The Ethics Of Accountability In Managed Care Reform

PROLOGUE: No country in the world can afford all of the medical care that providers can render to populations. Thus, in every nation governments and private-sector organizations design mechanisms that ration resources in ways that seem compatible with the values of a particular society. For the most part, governments establish these mechanisms, and most of the resources flow through public budgets or at least publicly fashioned funding channels. But in the United States the purchasers of medical care have increasingly favored the allocation of resources through marketlike mechanisms rather than by government regulation. Consumers and providers have found many of these strictures objectionable and have argued that private health plans must be called to greater accountability for their allocation decisions. In this paper Norman Daniels, a philosopher, and James Sabin, a physician, argue that the basis for assuring accountability in a democratic society is through the use of processes that accentuate fairness and openness. In the current political climate, neither party seems prepared to leave the development of these processes to the private marketplace, but whether Congress can achieve consensus on these contentious issues before the end of the 105th session is debatable. Daniels is Goldthwaite Professor and former chair of the Philosophy Department at Tufts University. He has written widely on ethics and public policy, and he recently coauthored a book on the ethical implications of the human genome project. Sabin is an associate clinical professor of psychiatry at the Harvard Medical School and codirects the Center for Ethics in Managed Care sponsored by Harvard Pilgrim Health Care Center and the Division of Medical Ethics at Harvard. ABSTRACT: Two notions of accountability embodied in proposals to reform managed care have different ethical implications. Market accountability requires plans to inform purchasers and consumers about performance and options, in theory legitimizing limits to care through consumer choice. Recognizing the limits of consumer choice, accountability for reasonableness requires that the rationales for limits to services be public and be based on reasons or rules that “fair-minded” people can agree are relevant to pursuing appropriate patient care under necessary resource constraints. Accountability for reasonableness educates clinicians and patients about the need for limits and empowers a more focused public deliberation in which ultimate authority for limiting care rests with democratic processes.