Policy and Ethics

• Summary
• What is Integrated Care?
• Policy Issues Around Integrated Care
  • Co-ordinated Care
  • Managed Care and Health Plans
  • Health Action Zones
• What are the Risks Associated with Integrated Care?
• Ethics of Integrated Care
• Conclusions
• References
• Disclaimer

Summary

This paper describes some of the policy issues underlying concepts of integrated care and looks at the ethical issues that these concepts raise.

The spectrum of integrated care spans "co-ordinated care" in Australia and New Zealand through to "managed care" in the US and "Health Action Zones" in the United Kingdom. At the "co-ordinated care" end of the spectrum, integrated care represents simple collaboration between different providers to provide ease of access for patients to services, whereas at the "managed care" end, it represents a fundamental shift of professional loyalty from an individual patient’s health to the health of populations. Health Action Zones are an extension of integrated care. They are local solutions that are aimed at improving the inequalities of socio-economic status that contribute to poor health.

The ethical issues surrounding a move from a traditional medical focus on individual patients (Hippocratic Code) to a population-based-medicine approach, are about different views of justice or fairness. Traditionally, the doctor has imposed his or her own personal understanding of the Hippocratic view on society. Integrated care is a different approach, improving the health of an individual patient only in the context of improving societal health. Neither approach is ethically superior, but each will arrive at a different set of trade-offs. The acceptability of those trade-offs depends on which version of social justice is preferred and to what or to whom we owe moral obligations in the provision of health care.

What is Integrated Care?

Integrated care means different things to different people. Integrated care refers to "methods and organisations to provide the most cost-effective and caring services to those with the greatest health needs and to ensure continuity of care and co-ordination between different services".  ¹   Integrated care covers a wide variety of arrangements ranging from "co-ordinated care" to "managed care" and health plans. At one end of the spectrum, integrated care could be a chronic disease management model     (eg cardiac failure or diabetes) or at the other end, a scheme responsible for maximising health gain for an enrolled population (geographic area or health plan). The complexity of the integrated care organisation therefore depends on the scope of the health risk covered.

While at its most simple, integrated care represents collaboration between different providers; at its most complex, it represents a fundamental shift of professional loyalty from individual patients to a group of patients, "whose aggregate health, physicians must maximise out of a fixed budget". The logical extension of integrated care is the Health Action Zones concept in the United Kingdom. The purpose of Health Action Zones in the UK is "to bring together all those contributing to the health of the local population to develop and implement a locally agreed strategy for improving the health of local people". Health Action Zones involve local authorities, community groups, the voluntary sector and local businesses in their work.  ³  

Policy Issues Around Integrated Care
 

Co-ordinated Care
Co-ordinated care is essentially a process to manage chronic illness and disability more effectively at a community level. Co-ordinated care is about the integration of community care, primary care and hospital services to reduce demand on traditional hospitals and provide health care more effectively in the community. The intention is that the health care for one consumer is managed by one agency.

The model represents a shift in the way health services are delivered from a funding-based model to an outcomes-based one. Hospitals are the major pillar of the health system, but do not necessarily lead to health gains. A critical aspect of co-ordinated care is to reduce hospital admissions and the major emphasis on secondary care by redeployment of resources to programmes that prevent the need for hospitalisation. The model requires patient enrolment and care planning. Services for enrolled patients can be allocated to a base plan, predictable-preventable events, and predictable-unpreventable events.  ²   Recognising preventable components allows resources to be reallocated. For example, while myocardial infarction rates cannot be immediately changed, admissions to hospital for heart failure can and the resulting savings could be put into programmes to reduce the prevalence of heart disease.

This is how the South Australian Health Commission envisages the model working:

Managed Care and Health Plans
Prepaid group health care began in the US in the 1940s as an insurgent, even radical form of medicine. Doctors sacrificed independent fee-for-service practice for a salary, collegial setting and a social ethic. The turning point was in the early 1970s when these plans were called Health Maintenance Organisations (HMOs). This organisational structure was resisted by clinicians as "socialistic", but today there are concerns of corporate meddling by non-clinicians - clinicians are caught between the patient on the one hand and the payers, employers and government.  ⁴   This sounds like a very familiar story despite significant differences between the Gross Domestic Products of the US and New Zealand.

In the US there appear to be two different forms of managed care - socially-oriented and market-oriented. Socially-oriented managed care plans realise efficiencies by prevention/education, incentives for cost-effective medicine and "best practice". Market-oriented managed care plans tend to use financial risk-sharing by clinicians so that clinician’s earnings are influenced by incentives not to treat some patients and the ethical conflict of interest is stark.  ⁴   While there appears to be a partial convergence developing between these two approaches, consumer satisfaction is greatly in favour of not-for-profit when compared to for-profit plans. It appears that patients are able to recognise the financial-ethical conflict of interest shared by for-profit clinicians. A major counterbalance to the excesses of managed care in the US has been the establishment of "checks and balances" including discerning consumerism, information on quality (HEDIS), medical professionalism, regulation and compulsory risk-pools between HMOs for catastrophically expensive conditions.  ⁵  

If New Zealand adopts proposals for managed care, it could do so either on the basis of local or geographic enrolment (community health plans), or on the basis of health insurance and managed competition (managed health plans). If the former were adopted, portability would be an issue for patients as they moved from one community to another. Funding of a community health plan could be on the basis of the Population Based Funding Formula (PBFF). If managed health plans were adopted, good risk adjustment mechanisms to prevent "cream skimming" - that is the prevention of plans selecting those individuals with the best health risk - would be critical for success. Whether the development of a good risk-adjusted capitation payment formula is technically feasible is debatable.  ⁶   The PBFF is a crude risk-adjusted capitation payment formula which has been used to allocate funding among the four regional offices of the THA (previously Regional Health Authorities). It would be attenuated if applied to smaller populations. The issue for managed competition is not whether there is a perfect formula, but whether there is a formula sufficiently robust to prevent "cream skimming". If not, community health plans by creating local monopsonistic insurance markets may be the answer. A mixture of both approaches is also possible. However, at the end of the day New Zealand may be just too small a population for managed competition. After all, we are not California.

