Psychotherapy, Parity, and Ethical Utilization Management.

Managed care has long functioned with the assumption of a split in clinical and ethical responsibility for treatment. The insurance company clinician has been seen as owing a primary obligation to the insurance company and its utilization management standards, while the treating clinician is seen as holding primary clinical and ethical responsibility for the patient and the treatment. This article explores the potential impact of mental health parity mandates and recent clarifications of the American Psychiatric Association's ethical code on this split for psychiatrists and other clinicians who develop utilization management standards or serve as utilization reviewers.

[Shared governance and reasonableness as ethical contributions to health policy]. / La gobernanza compartida y la razonabilidad como aportaciones éticas a la política sanitaria.

Health is one of the fundamental human rights. Recognizing it as a right means that the State has an obligation to ensure a minimum level of opportunities is maintained, and to restore it when lost. This minimum level may not be covered in periods of economic crisis, such as the one we are currently experiencing.Managed care, focused on economic questions, emerged after the crisis of 1973 in order to help make clinical decisions based on economic factors. In practice, the result of managed care was to turn economic cost control into an end in itself while forgetting about equity; something for which it has been challenged from an ethical perspective. Since then, many authors have attempted to reconcile efficiency and equity in health management, but the debate remains open.In this article, and basing our approach on the theories of P. Ruger and Norman Daniels, we argue that shared health governance and accountability for reasonableness can offer significant ethical contributions in the process of achieving an efficient and fair health system. In the model we propose, citizens, professionals and health institutions all play an active role in capacity building in the field of health. These capacities are related to healthy lifestyles, accessible and transparent information, the promotion of self-care, the acquisition of knowledge, skills and appropriate attitudes, leadership based on values and co-responsibility to achieve set goals in a reasonable way. If we develop these capacities, we will have used the current economic crisis as an opportunity for improving ethical practice in the field of health.

Regulated wet nursing: managed care or organized crime?

Wet nursing was widely practiced from antiquity. For the wealthy, it was a way to overcome the burdens of breastfeeding and increase the number of offspring. For the poor, it was an organized industry ensuring regular payment, and in some parishes the major source of income. The abuse of wet nursing, especially the taking in of several nurslings, prompted legislation which became the basis of public health laws in the second half of the 19th century. The qualifications demanded from a mercenary nurse codified by Soran in the 2nd century CE remained unchanged for 1,700 years. When artificial feeding lost its threat thanks to sewage disposal, improved plumbing, the introduction of rubber teats, cooling facilities and commercial formula, wet nursing declined towards the end of the 19th century.

Different labs.

In this case a young dentist has signed onto a managed care plan that has several attractive features. Eventually, however, he notices that he makes little or no net revenue for some of the work that he does. A colleague recommends that he use different labs for different patients, with labs matched to each patient's dental plan and coverage. Offshore labs are used for managed care patients. Three knowledgeable experts comment on the case, two with many years of private practice experience, two who are dental educators holding master's degrees in philosophy and bioethics.

Just caring: defining a basic benefit package.

What should be the content of a package of health care services that we would want to guarantee to all Americans? This question cannot be answered adequately apart from also addressing the issue of fair health care rationing. Consequently, as I argue in this essay, appeal to the language of "basic," "essential," "adequate," "minimally decent," or "medically necessary" for purposes of answering our question is unhelpful. All these notions are too vague to be useful. Cost matters. Effectiveness matters. The clinical circumstances of a patient matters. But what we must ultimately determine is what we mutually agree are the just claims to needed health care of each American in a relatively complex range of clinical circumstances. Answering this question will require a public moral conversation, a fair process of rational democratic deliberation aimed at defining both just claims to needed health care and just limits.

Brokering authenticity: Borderline personality disorder and the ethics of care in an American eating disorder clinic.

