Stephen Miles explores moral pitfalls of managed health care

Physician and researcher Stephen Miles discussed the advantages, problems and impact of managed health care in the United States in a Sept. 11 lecture sponsored by the Ethics Center on "The Ethics of Managed Care: New Tensions, Communitarian Ethics and Patient-Focused Medicine."

Miles, associate professor of medicine and biomedical ethics at the University of Minnesota, discussed trends of growth in managed care, HMOs and scarcity, HMO allocation authority and the problems with research to evaluate managed care.

"A managed care system is defined as the management of a set of diverse health care providers who are accountable for providing a defined set of health services to a defined population for a finite and defined set of resources," Miles said. "The conversion to managed care has risen rapidly over the past few years."

According to Miles, the benefits of managed care over traditional care include higher conformity to practice guidelines, which increases preventive care, and better "soft" outcomes, which include discovery of an earlier stage of cancer, heavier babies and lower blood pressure. "Hard" outcomes, including death and complications, had comparable results to traditional care.

Miles then discussed the problems of HMOs and scarcity in terms of allocations both inside and outside the organization. Competition for allocations within the HMO come from member services, infrastructure and imposed mandates and reserves, according to Miles. Outside the HMO, market competition on premiums and investor dividends contribute to access scarcity.

"HMOs manage scarce, valued resources," Miles said. "HMO allocation affects scarcity in the community as well as in the plan. If access, rather than member service, is the scarce resource that HMOs allocate, then public accountability is higher."

Managed care physicians have a responsibility to each patient, Miles emphasized. "In the individual patient ethic, gatekeeping is morally dubious because it generates a conflict between the responsibility of the physician as a primary advocate of the patient and as a guardian of society's resources," he said.

The foundation of a clinician's ethic for managed care resource association would highlight several tenets, according to Miles: clarification of population or member focus on resource allocation of health plans; development of public policy for allocation by private sector plans; and exploration of the public health role of plans. Resource allocation in an HMO era requires legitimized allocation authority, Miles continued.

This allocation authority is obstructed by policy barriers to population-based health care, Miles said. "[There is] a weak political sense of health care justice, no agreement on priorities or authority for rationing/resource allocation, no agreement on population-based outcome measures and inadequate risk adjusters for interplan comparison." Moreover, Miles continued, "who assigns responsibility for the health of a population, given multiple health systems, and patient choice of providers and systems?"

In conclusion, Miles stated that "we in the United States do not have a clear sense of health care justice. We do not have a sense of priorities. How do we balance the dichotomy of high-cost care and primary and secondary care? How do we handle the differences in public and private health care diseases?"

--Danielle Service

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