Will Health Care Reform Be An Ethical Win For America?

As I continue to work through the readings each week and read about the different ethical scenarios it’s very clear that the underlying source of many ethical dilemmas in health care is due to the fact that health care is a business and it’s also meant to serve the community. Many of the examples in the two books we are studying are meant to highlight the difficulty of running a business (especially a for-profit business) in an industry where people expect that society will be supported first and profits second.

I am a business owner of a health consultation company and I found the perspective of “cherry picking” in advertising on the part of Managed Care Organizations (MCOs) to be very interesting. The point was that MCOs should not solely seek out healthy individuals that have a low probability of needing coverage.

I thought to myself, “Why wouldn’t they have that approach? It’s the most profitable way for them to run their business?” And frankly, I’ve never thought of MCOs as being organizations that have the greater good of the people at the forefront. But, why are MCOs expected to advertise their services to everyone and other health care businesses don’t have this same expectation?

For example, is anyone keeping tabs on who walk-in clinics are advertising to? What if they aren’t marketing enough to underprivileged markets in their area? Is it wrong if they target upper middle class families for their services and not others? What if that makes the most sense for them from a business perspective? It’s important, after all, that they do stay in business.

What I find is that certain public interest groups expect organizations like big MCOs, pharma companies and other for-profit organizations to behave as if society’s wellbeing is their first priority. However, for the most part these organizations operate with the primary motivation of making profits and helping society is second, third and sometimes last on the list.

Should society expect these for-profit organizations—multi-billion dollar companies with their shareholder interests to operate with the wellbeing of society as first priority? Personally, I think it’s silly to keep expecting that.

Now, I don’t mean to say that companies should be given free rein to do whatever they want. There are certain boundaries that need to exist—drugs still need to go through clinical trials and there should be regulations about the claims that companies can make about what their products do and what they are indicated to treat. However, I don’t think people should keep expecting big MCOs and big pharma to start acting like Mother Theresa.

With all of this in mind, I wonder if the best thing we could do is to have a socialized health care option such as the one that President Obama has proposed. Now, I’m not saying that the bill is flawless and it may be a total flop in the end. However, it seems that society is expecting for there to be more health care institutions that have their interest in mind and not profits as first priority.

I know that the government can really make a mess of things if they get too involved, but I’m starting to wonder if the reform is exactly what the country needs. What if, on an ethical level for the citizens of America there was a place that everyone could go to get covered for health care? And the organization that provided it didn’t have the pressure from shareholders or any other for-profit objectives that private health organizations have? It’s not a perfect model, but maybe it’s better than the one that we have. It’s all theory, but it will be interesting to see what happens.

I’ve wanted to write about the situation with Jim at Qual Plus HMO. It was a pretty challenging situation and there were a lot of factors involved, two of the most significant being peer pressure and office politics.

When I first read through the scenario, my gut instinct was that it was definitely unethical for Joe to make a motion that the contractors provide their “final bids.” This is especially unethical considering his relationship with ACME construction, that a protocol had already been established for the whole process, and that he had already seen all of the bids.  I could empathize with Jim’s feelings that it was wrong to change the process at the last minute.

I read the outcome of what actually happened in the epilogue. Jim was ostracized and it seemed that he was being “managed out” of the organization. I thought about what (if anything) I would have advised him to do differently.

I worked in the corporate world for about 2 ½ years for a major company so I am very familiar with the political quandaries and the pressure to “play the game” in order to survive. I think that that pressure increases the higher you climb in a company and with that, the stakes also get higher.

What I’ve come to realize is that people don’t like feeling as if someone else “has dirt on them”—information about their behavior or choices that could compromise their career or how they are viewed by their superiors or colleagues. If an unethical choice is being made, they want to feel like everyone is “in on this together” and that nobody is going to be the tattle tale.

Jim did not leave this impression at all. It started when he “questioned the rationale, legality and ethical implications” of the decision to let the contractors provide final bids. Because he was “astonished” by the board’s actions he may have been communicating in an indignant way. I’m sure this would not have been received well.