This paper examines the moral work of a controversial psychiatric diagnosis--Borderline Personality Disorder--in an American eating disorder treatment center in the era of managed mental health care. Based on fieldwork at this clinic spanning more than 6 years, I consider how clinicians invoke aspects of Borderline Personality Disorder in everyday conversation, in a practice I call "borderline talk." I argue that borderline talk emerges in response to being caught between contradictory models of the subject entailed in managed care and psychodynamic discourses. Specifically, borderline talk enables clinicians to endorse a formulation of the subject that, although considered pathological, provides them with a clear path of ethical action in otherwise ethically ambiguous situations. These kinds of everyday ethical negotiations percolate throughout the American health care system and are key mechanisms through which notions of economic expediency become entangled with concepts of the healthy subject. As clinicians struggle out a course of action between competing ethical imperatives, they also struggle out the workability--and failures--of various articulations of the subject within contemporary American cultural ideologies of health and pathology.

'Care': moral concept or merely an organisational suffix?

BACKGROUND: Over recent decades, a couple of interesting trends have occurred in regard to human services practices in Australia. First, there has been a significant shift from practices that previously have intentionally responded to emerging and continuing human need within communities to practices that are now managed within a context of managerialism and influenced by market forces. Second, in such a changing context, increasingly, organisations have added the suffix 'care' to their organisational name. One is therefore left to consider why this latter change has occurred, and how is care being considered, particularly in organisations supporting people with intellectual disability (ID). METHOD: A conceptual-theoretical analysis is undertaken to explore the characteristics of human services that embrace managerialism. The moral constructions of personhood in regard to people with ID within this service context are investigated; and the implications of how care is practised are considered. RESULTS: An immoral-amoral binary of personhood within an underpinning neo-liberal context is identified and analysed. Further analysis reveals a more insidious independent-dependent binary for people with an ID linked to a dominating Ethic of Normalcy. This latter binary suggests that care seemingly becomes neither ethically relevant nor legitimate for people with ID in managerialist service contexts. CONCLUSIONS: Ethical transformation in regard to care is needed for contemporary human services practice for people with ID. The underpinning Ethic of Normalcy is challenged for an Ethic of Engagement; whereby a deep understanding of care as a moral concept needs to be at the core of practice, rather than merely attached in an organisational name.

Rekindling commitment: reflections from a pastoral educator enmeshed in direct support professional workforce development and person centered supports.

BACKGROUND: Services with people with intellectual disabilities (ID) are increasingly structured by regulations, policies and licensing standards by public funding entities. The key responsibility for direct care staff often becomes that of compliance with all the rules and regulations. METHOD: The impact of an increasing focus on compliance with regulations in the systems of services and supports for people with ID is explored along with the absence of focus on professional commitment and relationships. This exploration is done through a review of literature and also anecdotes and observations from 30 years of professional experience in working with direct care staff. RESULTS: Whether the source for enhanced regulation is concern about health and safety, honouring rights, meeting laws and/or an underlying fear that we cannot rely on the caregivers because of the turnover or lack of skill; we end up building a system based more and more on compliance, on regulations, programme and behavioural plans and competencies, without the same kind of concern or attention for people who are doing the caring, their motivation and what they need. One of the hypotheses and conclusions of this article is that the focus on compliance diminishes professional competence and commitment, and contributes both to staff disillusionment and to the rapid turnover. CONCLUSIONS: As recruitment and turnover in the direct support professional workforce become ever more difficult problems, the newer focus on person-centred planning, self-directed supports and workforce development have both possibilities and problems in enhancing staff commitment in relationships with people they support. The importance of enhancing and supporting commitment also calls for new forms of professional identity and education that recapture the language and habits of commitment while also providing opportunities for staff to reflect on the values, visions and commitments that support their work.

Internal and external goods: a philosophical critique of the hybridisation of professionalism.

