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Ethical Integrity in Health Care Organizations

Published online by Cambridge University Press:  01 January 2021

Jessica Mantel
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Extract

The rise of managed care initiated a steady decline in solo and small group physician practices and the emergence of new delivery models built around large health care organizations (HCOs). Health care reform has only accelerated this trend as public and private payors shift to new payment methodologies that reward clinical and financial integration among providers. As a result, patients increasingly receive care from physicians and other health professionals organized into collaborative partnerships with one another and institutional providers, such as hospitals. As described below, this new organizational dynamic profoundly influences the clinical judgment of physicians. No longer can society simply depend on the professionalism of individual physicians to ensure ethical integrity in the health care setting. Rather, ethical integrity in the health care setting also requires a strong foundation of organizational ethics.

Type
JLME Column: Currents in Contemporary Bioethics
Information
Journal of Law, Medicine & Ethics , Volume 43 , Issue 3 , Autumn 2015 , pp. 661 - 665
Copyright
Copyright © American Society of Law, Medicine and Ethics 2015

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References

See Mantel, J., “The Myth of the Independent Physician: Implications for Health Law, Policy and Ethics,” Case Western Reserve Law Review 64, no. 2 (2013): 455–520.Google Scholar
See Schein, E., Organizational Culture and Leadership, 4th ed. (San Francisco: John Wiley & Sons, Inc., 2010): at 21.Google Scholar
Id., at Figure 2.1.Google Scholar
See Mantel, , supra note 1.Google Scholar
See Eddy, D. M., “Variation in Physician Practice: The Role of Uncertainty,” Health Affairs 3, no. 2 (1984): 74–89.Google Scholar
See Schein, , supra note 2, at 235–258.Google Scholar
See Mantel, J., “Spending Medicare's Dollars Wisely: Taking Aim at Hospitals' Cultures of Overtreatment,” Michigan Journal of Law Reform (forthcoming 2015).Google Scholar
See Kahan, D. M., “The Supreme Court 2010 Term: Forward: Neutral Principles, Motivated Cognition, and Some Problems for Constitutional Law,” Harvard Law Review 125, no. 1 (2011): 1–77. For example, studies have found that individuals have faster reaction times when generating and endorsing memories and beliefs consistent with conclusions that promote an individual's self-interest or desired ends. See Kunda, Z., “The Case for Motivated Reasoning,” Psychology Bulletin 108, no. 3 (1990): 480–498 (summarizing studies on biased memory search).Google Scholar
See Kahneman, D., Thinking Fast and Slow (New York: Farrar, Straus and Giroux, 2011): At 105; Regan, M. C. Jr., “Moral Institutions and Organizational Culture,” St. Louis University Law Journal 51, no. 4 (2007): 941–987. This does not mean deliberative reasoning cannot override our initial impressions – it can – but doing so requires mobilizing substantial mental focus, something individuals do infrequently, particularly when their mental capacity is otherwise taxed by the complexity of the situation or performing other tasks. See Kahneman, , supra at 81; Moore, D. Lowenstein, G., “Self-Interest, Automaticity, and the Psychology of Conflict of Interest,” Social Justice Research 17, no. 2 (2004): 189–202.Google Scholar
See Mantel, , supra note 1; Grochowski, E. C., “Ethical Issues in Managed Care: Can the Traditional Physician-Patient Relationship Be Preserved in the Era of Managed Care or Should It Be Replaced by a Group Ethic,” University of Michigan Journal of Law Reform 32, no. 4 (1998–1999): 619–660.Google Scholar
Mano-Negrin, R. Mittman, B., “Theorising [sic] the Social Within Physician Decision Making,” Journal of Management in Medicine 15, nos. 4–5 (2001): 259–266; Borbas, C. et al. , “The Role of Clinical Opinion Leaders in Guideline Implementation and Quality Improvement,” Chest 118, no. 2 (2000): At 24S–32S.CrossRefGoogle Scholar
See Mantel, , supra note 1.Google Scholar
See Wennberg, J. E. et al. , Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care, The Dartmouth Institute for Health Policy and Clinical Practice (2008): At 39, 46–49, 52 (describing the association between available resources and clinical decision-making). Although a possible explanation for the positive relationship between supply and utilization may be that regions with sicker patients acquire more medical resources because their patients require more care, researchers at the Dartmouth Atlas Project found that the prevalence and severity of illness accounts for remarkably little of the variation in utilization rates across hospital regions. Id., at 9.Google Scholar
