Position Statement on Managed Care

Transcription

1 Psitin Statement n Managed Care The Cuncil n Cathlic Healthcare f the Michigan Health and Hspital Assciatin I. Intrductin In this Psitin Statement, the Cuncil n Cathlic Healthcare f the Michigan Health and Hspital Assciatin (CCHC/MHA) seeks t identify sme f the mre prminent ethical challenges managed care faces and t make recmmendatins abut hw these challenges can be met. In ding s, the Cuncil draws n values and principles rted in the Rman Cathlic traditin. Hwever, these values and principles are nt unique t the Cathlic traditin. Therefre, it is hped that peple frm ther traditins can draw upn this dcument fr their wn ethical reflectin n managed care. II. Ethically Respnsible Managed Care The Cuncil supprts the shift t managed care arrangements frm traditinal feefr-service health care financing pursuant t the elements identified in this dcument. Managed care, in tandem with pre-paid capitatin payments, represents an pprtunity fr health care resurces t be allcated apprpriately acrss the full spectrum f the healthcare delivery cntinuum. This cntinuum includes preventin, utreach, and emergent, acute, chrnic, rehabilitative, and end f life care fr imprving physical, emtinal, and spiritual health. Resurces allcated twards preventin f illness as well as apprpriate emphasis n the treatment f chrnic cnditins will result in a healthier ppulatin, and ne less reliant n cstly acute and skilled lng-term care services. Value t the patient is als derived frm increased benefits and decreased financial respnsibility in a cntrlled prvider envirnment stressing respnsible chices and mnitring quality. True managed care manages care as its first pririty; it des nt seek primarily t manage access. When the physical, emtinal, and spiritual needs f the patient are paramunt in decisins made by the stakehlders in managed care, patients will be treated with dignity and respect in the mst apprpriate setting. Duplicatin and fragmentatin f services will be reduced, resulting in higher quality and cst effective health care delivery. By shifting mre f the ppulatin int high quality managed care arrangements, there will be attainable pprtunities fr increased access t health care cverage fr thse currently uninsured r underinsured. The CCHC/MHA recgnizes that the incentives in prepaid capitatin have the ptential t result in underutilizatin and ther inapprpriate barriers t access and persnal chice. Managed care is challenged t successfully incrprate the interests f the plan, purchasers, prviders, and patients. Therefre, there are

2 apprpriate circumstances and issues requiring public plicy decisins and versight f managed care arrangements. Hwever, the cre elements f managed care must be preserved in rder t achieve the wrthwhile ends cited abve. Thse cre elements include: The ability f the managed care plan t select an exclusive netwrk f prviders that meet apprpriate criteria fr quality, utilizatin f resurces, and access t enrllees; The ability f physicians and ther prviders t manage the medical needs f patients; The ability f the managed care plan t negtiate directly with purchasers regarding price, benefits, and vlume f enrllees included in managed care cntracts; and, The maintenance f the apprpriate allcatin f respnsibility and accuntability f the varius stakehlders in the arrangement patient, prvider, plan, and purchaser. When purchasers cntract fr health care benefits n behalf f emplyees, there are factrs that are nt in the direct cntrl f all stakehlders. Therefre, managed care plan administratins are encuraged t educate purchasers and t advcate fr benefit packages that prmte individual and cmmunity health. Purchasers and unins are encuraged t negtiate emplyee benefit packages that prvide incentives fr health preventin and prmtin, managed health care, and apprpriate use f the health care delivery system. Prviders are challenged t becme accuntable fr clinical utcmes. Patients are challenged t lead healthier lifestyles and t reduce inapprpriate demand fr health care services. This dcument ffers the fllwing principles and guidelines as a mdel f what managed care shuld be and all stakehlders are encuraged t view it as such. Additinally, the Cuncil hpes that this dcument will be used as a framewrk by decisin-makers wh shape public plicy t assist them in measuring managed care prgrams in light f values and guidelines which best serve the public s interest. III. Principles A. Fur cre principles, which are f particular relevance fr the Cathlic health care ministry, are identified here, with a brief explanatin f their meaning and significance fr Cathlic health care in the United States tday: 1. Human dignity Every human being, regardless f race, creed r natinal rigin, pssesses an inalienable dignity presumed frm cnceptin until natural death, and must be respected as an inherently valuable member f the human cmmunity. Because healthcare is essential fr human dignity and fulfilling quality f life, all persns have a right t a basic level f quality cmprehensive care.

