Managed care and Physician Profiling.. Autonomy, Beneficence or Maleficence?
Autonomy is the “personal rule of the self that is free from both controlling interferences by others and from personal limitations that prevent meaningful choice.” Autonomous individuals act intentionally, with understanding, and without controlling influences. Respect for autonomy is one of the fundamental guidelines of Medical ethics
Clinically individuals may come to doctors for guidance in making choices because they do not have the necessary background or information for making informed choices. Autonomy in medicine is not simply allowing patients to make their own decisions, but creating suitable conditions,( eg through patient counselling and education) to champion autonomous choice in others. For a physician, respect for autonomy includes respecting an individual’s right to self-determination as well as creating the conditions necessary for autonomous choice.
Thus you will present all treatment options to a patient, explain risks and benefits in terms that a patient understands.
Some of the most common and difficult ethical issues to navigate arise when the patient’s autonomous decision conflicts with the physician’s beneficent duty to look out for the patient’s best interests. For example, a patient who has severe Peripheral Vascular Disease and who continues to smoke or a patient with a worsening bacterial infection who refuses antibiotics. As long as the patient meets the criteria for making an autonomous choice (the patient understands the decision at hand and is not basing the decision on delusional ideas), then the physician should respect the patient’s decisions even while trying to convince the patient otherwise.
Lets now look at this in the context of Physician Profiling and patient wellness efforts by Managed care companies have been around for more than 10 years.
As Information technology improves and the Funders ability to store, sort and mine vast silos of data becomes more evident. The Family Physician increasingly finds himself placed under strain to change his time honoured and trusted treatment and prescribing plans, and move to medication which is funder chosen ( and often based upon price), follow algorithms based on Pharmacoeconomics and which often ignore patient preference and generally placed into a situation where his and his patient’s autonomy is serially undermined by the computer power of the Funders.
Lets not overlook or minimise the beneficence of the Funder’s Primary Preventative programs, in that items such as Mammograms etc are paid from risk to encourage patient and physician usage of the modality. Remember however that much of this is simply an actuarial calculation confirming that paying for preventive measures is more costly than the older thinking of paying only for curative services. ( Remember when every patient who came in for a routine PAP smear. Or BP check was told that their funder did not pay for routine check-ups)
In being adjudicated on their practicing behaviour FPs are now increasingly penalised as “practicing poor medicine” if their patients are not using these primary preventative benefits.
From a Medical Ethics point of view, the patients inherent autonomy is being progressively assailed by the increasing paternalism of the funding organisations in the name of Pharmacoeconomics and their drive to save downstream costs.
Don’t get me wrong; Preventative healthcare should be the watchword of every doctor in RSA, but this modality is routinely undermined by the Funder’s open cheque book attitude permitting direct access to specialist and hospital services whilst economising on the 6% piece of pie taken home by the FPs. (Remember that many funders have administrators which are for profit, and curtailing specialist and hospital access by their members, could result in those members moving to another scheme. Do I smell the scent of maleficence here? I may be wrong.)
The current answer to the invasion into the Provider and Patients space is to be found in the IPA Foundation’s peer review programs, which have found increasing acceptability and fairness with Funders and Family practitioners alike. It can however only do so much and is dependent on you, the FP, reading your quarterly reports considering the advices of your Peer review officers, and most importantly reverting to us should you feel that you or your patient has been prejudiced in any way whatsoever in the process.
Stony silence, or laughing the peer review reports off, cause you ,as well as those you treat, more harm than good. Peer review is open to representation by you and reconsideration of your category is approached in the most open minded and transparent manner. Funders do make errors , and without your feedback , these too could be overlooked.
Help us to help you the FPs recapture your previously revered position. Email your problems and indeed any other Funder related problems , in to us, as we have access to the correct channels to get your complaint heard , and if necessary corrected.