Ethical Guidelines for Patient Treatment in a Managed Care Environment
Bernard Frankel, MSW, PhD, CGP

There are a number of organizations working to safeguard patient rights and clinical freedom in today’s managed care environment. One widely known national interdisciplinary organization is the National Academies of Practice (NAP). This group consists of nine disciplines–dentistry, medicine, nursing, optometry, osteopathic medicine, podiatric medicine, psychology, social work, and veterinary medicine–each limited to 100 members who are elected as “outstanding practitioners.”

The following is a summary of NAP’s position paper on patient care. Ethical guidelines are founded on an ideology of patient advocacy. Preserving patient welfare must be the principal objective in resolving ethical dilemmas or challenges that arise from patient care delivery systems. Reimbursement arrangements in health care plans have increasingly changed from fee for service to external managed care regulations. However, virtually all managed care plans have shifted risk from payers to health care professionals. The transfer of financial risk has invited ethical conflicts in creating a tension between economic availability and clinical care considerations. The following ethical guidelines are prescribed:

1. Professional Commitment to Patient Needs Must Remain the Prime Concern.
   1. Patients are to be provided access to appropriate services.
   2. Benefits need to meet with patient satisfaction.
   3. Practitioners’ decision-making should not be hampered by a rigid adherence to so-called clinical guidelines.
   4. Specialist services should be available when patient needs exceed the skill and knowledge of the primary care provider.
2. Informational Disclosure
   The patient has the right of informed consent and is entitled to information about all reasonable clinical options regardless of economic restrictions or contractual prohibitions. This right supersedes any “gag” rule or restrictions as to discussions of insurance coverage.
3. Teaching and Research in Patient Care
   1. a. Demands for economy and efficiency should not be allowed to conflict with teaching and research functions.
   2. Patient care requires advancing the knowledge of health care providers.
4. Confidentiality
   1. Utilization reviews and quality assurance procedures should not breach the confidentiality of patient data.
   2. The patient has the right to control sensitive personal information and the enduring value of enhancing mutual trust and respect in patient-provider relationship depends on safeguarding confidentiality.
   3. Disclosure of confidential information requires patient consent.
5. Prevention
   The ethical principle of beneficence recognizes the desirability of preventing disease and promoting health. Patients have the right to have available and to initiate preventive and wellness measures.

Another publication on managed care is a 32-page manual for consumers and therapists entitled the Mental Health Consumer Protection Manual: A Guide to Solving Problems with Insurance and Managed Care. This is published by the National Coalition of Mental Health Professionals and Consumers, a large nationwide multidisciplinary membership organization that is dedicated to the dissolution of managed care plans. The NAP can be reached at: Box 438 Commack, New York 11725; e-mail: NCMHPC@aol.com.

This article was published in the August/September 1999 issue of The Group Circle.