3 IV. 2. Special cncern fr pr and vulnerable persns Persns wh are marginalized fr whatever reasn require a special respnse frm the cmmunity. As a matter f bth justice and charity, structures and systems must be in place t meet their special needs. The pr must have their right t basic health care hnred. 3. The cmmn gd Human life is a life in cmmunity. The cmmn gd is the sum ttal f thse cnditins necessary fr all persns t have fulfilling lives. In seeking t prmte the gd f individuals, cnsideratin must be given fr the needs f the cmmunity. Decisins abut the use f resurces must be made in light f their ptential t cntribute t the gd f the whle cmmunity. Health care resurces, ne f many scial gds, are limited and must be managed wisely. Respnsible stewardship f health care resurces can be accmplished best in dialgue with peple frm all circles f sciety, while acknwledging that respnsibilities shuld nrmally be held and decisins made by thse mst affected by them. 4. Healthcare is a service Healthcare is a fundamental gd. It shuld never be treated as a mere cmmdity, nr shuld it be used primarily as a means t maximize prfits r prvide returns t investrs. Guidelines and Strategies NOTE: Legislative initiatives shuld be supprted that encurage health care rganizatins t implement managed care in line with the fllwing guidelines and strategies in rder t achieve the principles set ut abve.. Access and Allcatin 1. Managed care partnerships and cntracts shall meet minimum slvency standards. 2. The managed care plan shall seek partnerships and cntracts that shall nt undermine the understanding that health care is a basic human right. 3. Partnerships and cntracts shall permit patients t have equitable access t basic, cmprehensive health care benefits sufficient t maintain and prmte gd health, as well as t treat disease and disability. 4. Treatment shall nt be unreasnably denied t patients with preexisting cnditins, recgnizing the mral hazard issue and within the risk-adjusted financial ability f the Plan. 5. Capitatin cntracts shall be apprpriately cnstructed s as t ensure that prviders and patients are able t discuss any and all medically valid and effective treatment ptins.

4 6. An analysis f the health needs f the cmmunities served shall be made. Based n that analysis, elements shall be included in the benefits package that advance the health status f the cmmunity. 7. Substantive effrts shall be undertaken t prvide health care t the uninsured and underinsured in the cmmunities served by the managed care plan, whether r nt they are members f the plan. A. Operatinal and Patient-Prvider Relatinships 1. The managed care plan shall seek partnerships and cntracts that enhance a cmmitment t human dignity and respect fr the sacredness f human life frm cnceptin until death. 2. The managed care plan shall seek partnerships and cntracts that prmte a reasnable chice fr patients in selecting their physician r ther prviders and encurage a strng and an nging patient-prvider relatinship. 3. The managed care plan shall implement plicies and prcedures that ensure patient access t all infrmatin necessary fr making infrmed decisins, including the disclsure f all clinical and financial implicatins r incentives and arrangements. 4. The managed care plan shall maintain respnsive and just prcesses fr patients r prviders t appeal any denials, curtailment, r alteratin f treatment. 5. The managed care plan shall nt deny payment fr any emergency treatment that a "reasnable" r "prudent" lay persn wuld cnsider an emergency. 6. The managed care plan shall ensure that language and cultural differences are nt barriers t treatment. 7. Patient cnfidentiality shall be prtected especially in the areas f behaviral medicine, AIDS, genetic testing, and ther cnditins fr which there are significant scial repercussins. 8. Patients shall have advance disclsure regarding the plan s plicies and prcedures including due prcess rights, hw t access preventin services, hw t make use f patient advance directives fr their care, and the right t refuse treatment. 9. Resurces shall be available fr adequate pain management; and care prviders shall be educated s as t be able t prvide adequate pain management. 10. The managed care plan shall utilize bjective criteria and clinician versight in determining quality and making clinical judgments. 11. Physician risk arrangements shall be structured in such a way s as nt t cmprmise acceptable standards f patient quality care. 12. The managed care plan shall adhere t natinally recgnized quality standards and shall have quality indicatr infrmatin available fr public review. B. Medical Educatin 1. The managed care plan shall prmte and supprt educatinal pprtunities fr medical staffs and ther prfessinal caregivers

5 September 16, 1998 t enhance their knwledge and understanding f the cre elements f managed care, including its ethical issues. 2. Teaching prgrams shall include cllabrative arrangements with managed care plans t best equip residents entering the prfessins in a managed care envirnment. 3. The managed care plan shall apprpriately recgnize the cst f graduate medical educatin and research in their financial arrangements with prviders. C. Marketing Practices 1. The managed care plan shall seek negtiated rates that are actuarially sund. 2. The managed care plan shall adpt mechanisms t ensure that advertising is truthful, equitably distributed and marketed, and representative f the plan s values and ethical cmmitments. Marketing and enrllment ffices shall be accessible t all. 3. Marketing plans shall nt define their market area in a manner that will inapprpriately discriminate against individuals, prviders, r businesses. 4. Cmpensatin payments shall nt have incentives incnsistent with the guidelines identified in this dcument.