He then proceeds to speak with the company’s attorney, the CEO of the company and the ethics committee about the decision that was made. No one seems to find anything wrong with what has happened, but at this point Jim may have made too many waves.

In corporate politics, a lot goes on behind the scenes and there can be more going on in a situation than what it seems. The attorney could have called the CEO and let him know about the call from Jim. The woman at the ethics committee could have told someone that Jim called her about the issue and word could have travelled through the “corporate grapevine” that Jim was making a big deal out of nothing and that he’s not a “team player.”

I think that Jim should have initially tried to be much more discreet so that he could still get his questions answered without creating this big stir. I think that he is being managed out because the higher ups have determined that he’s too much of a “goody two shoes.” We already know that there is some unethical behavior going on with Brent (the CEO) and the board members. These guys don’t want to feel like someone is “watching them” ready to call legal or the ethics committee to report their behavior.

It would have been ideal if Qual Plus had some kind of ethics line where employees could call in anonymously and have their questions answered. That way they don’t run the risk of being ousted by their colleagues or superiors and it’s on record that they did the moral thing by calling the action into question.

As far as whether Jim should have fought to the end for what he believed to be right, I think it’s a matter of personal conviction and what you are willing to risk. Hoffman and Nelson say that risk taking is part of integrity (p. 11). But how much one is willing to risk is a personal decision and even ethics can’t define any cut and dry rules that should apply to all situations.

In this case, I don’t think that I would have risked my job to fight for proper procedure in the construction bidding. I do believe that Jim had a moral obligation to ask someone else what should be done and I would have done the same, but it would have been best if he could have done it anonymously or if he could have “kept his cool” a little bit better.  Ethics is very important, but it doesn't always have to be in direct opposition of keeping your job. 

I wrote my mini paper on the ethical challenges of the pharmaceutical industry—specifically, the issue of gifting physicians with lunches, dinners and office supplies. I used to be a drug rep so I can speak on this with some authority.

I came into the industry in 2008, so I never saw the extravagant gifts like vacation packages and tickets to Orlando Magic games. My company had done away with that in the mid-2000s due to a great deal of pressure (and scrutiny) from the general public.

I did, however, bring doctors and their staff lunches, take them out to dinners and supply them with pens, notepads, medical instruments and other drug paraphernalia. I remember the looks on the patients’ faces when I would walk into a packed waiting room bringing bags of piping hot food from Macaroni Grill. The looks I got were not very nice.

In 2009, the pHRMA organization, a pharmaceutical advocacy group, announced that they were changing their code of ethics in terms of what was appropriate in rep interactions with doctors. As a result of their updated code, several companies (including mine) got rid of the notepads, pens and many of the other office supplies that we were giving doctors. We were only allowed to give educational material (like a poster on the common causes of asthma) and lunches and dinners had a spending threshold where before it was pretty much unlimited.

Pretty much all of the big companies agreed to the new code of ethics even though it was voluntary.  I assume that Pfizer didn’t want to look bad if GlaxoSmithKline was going along with the changes. So the heavy hitters all jumped in.

Even though my company made changes in how reps interact with physicians, I don’t feel like it really helped that much. Perhaps it helped in a very small way with public perception of pharma (and that’s why I think that they all did it—for the publicity) but it did very little to influence the culture of the organization.

When a company is built on deceit and dishonesty, twisting the truth when it benefits them and encouraging employees to “tell the best story” when selling their products it will not turn into a morally upright company simply because the leaders have decided to stop giving notepads to doctors. Despite the change of several big pharmaceutical companies to adopt the practices of the pHRMA code, there is absolutely no shortage of drug industry scandals, off label promotions and FDA sanctions for misconduct.

The pharma industry was one of the most corrupt and backward industries I have ever worked for. However, I do consider it an extremely valuable experience in terms of my development as a leader and as an individual and I would never take it back. I gained clarity in what I stand for and believe in and I learned that company culture is extremely important. Leaders have to BE what they want to see in people instead of offering lip service and industry buzzwords to create the “feeling” (not a reality) of being an outstanding company.

I truly believe that good ethics in a company starts with great leaders, which is why I’m really glad that I’m taking this course and learning how to develop myself in this area.

