J Oral Maxlllofac Surg 54:3&?5, 1996
Ethical Dilemmas in Managed Care
As managed care rapidly spreads across our health care delivery system, new and unexpected problems continue to arise. We are all aware of the emphasis on reduced cost at the expense of quality treatment, loss of freedom of choice in selecting providers, and reduc- tion in the scope of available services. Now, however, we are also beginning to encounter serious ethical is- sues in attempting to maintain our traditional role in the doctor-patient relationship.
Some of these issues recently became very clear to me when I was consulted by a young woman who had a 6-month history of pain in her left temporomandibu- lar joint accompanied by an extremely loud popping sound on mouth opening. In the past month she also had begun to have intermittent locking, which she re- lieved by manipulating her jaw. There had been no significant reduction of symptoms from the use of moist heat, soft diet, and nonsteroidal anti-inflamma- tory drugs. When authorization to perform a dis- coplasty was requested from her health maintenance organization (HMO), it was denied because I had not attempted first to treat the patient nonsurgically. An appeal to the medical director led to a query about why I had not used physical therapy, equilibration, or nutritional counseling. Suddenly, I was faced with an ethical dilemma-as a participant in a managed care program is it my obligation to act as an agent to en- hance their profitability or is my first responsibility to see that the patient receives appropriate treatment?
Emmanuael and Dubler have defined the seven Cs of a good doctor-patient relationship as choice, competence, communication, compassion, continuity of care, (no) conflict of interest, and confidentiality. Although managed care should not have an influence on competence, compassion, continuity, and confiden- tiality, it clearly challenges the other characteristics of the doctor-patient relationship. Choice is obviously not the same as it was under indemnity programs. It de- pends on the plan selected by the patient and whether you are a participant. Thus, patients may not have the choice of continuing a long-term relationship when their doctor is excluded or does not belong to the net- work. Such plans also prevent referral to nonpartici- pants, even when they may be the ones able to provide the best treatment.
Communication is often the most important criterion by which patients judge the quality of their relationship with their doctor, and this can be severely hampered in the managed care system. Referred to as gag clauses, many HMO contracts contain provisions that limit the doctors ability to talk freely with patients about treatment options and HMO policies. Such re- strictions interfere with our ethical and legal duty to provide patients with information about the benefits, risks, and cost of treatment-information to which they are entitled. In some plans, the doctor is not even permitted to discuss the recommended procedure until authorization to provide that treatment is obtained. The explanation that such a rule is an effort to guarantee high-quality care by making sure doctors are aware of the best treatments before discussing them with pa- tients seems to be a very specious argument.
The most compromising aspect of any managed care program in terms of the doctor-patient relationship deals with conflict of interest because the system is designed to provide compensation for withholding care rather than providing it. This is perhaps the very heart of the issue. When a service is denied or modified by what you believe has been an inappropriate utilization review, is your responsibility to the patient or to the managed care company? If you treat as ordered, and without protest, not only have you violated your professional obligation but also you assume full legal responsibility for any untoward sequelae.
The solution to these ethical dilemmas can be found in the pledge that we all made when we became mem- bers of the American Association of Oral and Maxillo- facial Surgeons. In this pledge we promise to practice oral and maxillofacial surgery with honesty and to place the welfare of [our] patients above all else. In other words, our first obligation is to serve those per- sons who seek our help and trust us to provide it the best possible way. No matter what changes occur in the health care delivery system, our main contract is still with the patient. We are their advocate and not the insurers. That is the way it has always been, and the way it must always be.
DANIEL M. LASKIN