Response by Kenneth E. Wolf

Ethics Roundtable: When the Healthcare Plan Limits Care

Kenneth E. Wolf, Ph.D.
Chief, Communicative Sciences and Disorders
King/Drew Medical Center
Associate Professor of Otolaryngology
Assistant Dean for Educational Affairs
Drew University of Medicine and Science
Los Angeles, California

The first reaction upon reading this case study is that poor Mrs. Morgan has the misfortune of being covered by one of those terrible and greedy HMOs that thinks more of their bottom line than they do about their membersL needs. However, this case actually illustrates the need to fully educate the Primary Care Physician (PCP) about the real meaning of the results of the diagnostic tests already ordered, and how use of that information may actually be more cost-effective and lead to a better clinical outcome than the clinical path chosen.

The audiologist could have telephoned the PCP immediately upon obtaining these results and explained that there was a high level of suspicion for retrocochlear pathology. During the conversation, the recommendation for an ABR and an ENT consult could have been made, signaling the potential for a serious medical condition requiring specialty evaluation/intervention. The timing of the telephone call demonstrates to the PCP that the findings call for prompt attention. A written report follows within 24 hours. If there is still resistance after voice-to-voice or face-to-face discussion with the PCP, the audiologist may offer to provide peer-reviewed evidence to support the need for further testing and referral. Recommendations for amplification could have been deferred at this time or qualified with a statement such as "after suspicion of retrocochlear pathology has been removed," again, demonstrating that the medical condition needs action that takes precedent over selling a hearing aid.

If the above fails, the audiologist should appeal it to the Utilization Review (UR) team, or higher body within the HMO. The audiologist should also inform Mrs. Morgan of his concerns and recommend that she see an ENT before further pursuit of amplification. The audiologist runs the risk of irritating the PCP and case manager if he simply tells Mrs. Morgan to ignore what they have told her, however, most PCPs are actually receptive to good information, supported by evidence, especially if it results in improved outcomes and patient satisfaction.

The audiologist may fear that alienating the PCP might reduce or eliminate referrals (but does he really want to be affiliated with a health care organization that does not act in its patientLs best interests?). HMOs cannot "gag" or prevent their providers from telling their patients the truth about their conditions and treatments (even though they tried at one time, and professional codes of ethics and many state statues prohibited it). However, if a provider is viewed as not being a team player or shows excessive use of resources (including referrals and tests that can not be fully justified with contemporary literature), that HMOLs UR may stop or reduce referrals and eventually terminate the contractual agreement.

The audiologist's role to the patient is simple: full disclosure of the potential problem and that a retrocochlear problem has not been adequately ruled out. Simply selling a hearing aid because it has been authorized when the audiologist knows, based on clinical data, that this ear has not been established as medically safe, is unacceptable. The audiologist must serve as the patientLs advocate in this case, even if other providers are not, or that there is a potential loss of hearing aid referrals and sales. The consequences of doing so may be negative, but then one must ask themselves if they truly would like this level of service for themselves or their loved ones? If the answer is NO, and I hope it is, then does the audiologist really want to be affiliated with an organization that does business that way? Answering those questions makes it a lot easier to walk away from an unfavorable situation.

Remember, most HMOs, contrary to the anecdotal reports in the popular press, really want their patients to be well treated and satisfied. It is often less expensive to treat a patient fully and adequately early-on, then it is to treat an un- or underserved condition later in the course of disease. Managed care organizations are willing to provide the appropriate diagnostic and treatment services necessary, but in return, they except and demand evidence to support requests and claims. It is our obligation, to our patients, our professions, our colleagues, and our affiliations to provide that data.

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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