My husband and I often watch TedTalks on our Apple TV. About a month ago, they had a very interesting speaker by the name of Atul Gawande. He is an author and surgeon and his talk was about the many issues that plague the medical community, particularly the occurrences of incomplete and inadequate care. He discusses the attitudes amongst the physician community and how certain ideals of perfection can impact behaviors.

I thought that his talk echoed some of the same concepts discussed in the medical errors chapter (pp. 160- 161) of Managing Ethically. In this chapter Dr. Morreim discusses the legal and ethical imperatives in dealing with medical errors. He notes that the healthcare culture views doctors as error-proof gods and this is similar to Gawande’s perspective in the TedTalk. Gawande also acknowledges that the physician community places in emphasis on being a “cowboy”—kind of like the “answering to no one” mentality—and how this attitude belittles the importance of rules and structure.

What I find to be very interesting is how this attitude can prevent physicians and medical staff in general from taking the ethical high road in situations. If doctors are held up to a standard of perfection, I would think that they would be much more likely to hide their errors or downplay them so that they save face in front of their superiors and colleagues. This is damaging not only to the patient who may be harmed as a result, but it also does not allow for the improvement in systems due to fear of judgment or repercussions.  

Perhaps these attitudes are the reason why public records of physician errors are so controversial. In a culture where perfection is the standard, any doctor would be fearful of losing patients because of this information going public.

I think that there are several ways to help deal with this problem. Firstly, healthcare managers need to be intentional about creating a culture of teamwork. Doctors do not do their jobs alone. They rely on nurses, other physicians and a full staff of people to help them succeed in caring for patients. The healthcare environment should place more emphasis on teams and less on individuals. Certainly, there are times when individuals need to be praised or held accountable for their actions, but all around a culture that focuses more on teamwork could be helpful.

Additionally, managers need to create a safe environment for error reporting.  The staff should feel comfortable reporting errors without fear of being punished or judged. The more employees share in this area the more a hospital can improve in their systems.

Finally, I like the suggestion that Gawande makes in his TedTalk video: checklists. There are a variety of strategies that can be used for reducing medical errors, but Gawande notes that even in surgery using checklists decreased complication rates by 35% and death rates by 47% in hospitals that implemented the technique. He agrees that overcoming physician attitudes around checklists will be a challenge, but the outcomes of this idea appear to be promising.

I’m sure that there are many more ways to reduce errors in hospitals, but a key aspect of that is to create a culture where people feel comfortable admitting that they made a mistake.

The Ted Talk Video is below.

Ethics--A Not So Black and White Topic

I never took an ethics or philosophy course in school so these concepts are all new to me which is exciting. When I think of the word ethics, typically I associate that with examples of unethical behavior as opposed to positive examples of ethical behavior. This is most likely because the negative examples get all the media attention (Enron, Wall Street, etc.).

I worked for a major pharmaceutical company for a little over two years and I would have to say that in my role as a sales rep I have never experienced more ethical challenges. Every day I was faced with decisions about whether or not to skew the truth a bit, over exaggerate or sometimes even outright lie. It was a very interesting situation. I was working for an organization that prided themselves on being “transparent”’ and honest in the midst of many other (pharmaceutical) companies that were being flamed by the press for hiding life or death clinical information from the FDA.

It was a cynical environment to work in and pretty much the entire 2 years that I was there the morale of the company was very low. I remember when rumors started leaking that my company had (illegally) tested vaccines on indigenous tribes in Africa. I remember one drug scandal after another that broke out and the reports of reps selling drugs “off label.” I remember the scowls on patients’ faces as I brought in big bags of catered lunch to offices along with lots of pens, notepads and other drug company paraphernalia.  Looking back, I don’t blame them.

As I read over the Basic Ethical Terms and Normative Theories I couldn’t help but think about my days as a drug rep. I find that some of history’s greatest transgressions have been justified by the “greater good of the people.” There are so many ways to argue what may be right or wrong or what makes something “good.” To me, the greater question is whose perspective is deemed to be most important which the writer of the website points out. This is a key point in differentiating the three Theories of the Good (utilitarianism, care ethics and ethical egoism).

