasible.

Other possibilities include telling the patient that she has the right to seek treatment on her own in the event of a disagreement, and if possible, get the HMO to pay for it later. Patients can use their employee benefits administrator, demand re-evaluation from the managed care review board, write the medical director, document clinical reasons for the denial and the names, titles, dates and times in conversations, and calls that were never returned. Complaints to a disease advocacy group, local legislators, and the state insurance department may all yield a settlement.

Finally, legally established grievance and appeals mechanisms exist as do advocates provided by a consumer protection agency or the state attorney general. Avoiding litigation and arbitration is important here, as these processes put most patients at a disadvantage relative to the managed care organization. The poor, the powerless, the uneducated, the uninsured, the underinsured, and the home bound elderly do not have access to an attorney or to the media, and will end up being squashed unless they know about and use their formal grievance and appeals rights. [Adapted from Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics (Hatherleigh Press, New York, 1998)]

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]

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