BACKGROUND: Recent literature on professionalism describes the hybridisation of professional practices because of the pressures of neo-liberal managerialism. While the general opinion appears to be that this development was inevitable given the task of service organisations to operate on the market, this paper questions that blurring the distinction between professional and managerial responsibilities is sound business advice for market-orientated service providers. METHOD: The method is philosophical analysis. A normative account of 'true' professionalism is discussed in order to determine the relation between professionalism and managerialism. By placing this account in the framework of Aristotelian moral philosophy, three distinctions are presented to argue that professional practices will most likely be successful in managerial terms when the internal values of professional practices are not mixed up with the external values of the service organisation. RESULTS: The analysis results in an argument about economic value as a contingent 'by-product' of professional expertise. The outcome is the prediction that professional activity will be most responsive to organisational goals implemented and monitored by management to the extent that professionals are enabled to serve the goals internal to their profession. Professional excellence will be most profitable when professionals do not have to mind about being profitable. CONCLUSIONS: Neo-liberal managerialism assumes that making professionals share managerial values of accountability and transparency will improve both the economic performance of service organisations and the quality of their services. The argument concerning the contribution to these values by professionals as a contingent by-product of professional excellence shows that this assumption is questionable.

Holding services to account.

BACKGROUND: Recently, the frequency of audit inspections of health services for people with intellectual disability (ID) in the UK has increased, from occasional inquiries to a systematic audit of all services. From 2008, a process of continuous audit 'surveillance' of specialist health services is to be introduced. Similar regimes of inspection are in place for social care services. AIM: To explore the conceptual positions which inform audit, through detailed examination of the investigation into the learning disability service at Sutton and Merton. FINDINGS: Audit is distinct from evaluation because it neither provides opportunities for service staff to give an account of their work nor represents a search for knowledge. Audit investigates adherence to government policy. In ID, audits measure aspirations derived from normalisation, despite research showing that some of these aspirations have not been achieved by any service. As audit consumes significant public resource, it is questionable whether the dominant finding of the Healthcare Commission's investigation into Sutton and Merton, that the ID service was chronically under-funded, represents value for money. DISCUSSION AND CONCLUSIONS: While basic checks on minimum standards will always be necessary, service excellence requires not audit but research-driven evaluation. Audits inhibit rather than open-up debate about improving support to people with ID. They impose an ideology, squander resource, and demoralise carers and staff. Evaluations challenge the implicit management-versus-professional binary enacted by audit, and can inform new care systems which make effective use of all those engaged with people with ID.

Learning from the legal history of billing for medical fees.

INTRODUCTION: When patients pay for care out-of-pocket, physicians must balance their professional obligations to serve with the commercial demands of medical practice. Consumer-directed health care makes this problem newly pressing, but law and ethics have thought for millennia about how doctors should bill patients. HISTORICAL BACKGROUND: At various points in European history, the law restricted doctors' ability to bill for their services, but this legal aversion to commercializing medicine did not take root in the American colonies. Rather, US law has always treated selling medical services the way it treats other sales. Yet doctors acted differently in a crucial way. Driven by the economics of medical practice before the spread of health insurance, doctors charged patients according to what they thought each patient could afford. The use of sliding fee scales persisted until widespread health insurance drove a standardization of fees. CURRENT PRACTICE: Today, encouraged by Medicare rules and managed care discounts, providers use a perverse form of a sliding scale that charges the most to patients who can afford the least. Primary care physicians typically charge uninsured patients one third to one half more than they receive from insurers for basic office or hospital visits, and markups are substantially higher (2 to 2.5 times) for high-tech tests and specialists' invasive procedures. CONCLUSION: Ethical and professional principles might require providers to return to discounting fees for patients in straitened circumstances, but imposing such a duty formally (by law or by ethical code) on doctors would be harder both in principle and in practice than to impose such a duty on hospitals. Still, professional ethics should encourage physicians to give patients in economic trouble at least the benefit of the lowest rate they accept from an established payer.

A doubtful guest: managed care and mental health.

This article examines the ways in which mental health services have been affected by managed care and describes how to address some of the ethical conflicts that have always existed, but have been transformed immeasurably. It outlines the ethical dilemmas between the competing values of mental health providers and managed care, as well as the practical ethical considerations related to confidentiality, billing, and coding. It suggests that there can be no real improvement for mental health providers in the ethical minefield of managed care until they stop focusing on how distressed they are about it and start dealing with the larger, systemic issues in psychiatry and American health care. The article concludes by noting that the only way to effect meaningful change in the health care system is to combine knowledge with advocacy and to proactively define the standards needed to make the necessary choices.