For example, a drug company could justify illegally testing vaccines in humans because even though some may die or suffer terrible consequences, the greater good is that much more people will benefit from the “advancement” vaccines bring to medicine. This is utilitarianism.

If I were a person that was being subjected to that testing, I could talk about my rights as an individual and the unfairness of being forced into a potentially dangerous situation. I would be arguing for my own self-interest and this is ethical egoism.

In these two situations few people would argue against the fact that the pharmaceutical company is wrong and the individual is right. But what happens in situations that are not life or death?

For example, Iet’s say a colleague conveys in confidence that they are cheating the company in a way that is putting the organization in serious financial risk in order to pay for his five year-olds leukemia treatment. And let’s say that this should be covered by the company insurance, but due to budget cuts the company has had to scale back on insurance plans.

Should you tell your supervisor what’s happening? You know that your colleague will be fired and then how will their child’s treatment be paid? Are you being unethical by not sharing this? Should you tell? You know they’ll be after you if they find out that you knew and didn’t tell someone. So many things to consider!

It seems that ethics is this big conundrum of trying to balance all of the different perspectives involved in any given scenario. It is inevitable that the outcomes are not always fair. There is no clear right or wrong in many situations and it takes a lot of good judgment to be able to decipher what is appropriate for each circumstance. As a leader, I hope that this course gives me insight into how to discern ethical dilemmas in an appropriate way. 

The Government as HR Manager

The Government as HR Manager

I never thought about the government as a Human Resources Manager until I started reading Chapter 11 of the textbook: Compensation Practices, Planning and Challenges. In particular, compensation is of interest in relation to the Medicare program. Fried and Fottler discuss compensation strategy and how to reward employees for performance in a way that is meaningful to them. As I thought about the ideas presented about compensation and how doctors might perceive their roles and positions, I began to wonder what their perspective is on the government as an HR Manager. Fried and Fottler state that, “organizations earn a reputation for the amount they pay employees.” Well, what type of reputation has the federal government earned in regard to Medicare reimbursement for physicians?

In my experiences of working with physicians overall, I can say that my perception is that doctors (especially primary care physicians) aren’t very fond of the Medicare reimbursement system. A common complaint of physicians participating in the program is that the reimbursement rates are way too low. And who can blame them? According to the Washington Post, doctors have been paid below market rates for DECADES. Current reimbursement rates are at 25 to 35% below commercial insurance. In fact, reimbursement has become such a sore point for physicians that 31% of primary care practitioners have chosen to limit Medicare patients within their practice. These doctors are fearful of more cuts—which they can pretty much count on because it happens nearly every year. Another 60% of doctors are at least entertaining the idea of removing Medicare from their practice entirely (Newman, 2010).

One of the biggest problems with the payment system is the fact that the way costs are calculated has not been updated in several years. Congress is very fearful of promising not to make cuts due to the huge financial costs. Apparently, freezing Medicare reimbursements for the next ten years (meaning no slashes to payments) would cost $276 billion. But, that’s just FREEZING costs…who knows what would happen if physicians actually started to be paid market value for services.

These reimbursement issues are a pretty big deal. More and more medical school graduates are choosing higher paying specialties—i.e. anything but primary care where reimbursement is often the lowest. The younger generation of physicians has caught on to the mess that is Medicare reimbursement. Patients that are privately insured are much more profitable, and young doctors will be opening practices right out of school that restrict heavy Medicare so not to get themselves involved with the conundrum that older physicians are in. It’s particularly difficult for older doctors to hire younger replacements if their practice is heavy with Medicare. Considering the fact that in Florida alone 60% of physicians are 50 or older, this could be a serious problem if younger physicians are unwilling to replace them (Fritz, 2002).

This issue is also pretty far-reaching into the future as practitioners speculate about what might happen once the nation goes to the new healthcare program in 2014. What kind of reimbursement can clinicians expect from the new system if Medicare is treating them so poorly? If enough doctors opt out of this new program access could end up being a huge problem—and the program was designed to improve access, right?