See Baker, L. et al. , “The Relationship between Technology Availability and Health Care Spending,” Health Affairs Web W3–537, W3–542 (2003) (finding that greater availability of MRIs and CT units is associated with higher use and more spending). Cf. Brownlee, S., Over-treated (New Toek: Bloomsbury, 2007): At 161–63 (summarizing the comments of a hospital's chair of radiology, who stated that the availability of newer, faster machines “encourages physician to perform even more unnecessary tests,” thereby bolstering the hospital's revenue).Google Scholar
See Baker, , supra note 14.Google Scholar
See generally Silverman, H. J., “Organizational Ethics in Healthcare Organizations: Proactively Managing the Ethical Climate to Ensure Organizational Integrity,” HEC Forum 12, no. 3 (2000): 202–215; Goodstein, J. Lyman Potter, R., “Beyond Financial Incentives: Organizational Ethics and Organizational Integrity,” HEC. Forum 11, no. 4 (1999): 293–305; Renz, D. O. Eddy, W. B., “Organizations, Ethics, and Health Care: Building an Ethics Infrastructure for a New Era,” Bioethics Forum 12, no. 2 (Summer 1996): 29–39.CrossRefGoogle Scholar
See Zoubul, C., “Healthcare Institutional Ethics: Broader than Clinical Ethics,” in Health Care Ethics: Critical Issues for the 21st Century, Morris, E. ed., (Sudbury, Massachusetts: Jones and Bartlett Publishers, 2009): At 237.Google Scholar
See id., at 237–239.Google Scholar
See id.Google Scholar
See Guinn, D., “Corporate Compliance and Integrity Programs: The Uneasy Alliance between Law and Ethics,” HEC Forum 12, no. 4 (2000): 292–302.Google Scholar
See Mantel, , supra note 1 (discussing the competing obligations of HCOs).Google Scholar
See Mantel, J., “Accountable Care Organizations: Can We Have Our Cake and Eat It Too?” Seton Hall Law Review 42, no. 4 (2012): 1392–1442 (explaining the potential for accountable care organizations to achieve both lower costs and higher quality care).Google Scholar
Goodstein, Potter, , supra note 16, at 298.Google Scholar
Id., at 299.Google Scholar
See Silverman, , supra note 16; Renz, Eddy, , supra note 16.Google Scholar
See Silverman, , supra note 16; Renz, Eddy, , supra note 16.Google Scholar
Cf. Renz, Eddy, , supra note 16 (stating that building a new ethics infrastructure should be a “participatory process that involves those who have a stake in its operation”).Google Scholar
Hall, M. A., “A Corporate Ethic of ‘Care’ in Health Care,” Seattle Journal for Social Justice 3, no. 1 (2004): 417–428.Google Scholar
Cf. Renz, Eddy, , supra note 16 (comparing the narrow focus of hospital ethics committees to a broader ethics infrastructure).Google Scholar
See Goodstein, Potter, , supra note 16; Silverman, , supra note 16.Google Scholar
See O'Toole, B., “St. Louis System Has Corporate Ethics Committee,” Health Progress 87, no. 2 (2006): 42–45.Google Scholar
Cf. Silverman, , supra note 16 (urging that organizations have “forums that address ethics issues”); Goodstein, Potter, , supra note 16 (same).Google Scholar
See Pearson, S. D. et al. , No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence (New York: Oxford University Press, 2003): At 36–37.Google Scholar
See id.Google Scholar
Silverman, , supra note 16, at 211.Google Scholar
Silverman, , supra note 16.Google Scholar
Id.Google Scholar
Cf. Renz, Eddy, , supra note 16 (noting the importance of ethics and integrity audits that “assess whether the organization has lived up to its ethical standards”).Google Scholar
See Silverman, , supra note 16.Google Scholar
See Foglia, B. et al. , “Preventive Ethics: Addressing Ethics Quality Gaps on a Systems Level,” The Joint Commission Journal on Quality and Patient Safety 38, no. 3 (2012): 103–111.CrossRefGoogle Scholar
See id.Google Scholar
Although current Joint Commission standards for hospitals address hospitals' organizational culture, they focus on leadership creating “a culture of safety and quality,” ignoring that hospital leaders must balance these concerns with competing demands. See Joint Commission, 2015 Hospital Accreditation Standards (Illinois: Joint Commission Resources, Inc., 2015): At LD-16 to LD-20. The hospital accreditation standards also direct hospital leadership to address conflicts of interests involving licensed independent practitioners and/or staff that affects “the safety and quality of care, treatment, and services” in order to ensure ethical practices at the bedside and in the hospital's marketing and billing practices. See id., at LD.04.02.03. The Joint Commission's standards offer few guidelines for hospital leadership on the specific structures and processes hospitals should adopt in order to ensure their institution's ethical integrity.Google Scholar
For example, accountable care organizations could be required to adopt an ethics infrastructure as a condition of participation in the Medicare Shared Savings Program or analogous state Medicare shared savings programs, and hospitals and physician groups adopting an ethics infrastructure could be rewarded with higher payment rates under Medicare and Medicaid value-based purchasing initiatives.Google Scholar