Monday, August 09, 2010

Ethical Considerations for Global Healthcare Benefit Plans


Evaluation of a global healthcare option program addresses emerging ethical dilemmas faced by US executives

Members of the various management societies typically have codes of ethics they agree to abide by, this is in addition to the ethics code of their company or organization. For executives responsible for healthcare benefits, an interesting question arises as to whether the ethics of the medical profession apply to the members of management societies who are not directly involved in the healthcare industry? I believe the answer is yes, because helping the employer control costs through the provision of healthcare benefits is so completely intertwined with the employees livelihood, wellness and family...and is emerging to be a profound management challenge.

Those in management positions in every company should be familiar with medical ethics and the impact those principals have on employer decisions concerning health benefits programs. There are four encompassing principals in medical ethics: respect for persons, beneficence, non maleficence, and justice.

Respect. This principle is characterized by autonomy, truth-telling, confidentiality and fidelity. Autonomy means that each patient has the right to determine his or her own treatment. This principle underlies the concept of informed consent, which require that patients have the information and understanding necessary to govern their own medical decisions.

While there is no question that the US has the best healthcare in the world, information about the quality of physicians and hospitals is nearly impossible to determine. Providing information to employees about medical options overseas, especially for those procedures required by an employee whose medical outcomes are vastly superior to those available locally. The provision of a global healthcare option enables the employee to balance the various factors, and make an informed choice about their healthcare.

Autonomy does not exist if the employee is not informed completely, and is "led" to a conclusion someone else wants. A good example of this is the emerging ethical dilemma caused by corporate programs that offer "in-country medical tourism." In an attempt to reign in corporate benefit costs, companies have emerged to identify geographically far flung hospitals and physicians willing to offer steep discounts to increase volume. This is potentially an unethical business practice for two reasons: 1) the hospital and doctor are deeply discounting prices because their volumes are lower than required for proficiency, and perhaps not being forthcoming about medical outcomes and 2) the corporation is "leading" an employee to make a cost effective decision for the benefit of the company, and potentially exposing the employee to an increased medical risk.

Truth-telling dictates that the professional tell the whole truth, not a half-truth or a "white lie." Employer truth-telling concerning coverage of specific healthcare benefits is crucial. It is imperative that the corporation exert every available effort to document the medical outcome that an employee may expect to experience for a given surgeon/hospital combination. For example, it is critical to know that a US board certified orthopedic surgeon who has performed 400 hip surgeries with a 99.5% success rate and no complications in Bangalore is certainly an option to be made available, especially when the local orthopedic surgeon has performed 40, and the hospital is trying to address a concerning number of MRSA infections.

Fidelity is simply defined as keeping your promises. But are you keeping the promises made in your healthcare benefits program by not systematically scouring the industry for options? Many times, we are led to believe that this vigilance can be 'outsourced' to a consulting or benefits management firm. A myopic view does not provide absolution from this responsibility.

Beneficence involves acting in the best interests of the employee/patient. This requires that the professional do all they can to aid the patient. Coming to a hasty conclusion that a global healthcare benefits program will not be well received deprives an employee of a critical option that can be considered along with other treatment possibilities in the US.

Non-maleficence is derived from the Hippocratic Oath, which includes the statement, "First, do no harm." Health professionals are expected to recommend and provide treatment that is likely beneficial and to specifically avoid treatment that may prove harmful. Allowing or requiring that an employee undertake healthcare from a practitioner that recommends unnecessary treatment is maleficent because it exposes the patient to risks and costs of treatments. Examples of decisions that have demonstrated this principle of non-maleficence I have seen among the hundreds of patients we have sent to India include:
  • A bilateral hip replacement was recommended by a local US surgeon. After consultation, the Indian surgeon performed a hip resurfacing procedure...which relieved the pain in the non-surgical hip.
  • A hip replacement was recommended by a local US surgeon. After consultation and complete medical workup, the Indian surgeon determined that a large spinal tumor at the base of the skull was the proximate cause of the patients pain. The tumor was successfully removed, and hip pain alleviated...sparing the patient from an unnecessary hip replacement surgery.
  • Several obese patients were on a vast array of medications for diabetes control, joint pain and being treated for symptoms simply related to their obesity. Several had surgery scheduled for joint replacement. A complete medical workup followed by bariatric surgery has resulted in the loss of hundreds of pounds, complete avoidance of additional orthopedic surgery, and in most cases, a complete retreat of diabetic disease.

Further, these maleficent actions expend resources on patient resources that might be put to a different use. Corporate America is nearing the end of its ability to transfer healthcare costs to employees...and yet there is another tidal wave of costs emanating from the Obama healthcare legislation. It is more imperative now than ever for that corporate benefits executive expand their view outside the box.

Justice refers to actions that are impartial, fair and equal. Justice has applicability not only to the care of the individual employee/patient but also to making resource allocation decisions that are now required daily by the employer.

So how then does a global healthcare option program support the ethical responsibilities of the benefit executive?

  1. The employee is provided the autonomy of making an informed decisions with multiple options
  2. The employee is told the complete truth about a particular procedures, and the medical outcomes of the providers in the program, both in the US and India.
  3. The corporation demonstrates fidelity to the benefit program, and actually delivers more than promised
  4. The corporation has acted beneficently by examining the best options all over the world, rather than those that are locally expedient.
  5. The corporation protects the employee from maleficence, by challenging the opinions of local healthcare practitioners from world class medical experts.
  6. The well conceived global healthcare benefit program can demonstrate to a critical audience that justice has been fairly served to the employees.
So in addition to a global healthcare benefit program making sound economic sense, we find that it is also an ethical business decision.