Ensuring a fair deal for all in the health care system

A new report describes how fairness can be improved in health care coverage decisions.

Posted April 19, 2004.

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In a health care system viewed, with good reason, as increasingly polarized and contentious, the notion of "fairness" is taking quite a beating. Yet fairness -- along with other endangered species such as privacy and respect -- is key if the system will truly serve this society.

A new report entitled "Ensuring Fairness in Health Care Coverage Decisions" is an important step in restoring faith in this essential system. It is the work of a wide-ranging panel brought together by the AMA Institute for Ethics.

The report outlines a consensus on five criteria for fairness that insurers and others should follow: Health care coverage decisions should be participatory, equitable, consistent, compassionate, transparent and sensitive to value. These should be givens, but talk to just about any patient or physician and the war stories they tell underscore the need for commitment and progress in these areas.

The report was developed by the institute's Ethical Force Program. This broad-based effort was founded by the institute in 1997 to develop performance measures for health care ethics that can be applied to all participants in health care, including hospitals, physicians, health plans, employer/purchasers and investors.

The current health care environment has fostered a competitiveness among these stakeholders that leaves each of them feeling that the other ones are somehow getting a "better deal." This is particularly true for physicians and patients, many of whom feel powerless.

Often, patients think that their physicians are complicit in a system that cares more about cutting costs than providing them with the best care. From their perspective, the system is not user-friendly but instead cloaked in subterfuge.

Greater transparency could go a long way toward fixing that perception. Indeed, it is essential for patients to better understand the roles of all the players in the health care delivery system, from their employer or benefits purchaser to their physicians.

Other recommendations are just as important. They include involving patient representatives in designing health benefit packages, explaining coverage denials in language that is easily understandable by patients and making sure that financial incentives are not placed on decision-makers to affect coverage decisions.

The Ethical Force Program oversight body consists of a diverse group of health care leaders who remove their "institutional hat" when serving on the committee. Their work product should not be construed as official policy positions of the organizations from which the members have been drawn.

But there are significant incentives for health-care coverage decision-makers to follow the report's recommendations.

Physicians and patients certainly would applaud such a move. Health plans, as the face of emotionally charged coverage decisions, should recognize the business value of being able to demonstrate attention to organizational attitudes and policies that reflect fairness and consistency.

For health plan purchasers, the report provides a forward-looking method for evaluating coverage decision-making processes that could avoid later appeals and changes. The report also suggests that health care organizations might find their investors more willing to increase their investment because of their ability to monitor the organization's ethical behavior.

Ethical standards legitimately vary across business, public health, and professional relations. "Ensuring Fairness in Health Care Coverage Decisions" is the first widely accepted set of ethical standards for everyone in the health care system. As such, it can serve as a road map to a better health care system in which the patient understands how health care coverage decisions are made and the trustworthiness of the system is improved.

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External links

The Ethical Force Program (link)

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