NATIONAL ACADEMIES OF PRACTICE

 

ETHICAL GUIDELINES FOR PROFESSIONAL CARE AND SERVICES

IN A MANAGED HEALTH CARE ENVIRONMENT

 

PREAMBLE

Ethical guidelines of the National Academies of Practice regarding professional care and services are founded on an ideology of patient advocacy. Moreover, preserving the patient's welfare must be the principal objective in resolving ethical dilemmas or challenges that arise from patient care delivery systems. Many health care professionals recognize that managed care was created with the intent to offer an excellent opportunity to advance quality standards of practice and care while reducing unnecessary and wasteful health care. A further purpose was to achieve a more balanced and socially responsive approach to the achievement of desirable health outcomes in our communities through the use of prudent interdisciplinary resources.

During the last decade, reimbursement arrangements in the health care enterprise have increasingly changed from fee-for-service to some type of externally managed care. However, virtually all managed care plans tend to shift financial risk from payers to health professionals.This transfer of financial risk has the potential to invite ethical conflicts by way of creating a tension between economic availability and clinical care considerations bearing on patient care, patient fights and advancing the knowledge base of the health care professions. The purpose of the ethical guidelines is to set forth the positions of the National Academies of Practice on certain of these pertinent issues.

 

1. PROFESSIONAL COMMITMENT TO PATIENT NEEDS MUST REMAIN THE PRIME CONCERN

Patient-focused care has the potential to be threatened by economic pressures to abbreviate the utilization and scope of professional services. While mindful of economy and efficiency in health care services, an ethically based patient-practitioner relationship should admit no unreasonable diminution of the professional's commitment to the patient's need and care consistent with accepted standards of clinical care.

It is the position of the National Academies of Practice that it is unethical to compromise a patient's needs and quality care concerns to satisfy financial objectives. The patient's right to appropriate care must not be diluted by economic pressures. The benefits offered by all health care providers should:

The rationale for these positions derives from a patient or consumer-focused value, that has remained constant in the historical evolution of Western ethics, is reiterated in contemporary health professional codes of ethics and can be found in current regulatory statements such as the Patient Rights Standards of the Joint Commission on the Accreditation of Healthcare Organizations. Health professionals must refrain from subordinating the patient's welfare to economic mandates thereby potentially creating an incursion on the patient's rights. The fiduciary role of the provider must be balanced with the patient's needs.

 

II. INFORMATIONAL DISCLOSURE

Questions frequently arise over whether the practitioner has an ethical obligation to present reasonably considered clinical options for care and services regardless of those economic restrictions or contractual prohibitions, such as "gag rules", that may be dictated by the patient's insurance or managed health care plan.

It is the position of the National Academies of Practice that all reasonable clinical options for care and services, consistent with sound and accepted clinical standards, should be presented to the patient and that the practitioner should not be deterred through gag rules or otherwise constrained to present only those options for care and services that are covered by the patient's policy or plan.

The rationale for this position inheres in the patient's right of informed consent as a service consumer. This right entititles the patient access to information whose scope may exceed that allowed by the health insurance policy or health care plan. The patient's right of informed consent also repudiates attempts to restrict patient-provider discussions to the plan coverage.

 

III. TEACHING AND RESEARCH IN PATIENT CARE

A clinical environment that includes teaching and research functions traditionally has represented a hallmark of health care delivery. Teaching and research functions are quintessential ingredients in the advancement of knowledge about the patient's needs and the deployment of sophisticated services. With pressures to produce utilization efficiencies and fiscal economies, managed care arrangements may conflict with teaching and research functions. The values of teaching and research, which are enduring in the advancement of science, must not be lost.

It is the position of the National Academies of Practice that demands for increased economy and efficiency in the health care environment should not be allowed to conflict with teaching and research functions. Such demands risk retarding the advancement of knowledge and training in the health sciences and are of consequential importance.

The rationale for this position inheres in the ongoing necessity of scientific research to realize patient-centered achievements. These beneficial goals require an unremitting effort not only to train but to advance the knowledge base of health care professionals.

 

IV. CONFIDENTIALITY

The confidentiality of patient data in clinical encounters is a primary concern. Although utilization review and quality assurance are customary and appropriate functions in every health care environment, these activities should not breach the confidentiality of patient data. Safeguards must be adopted when persons engaged in utilization and quality assurance reviews have access to patient files.

It is the position of the National Academies of Practice that utilization studies and q assurance reviews are appropriate functions in an efficient and effective health care system. However; safeguards must be adopted, codified and implemented to protect the privacy and confidentiality of patient data and the practitioner's clinical material. Confidential information can be disclosed only with the patient's consent except in instances where withholding that information poses unreasonable and foreseeable harm to the patient or identifiable others.

The rationale for this position is founded on the patient's autonomous right to control sensitive personal information. It is further based upon an historical recognition in the Oath of Hippocrates and corroborated throughout the centuries, of the enduring value of preserving confidentiality in order to enhance mutual trust and respect in the patient-provider relationship.

V. PREVENTION

While direct care based upon episodes of illness, disease, or disability is always appropriate, concerns about preventive services as an integral part of clinical care should be of utmost concern to all practitioners.

It is the position of the National Academies of Practice that every health care enterprise should acknowledge the critical importance of the teaching and inculcation of prevention as well as the need for competently delivered patient care services.

The rationale for this position derives from the ethical principle of beneficence, which recognizes the desirability of preventing illness and disease and promoting health among all persons and communities. The principle of autonomy argues for the informed patient's right to initiate preventive and wellness measures. This fight is dependent upon the patient having access to relevant health information and strategies which are essential ingredients of patient care and services.

Approved by mail ballot of the Council of the National Academies of Practice and affirmed by President Ron Fair, O.D. on 2 June 1997.

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Updated July 2, 1999
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