The bottom line is this: Nobody wants to work for free, including doctors. The government needs to figure out how to “reward employee performance” and “attract and retain high-performing employees” without breaking the bank (Fried & Fottler, 2008). But is that possible? Maybe the entire Medicare program needs a complete and total overhaul. In the future it’s not hard to see why doctors would “quit” Medicare and government programs altogether. Hopefully, the government will give our physicians more incentive to see Medicare patients. There’s nothing wrong with a little bit of optimism, but let’s just say I’m not holding my breath.

References

Fried, B.J. & Fottler, M.D. (2008). Human Resources in Healthcare: Managing for Success (3rd Ed.). Chicago: Health Administration Press.

Fritz, S. (7 October 2002). Young doctors may avoid Florida. Saint Petersburg Times, p. 3A.

Newman, M.A. (19 June 2010). A fix for the ‘doc fix.’ The Washington Post, p. A17.

Pay for Performance

Health reform discussions over the past couple of years (centered on the Obama/McCain election) have shed light on the state of healthcare in the U.S. for the American public. As policymakers and elected officials have attempted to rectify our somewhat broken healthcare system (it depends on who you ask) a topic that often comes up is healthcare quality. What can we do about quality and the fact that we spend so many dollars on healthcare for below average outcomes? The question has sparked plenty of debate. One suggestion for the quality problem relating specifically to physicians is pay for performance (P4P). This is highly controversial and criticized—especially among primary care physicians. A New York Times article addresses some of the key points of the discussion and a recent study related to P4P published in The Journal of the American Medical Association (JAMA).

The article opens with a primary care physician expressing his dissatisfaction of a letter from an insurance company that notified him of his “quality ranking.” The quality ranking is essentially a way for the insurance company to objectively and uniformly measure their physician partners. This doesn’t seem like a bad idea, actually. However, even though the doctor maintained a high quality ranking he was still unhappy with the system. His argument was that the insurance company shouldn’t assume that the way he practices medicine has any direct connection to patient outcomes. I’ll be completely honest. At first glance it sounds to me as though the doctor wants to make an excuse or “have an out” when quality in his office falls below average. The second thought I had is that doctors in general don’t typically like to be held accountable to anyone because the very nature of their profession offers a high level of autonomy. But it doesn’t make sense that outcomes aren’t correlated to physician care.

The doctor then went on to talk about a patient with high blood pressure that he’d been dealing with for several years. This particular patient couldn’t afford to take time off work for appointments and his argument was that he should not be accountable for her poor health because of her job situation. Okay, I can understand that. However, I believe that for most doctors situations like that are the exception and not the norm. I believe that most people want to obey the doctor’s orders—especially if they have a pretty severe condition. On some level I can understand why this doctor is irritated, but I don’t think the solution is to let all doctors “off the hook.” Performance management measures need to be in place for all employees including doctors.

The JAMA study discussed in The New York Times article reveals that WHO doctors are actually treating makes a difference in P4P rankings. For example, doctors that treat more minorities and non-English speaking or underinsured patients typically have lower quality scores when rankings are not adjusted for these factors. However, after adjusting for the type of patient that the doctor is typically treating, many of the lower ranking doctors increased their scores up to 10 points.

According to Fried and Fottler, performance management is essential because “you can’t manage what you can’t measure.” Physicians can be difficult to work with and they can definitely be difficult to manage—but even they need to be held accountable to some set standards. The goal of performance management is to create goals and an action plan to achieve them. Progress must be monitored to ensure that employees are on target, so set standards must be in place and enforced—even for doctors (Fried, 2008).

I realize that P4P is controversial and many healthcare practitioners believe that it should be done away with. However, I don’t think the solution is to throw the baby out with the bath water. P4P can work, there simply need to be adjustments in place to account for extreme differences in physician patient populations. It will be interesting to see if P4P effectively motivates physicians over time.

References

Chen, P.W. (1 October 2010). Paying doctors for patient performance. The New York Times. Retrieved October 25, 2010 from LEXIS-NEXIS Academic Database.

Fried, B.J. & Fottler, M.D. (2008). Human Resources in Healthcare: Managing for Success (3rd Ed.). Chicago: Health Administration Press.