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-Ethical Dilemmas in Managed Care Despite its possible defects, the traditional fee-for-

service system has one great advantage; it allows one to do what is necessary for patients. All this has changed under today’s system of managed care, as we find ourselves facing a dual ethical responsibility. On the one hand, there is the need to act on behalf of the insurers by upholding their rules of coverage, thus maintaining the integrity of the system and protecting patients from unfair and unequal treatment. On the other hand. we have the responsibility as health care professionals to act as advocates on behalf of the patients to see that our abiding by these rules still allows them to receive appropriate treatment for their condition. LJnfortunately, one often finds these 2 roles conflicting. In such situations, which should take precedent?

There has been much discussion about the ethical issues involved with miscoding a diagnosis to obtain insurance coverage for a patient, and this still remains an unresolved issue. Although exaggerating the sever- ity of the condition, documenting nonexistent symp- toms, and changing the diagnosis may solve the immediate problem for the patient, it can have a number of negative secondary results. including the effect that lying may have on trust in the doctor- patient relationship, the fear when the uninformed patient inadvertently learns about the more serious diagnosis, and the risk of potential compromise in the coverage of future health care needs. These possibili- ties have to be weighed seriously against the immedi- ate gain for the patient.

Most contemporary medical ethicists argue that the doctor must pursue what is in the best interest of the patient regardless of the cost. However, such an approach may not be realistic, and we may need to be more global in our thinking. After all, put very simply, there are only so many health care dollars to go around. Increasing costs by circumventing managed care guidelines can only lead to stricter rules, with the exclusion of more procedures from coverage, an increase in insurance premiums so that costs will become prohibitive for some people, and a reduction in special care programs. Therefore, by providing preferential treatment for a few, we may actually be jeopardizing the health care of many.

At one time, cost-beneft rates were not a serious consideration, because providing even the best of

care was not expensive. However, all this has been changed by the explosion of technology in the latter half of the 20th century, as well as by the increased emphasis on improved patient protection and the use of disposable supplies. The cost of drugs has also escalated. Thus, one now needs to think twice about a small benefit being achieved at great expense before deciding to order magnetic resonance imaging, a new antibiotic, or an expensive laboratory test, or to allow a patient to spend an extra day in the hospital. When the resources being withheld from the patients are only slightly better than those that are less expensive, it may be more ethical to accede to the third-party payer’s rules.

However, managed care is not a one way street; the insurance carriers also have some ethical responsibili- ties toward the doctor and the patient. First, there should be no restrictions on the choice of care providers. Second, there should be no limitations on access to appropriate specialty care. Finally, there should be a reasonable mechanism for appealing the denial of treatment. The definition of what constitutes medical necessity continues to be a hotly debated topic, and both the public and the health care profes- sions share a concern over the fact that the responsibil- ity for making such decisions, once relegated to the doctor, has now been eroded by the insurance carriers using nonphysicians and nondentists to determine what can and cannot be done for patients. To hide behind semantic interpretations of language is no less unethical than altering an insurance code to obtain coverage.

Although no one is completely happy with man- aged care, dealing with societal needs leaves us little choice, and we will have to learn to live within the system. However, that does not mean that the system cannot be changed; but doing so should not involve the surreptitious evasion of the rules. Rather, we need to aggressively appeal unjust decisions, voice open opposition to unfair regulations, and support efforts to legislatively change the process. Active patient advo- cacy, and not passive deception, will ultimately re- solve the ethical dilemmas of the managed care system.

DANIEL M. LWIN

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