Confused over the ethics of managed care

At the recent Academy Awards ceremony, Jon Stewart joked that because of movie piracy, the glamorous stars present could barely afford enough fabric to cover their cleavages.

At the recent Academy Awards ceremony, Jon Stewart joked that because of movie piracy, the glamorous stars present could barely afford enough fabric to cover their cleavages. In the music industry, where piracy has long been a problem, the Supreme Court has ruled that those responsible for technology that allows music piracy could be sued. A spokesman for the music industry applauded the decision, saying that those who engage in such piracy are “confused,” and hoped that the court decision will bring some clarity to the issue.

Young people who engage in piracy may disagree. They would argue that recordings cost too much, especially when they only want one or two songs, and that the artists make too much money. By focusing on money, they avoid the real issue - ethics. These youngsters, who may be good kids much like our own, are “confused,” so piracy is rampant.

Dentistry has a similar situation. Some 20 years ago, a dental society meeting was convened to introduce us to PPO programs. A panel of experts debated whether it would be profitable for dentists to join PPOs. Someone asked, “Regardless of profitability, is it ethical?” The reply: “When your financial survival is in question, ethics do not matter.” Right then, PPO executives must have been high-fiving amongst themselves. As long as we focus on money instead of ethics, they win. Today, PPOs and other forms of managed care are solidly entrenched in dentistry. Did this happen because we asked the wrong questions?

Instead of asking managed-care programs what they pay, should we be asking ourselves:

Is it fair to charge some patients a lower fee than others for the same service?

If we agree to a lower fee, might we even unconsciously provide a lesser service, compromising our professional responsibility? Does it happen? Should we ask our staff members?

Does it compromise trust when we are “preferred” not based on our reputations, but on our willingness to reduce our fees to insurance companies? And, does it compromise trust when patients must constantly change doctors because their insurance plan has changed?

Ethical values such as fairness, responsibility, and trust are at stake; but do we consider them when we sign up for managed care?

Managed care itself is not unethical. It’s the way we incorporate it into our practices that makes the difference. So, how can we apply ethical values to managed care? What if we offer the same fee for the same service to all our patients? If we accept the reimbursement of an insurance program as a “fair” fee, then shouldn’t we offer that fee to all our patients? How simple! Would that eliminate the “confusion” in our profession? Would it also hold insurance programs to an ethical standard in the marketplace? So, what’s the downside?

Such a policy is based on fairness. If we act fairly, are we not more likely to be responsible? Would that engender trust? So why don’t we do it? Could it be that we are “confused?”

At the PPO meeting referred to earlier, CDS (now Delta Dental) vice president John Field boldly asserted that any dentist who discounts to an insurance program is charging too much to begin with. Yet, Delta has adopted PPO and other forms of reduced-fee, managed-care programs. They admit that they had to respond to competition in the industry. Delta, along with the companies that select such programs, got “confused,” and ethics became secondary to profits.

When we find ourselves trapped in the frustrations and compromises of managed care, we often turn to dental consultants. They help us develop business skills and people skills. They advise us to keep or discard the managed-care programs based on our numbers. But, do they help us recognize the fundamental ethical flaw of what we’ve gotten ourselves into? Do they help us recognize the inequity of the system and to change it, not only to benefit their clients, but everyone in dentistry, even patients?

Consultants are ethical people, but are they sensitive to this issue? Or, is it irrelevant to them because they have a different formula for success that’s independent of insurance, and their clients are doing well by it? Is it even in their interest to address the issue? Would we be so eager to pay so handsomely for their services if we were not so overwhelmed by the might of the insurance industry?

If consultants do not help us recognize the fundamental ethical flaw in the system so that we can change it, then they are just helping us rearrange deck chairs on the Titanic, or helping a select few into lifeboats before the ship sinks. Why does it seem that when this issue is presented to them, some respond as if they’re hearing it for the very first time? Do consultants, who are the most thoughtful, reasoning, and articulate people in dentistry, also get “confused?” Consider these cases:

At a dental workshop with a prominent consultant group, some doctors initiated a lively yet respectful discussion on the ethics of managed care. Throughout the exchange, the instructors stood by in silence. When asked why, they said, “It wasn’t on the agenda.”

A coach of another very prominent dental consultant group was receptive and motivated to help spread the message. He had asked his colleagues to read an article on the issue and offer feedback. Out of some 20 people, two responded. Since the most common response to discussions of ethics is “no response,” getting two responses is fantastic! Sadly, neither were useful.

After hearing a prominent consultant speak at a meeting, I felt he might be able to offer me some insight. I talked with him at length to let him know of my particular philosophy, concerns, and situation. I told him that because I question the ethics of having multiple fees for the same service, I do not participate in reduced-fee programs. Consequently, patients in these programs who may need more dental care cannot choose to come to me [unless they can afford to pay for it themselves].

The conventional advice from consultants is for us to shift from “need-based” to “want-based” dentistry, which is independent of insurance. This has proven to be a successful business model. But in doing so, are we simply shifting from under-treatment in a managed-care system to over-treatment, justified by “It’s what the patient wants”?

Could this consultant help me? “Only if you’re willing to do the dentistry I teach,” he said. Since his credential is in business, what kind of dentistry does he teach? Has he confused clinical dentistry with “bottom-line” dentistry? Is he teaching us to ask patients, “Would you like veneers with that?”

What about patients? At a university alumni gathering, a well-dressed and articulate mature lady walked in on a conversation on ethics and dentistry. She said that she couldn’t find a dentist who would take her insurance. “Imagine,” she said indignantly, “the ethics of a dentist who would tell me that I have the wrong insurance!” To her, the problem is not with an insurance company that has sold her a bill of goods or the patients who fell for it, but with the doctors who won’t go along. Are we surprised that patients are “confused?”

Considering the prevalence and the impunity with which young people engage in music piracy, would anyone relish the opportunity to address their “confusion” over the ethics of the practice? Considering the prevalence of managed care in health care, I wonder if any of us would relish addressing the “confusion” among our dental and medical peers, consultants, business executives, and especially our patients.

When it comes to the ethics of managed care, are we all “confused?” How can we bring some ethical clarity into the issue? What happens to our profession, our society, and our children’s future if we don’t? I hope we don’t find that question confusing.

I sincerely hope that readers - especially our thoughtful and articulate leaders, consultants, and colleagues, whether they participate in managed-care programs or not - will respond vigorously. Do we still have a window of opportunity to address the issue, or is it already too late?

Dr. William Hsiang received his dental training at the University of Pennsylvania School of Dental Medicine, and Albert Einstein’s General Practice Residency in Philadelphia. He completed the first training program for ethics educators from the Josephson Institute of Ethics in Los Angeles in 1990, and attended the Intensive Bioethics Course for Dentists at Georgetown University in 1994. He is married and has two daughters. He resides and practices in Irvine, Calif. Dr. Hsiang may be reached at (949) 551-2024, or via e-mail at DrHsiang@yahoo.com.

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