As managed care becomes more prevalent and integrated delivery systems become a reality, boards and hospital management are exploring uncharted territory.
They are being asked to develop strategies, policies and operating plans that are not only complex but often risk-intensive. They're being asked to better meet community needs yet use their resources wisely. They're being asked to forge stronger relationships with physicians, who are their collaborators and their competitors. They're being asked to develop continuums of care when, in some cases, their expertise is really in providing one specific type of care. Finally, they are expected to keep their organizations on a sound financial course.
Tough times? You bet.
In the quest to meet such needs and expectations, it's understandable that certain other priorities will move down the list. There's one priority, however, that must remain at the top and guide every other decision related to managed care and integrated delivery systems: Boards and senior management must never lose sight of their ethical responsibility to the communities they serve, their patients and the staffs they depend on every day.
In most cases, the organization's mission will directly or indirectly speak to these ethical responsibilities. But it's the duty of the governing board and the management team to ensure that specific strategic initiatives and business plan action steps meet this ethical imperative.
As healthcare consultant Paul Hofmann writes in Healthcare Executive magazine: "The organization's responsibility is to ensure that sufficient resources are available to facilitate optimal care and that economic incentives do not supplant the organization's mission of improving community health status. In turn, individual providers must be vigilant about putting their patients' medical needs above all else."
The American College of Healthcare Executives' Code of Ethics sounds a similar note when it states, "The healthcare executive shall provide healthcare services consistent with available resources and assure the existence of a resource allocation process that considers ethical ramifications; (and) conduct both competitive and cooperative activities in ways that improve community healthcare services." As a trustee, your role is to help ensure that your organization's initiatives are in accord with these ethical guidelines.
In addition, your oversight can help promote a working environment that supports healthcare executives in their efforts to function as what the ACHE's Code of Ethics describes as moral agents: "In organizations that deliver healthcare services, (healthcare executives) must safeguard and foster the rights, interests and prerogatives of patients or others served. The role of moral agent requires that healthcare executives speak out and take actions necessary to promote such rights, interests and prerogatives if they are threatened."
You also must pay particular attention to your organization's primary-care physicians, who often serve as gatekeepers in a managed-care or integrated delivery environment. "If they are expected to decrease referrals to specialists," says Hofmann, "you have an ethical responsibility to ensure that they have the appropriate level of training to care for a broader spectrum of patient ills."
Care must be taken in contemplating mergers, acquisitions or partnerships. Beyond simply assessing the other organization's balance sheet, it's important to compare both organizations' missions, visions and values. Are they compatible, particularly in their commitments to the communities and patients they serve?
Even if both organizations-and their respective corporate cultures-are ethically compatible, it is still necessary to assess the community impact of the proposed partnership. What effect will potential duplication or consolidation of services have? Can the new medical staff meet the community needs? Hofmann recommends bringing together stakeholders such as major donors, employers, health plan representatives and community leaders to discuss plans. Such a meeting can be invaluable in obtaining stakeholders' support and uncovering any concerns they may have. Once you have invited concerns, action plans must address at least the most critical ones as well as promote realistic expectations of the new organization.
In the end it is helpful to have specific, qualitative guidelines by which to determine how well your integrated delivery system or managed-care plan meets its ethical responsibilities. For example, Hofmann notes that an organization's managed-care activities should not:
Cause anxiety or inconvenience patients.
Create an excessive administrative burden for practitioners and institutional providers.
Deny reimbursement for potentially life-saving treatment.
Exclude competent providers.
Provide incentives for withholding care.
Unnecessarily restrict patient choice of providers.
Obviously each board must evaluate its organization's managed-care or integrated delivery initiatives based on the communities it serves, the type of care it provides and other factors unique to that organization or system. But once those ethical criteria are established, it's imperative that they function as litmus tests. To pursue a business strategy or action plan that fails to meet ethical criteria is to abdicate your organization's ethical responsibilities-rendering the success of any other aspect of the plan a meaningless victory at best.