Health Action Zones
Health Action Zones are a natural extension of integrated care and reflect a need to address major inequalities in health through local leadership and targeting. Health Action Zones are long term, spanning a period of five to seven years, recognising the need for a strategic approach. The concept is a response to socio-economic inequalities in health status but it is not yet clear how successful it will be. Nevertheless, given poor health status resulting from poverty in some communities, there is an opportunity to achieve some significant gains in health status.  ⁷  

Health Action Zones address three broad strategic objectives, which relate to better health and better care:  ³  

1. Identifying and addressing the public health needs of the local area.
2. Increasing the effectiveness, efficiency and responsiveness of services by addressing:
   - a commitment to services based on the needs of people
   - the need to develop primary care services where deprivation is at its greatest
   - the balance between preventive and population-based care
   - the organisation and structure of hospital services.
3. Developing partnerships for improving people’s health and relevant services, adding value through creating synergy between the work of different agencies.

Health Action Zones may have special status with exemptions from certain legislation to promote and improve innovation in service delivery.

What are the Risks Associated with Integrated Care?

In the absence of regulation and monitoring of integrated care, there are always opportunities for cost-shifting, moral hazard, under-purchasing, high transaction costs and poor quality of care. The roles of sanctions and incentives need to be considered carefully. In the US the use of financial sanctions is employed at both the institutional and individual levels. On the other hand, the UK is employing a "third way", based on relationships that are honest, open and trusting. While this is laudable, given the pressure on the health dollar, there needs to be a regulatory environment around integrated care.

Integrated care is about health gain (improved health outcomes). Therefore, concepts of health gain should provide a framework for monitoring the success or failure of integrated care organisations. However, the measurement of health outcomes is notoriously difficult. Furthermore, measurements of health outcome may only change slowly over a timeframe of many years. It was once described "as paint drying slowly". It could take a long time to detect the failure of an integrated care programme and by then it may be too late to avert the results of a problem.

Nevertheless, integrated care is happening now, albeit mainly at the co-ordinated care end of the spectrum. It is the trend the world is following in the pursuit of controlling health expenditure and improving the health of populations given the scarce health dollar. There is some criticism that there is not sufficient evidence to warrant the introduction of integrated care. Like most endeavours in health policy, evidence-based policy making is difficult. Random and blinded trials in health policy do not seem achievable in the timeframes available to the political process. However the Health Funding Authority is developing a number of integrated care pilots which it will be evaluating over the next few years. New Zealand’s three year electoral cycle may well overtake these developments.

Ethics of Integrated Care

There was a time when professional ethics alone gave health care moral commitment.  ⁸   The Hippocratic Oath enshrines the relationship between patient and doctor within the ’Hippocratic Code: "I will follow that system of regimen which according to my ability and judgement, I will consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous."  ⁹   The "four principles plus scope" approach to medical ethics provides a simple, and culturally neutral, approach to thinking about the ethical issues that surround health care.  ¹⁰   This approach employs four moral commitments, respect for autonomy, beneficence, non-maleficence and justice. The Hippocratic moral obligation provides net medical benefit to patients with minimal harm - beneficence, with non-maleficence. Where the "four principles plus scope" approach significantly differs from the Hippocratic Code depends on concepts of justice or fairness and to what or to whom we owe these moral obligations. This is at the heart of the ethical issues surrounding a move from the traditional medical focus on individual patients to the population-based-medicine approach inherent in integrated care.

New Zealanders believe in justice or fairness. In the context of the allocation of scarce resources in health care, different concepts of justice are in conflict. Do we allocate resources in proportion to those with like need (horizontal equity) or in proportion to the morally relevant inequalities such as socio-economic status (vertical equity)? This is particularly important when considering socio-economic disadvantage. Inequalities in socio-economic status are mirrored in health status - low income significantly increases the risk of premature death.  ⁷   Do we maximise the health benefit produced by the available resources? Economists would argue not to do so is unethical. Resources are scarce and we have to make choices in health care. Any choice results in an opportunity cost equal to the value of the alternative that is forgone. Wrong choices are unethical. However, as we have experienced in New Zealand, making choices in health care is not that easy.

We need to recognise the different competing concepts of justice. Traditionally the doctor has imposed his or her own personal understanding of the Hippocratic view on society. This view maximises the health of individual patients at the expense of social health gain. Integrated care is a different approach, improving the health of an individual patient only in the context of improving societal health. It is about balancing personal and population health measures. It is much more about horizontal and vertical equity. However, the process of maximising health gain for society will certainly prove an opportunity cost to some individual patient benefits. The different notions of justice surrounding population-based medicine clearly conflict with the traditional Hippocratic view. However, the time when professional ethics alone gave health care moral commitment may be over. Clinicians may have to balance the resources for a given individual patient in the context of the greater good.

Conclusions

The ethical issues surrounding a move from personal health care to a population-based-medicine approach are about different views of justice. Neither approach is ethically superior but each will arrive at a different set of trade-offs. The acceptability of those trade-offs will depend on which version of social justice is preferred.

References

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