The Ethics of Integrated Health Care Provision

Role Conflict
Any integrated care system which makes optimal use of the health care professionals within it to guide and direct policy has the effect of putting the professional in a dual role as both provider and rationer of care. Some professionals such as doctors and nurses like to see themselves as advocates for the best treatment for the particular patient. This has become a particularly widespread claim in reaction to managed care systems in the US.  ¹   However there is often a confusion between best and maximal in the pleas that are being made. It is clear that the best treatment for a given patient may not involve the maximal investigation and highest technology intervention that can be used. This was confirmed in the case of a Native American who was admitted to an American hospital with fairly obvious cardiomyopathy resulting from malnutrition and alcoholism and in whom a “cardiac consult” resulted in an interventional cardiologist calling in to see him, looking at the ECG, and ordering a coronary angiogram (to be done by the cardiologist himself). The propriety of this was questioned in the light of the overall clinical picture and an argument arose about whether the patient was being refused the best treatment on the ground of rationing and whether that was a function, in this case, of the mans non-white, non-middle-class status. The fact that the diagnostic intervention had its own morbidity and mortality was not considered because of the sorcerers broom effect of high technology medicine.  ²   Arguably, in this patient, the coronary angiogram should not have been performed until there had been a more thorough evaluation of the response of the heart to other measures, and both its risks and its costs avoided until it was clearly indicated in the light of total clinical management.

Any system where the expenditure on any single patient impacts on the total managed pool of funds and where the doctor has a management role in the use of those funds does casts the doctor in the problematic dual role. But, in reality, the only way that this problem has traditionally been avoided is through burying our heads in the sand over the real constraints on a public health care system. In the past, doctors have competed for funds for their own special interest areas of medicine by adopting the attitude that somebody would pay, rather than by critically assessing the total health care budget and playing an intelligent role in cost containment in the interests of overall efficiency.

Undertreatment and Overtreatment
Some systems link the doctors income, direct and indirect, to interventions performed and others link it to the level of savings achieved given the number of patients treated. The latter arrangement usually involves an allocation of funds for the total patient care budget with decisions about the purchase of services to be made within that budget. In this arrangement the controllers of the integrated care have savings to disburse if they provide the treatments required without using the funds available. If those savings are disbursed in such a way as to enhance the income of the health professionals, either directly (payments) or indirectly (payment for continuing medical education, subsidised travel, free care for the under 12-year-old patients with fee-for-service billing, or whatever) then an incentive is created to undertreat especially when otherwise the treatments involved would include expensive services like acute in-hospital treatment or high-cost surgery. This incentive is to be avoided as is the opposite incentive to overtreatment which is created by an uncapped fee-for-service with fees linked to identifiable interventions (the kind of context that operated with the cardiomyopathy patient mentioned earlier).

Innovation, Research, and Development
An integrated care scheme works best where all the interventions funded have fairly straightforward criteria for diagnosis and are fairly straightforward interventions. Under those ideal circumstances, mapping diagnoses (in the light of other risk factors) to payment categories is possible and a reasonable averaged cost for standard treatment can be settled without too much difficulty. However, if a new treatment is introduced with definite potential for better outcomes and less morbidity, it may initially be more expensive than the existing, standard treatments. There is a clear incentive in any integrated budget system to have a very high threshold for the introduction of such innovations in care until the pressure of patient demand becomes irresistible. That pressure is, however, most likely to arise where the patients have unfettered access to a wide range of providers, at least some of whom are not bound by the standardised route that might be favoured in certain integrated care schemes. Therefore, there is almost a reverse Kantian constraint (what I do should be permissible universally) on health care according to which it is acceptable to introduce a generally applicable system, provided only that it is not universal, in the formation of health care configurations. A built-in zone of exception is required to allow innovation and development, and decision within the system must be realistically contestable by consumers. What is more, this has to be a funding priority for the system to allow it to be truly self-sustaining in terms of research and development rather than parasitic upon other more balanced systems.

A Comprehensive Range of Services
Any integrated system needs to have a relatively well-balanced range of services. The initial decision as to which services will be included is, however, not made ex nihilo. However, there is something to be said for taking over existing arrangements and operating initially according to historical patterns of health care provision. What is to be said for that strategy is not Luddite but rather Darwinian. Any existing arrangement is likely to be a colloquy of tried and proven solutions to messy problems and unforeseen needs and the results of historical accident, prejudice, and traditional hierarchies of privilege. However neither of these groups of features comes ready labelled so that one does not know if one is dismantling or neglecting a feature of the system that will ultimately have to be recreated (at some expense) or one that is both dispensable and should be dispensed with. The Darwinian intuition is that a system which has evolved to have a certain form has usually adapted itself to multiple realities in its domain of operation and these may not be obvious to a de novo planning purview.

Individual Professional Judgement
It is appropriate to deal with two further general issues before moving on to compare different integrated care arrangements in terms of their ability to meet the ethical desiderata outlined.

Informed clinical decision-making
The first constraint is that the clinical decisions about diagnosis and management, although ideally linked to an evidential base, ought also to have the flexibility to be optimised for individual patient needs. This flexibility allows the doctor to exercise professional judgement in the best interests of the patient. Reflected in such judgements are other professional opinions based on the informal assessments of the abilities of more specialised colleagues. If these were to become undermined by the fact that some specialist services would offer cut-rate interventions, informally judged to be inferior in a given setting, then that would prevent the doctor from truly making a judgement about the best treatment for the patient.

However, informal judgements and patterns of practice are as subject to vagary and privilege as anything else. Therefore any integrated system must include a significant component of objective peer group audit which monitors outcomes and costs for diagnosis related groups adjusted for case mix or other factors which would affect risks and complications. These audits should ideally form part of the structure of self-education and professional reflective practice fostered by an integrated care arrangement.

Continuing medical or professional education (CME) is, as a consequence of this last point, an important part of any integrated care organisation with regular input required from those with specialised knowledge from within and without the particular integrated care scheme in question. Only in this way can the scheme remain truly open to advances in medicine and have a further check against narrow and closed in-house fixing of standards of care.

Empowering the patient
Although a very important part of providing professional care is the provision of clinically informed recommendations when requested by consumers (as indicated in the Code of Health and Disability Consumers Rights), this must be complemented by a genuine empowerment of the patient. True empowerment of the patient means that the patient is fully included in the health care decision-making process, not simply asked to rubber stamp recommendations for care that are not completely understood. Only under these circumstances can the openness of an integrated system have true effect.

1. Total integration. This is the most rational and the most dangerous of all the systems because it is highly prone to capture by an ideologically driven or unbalanced set of planners. If, for instance, a set of planners wedded to the market model or a production-line-costed-unit approach to health care were to take over such a system it might fall prey to many of the evils discussed above with consequent disruption of patient care.
2. Partial integration of funded services. This system combines the strengths of 1 and 3 and is to be commended on that basis. It is less prone to ideological capture but, depending on the proportion of funding to be held for integration of care, can effectively turn into 1.
3. Integrated autonomous providers. This system has all the advantages of independent co-operative individualism with diversity of thinking and consequent fertile innovative opportunities unless it is skewed or distorted by narrow funding arrangements which effectively deprive the individual providers of any flexibility of movement. It is also prone to some less attractive services falling between the cracks of the more assessable and easily planned aspects of care which can be costed, have margins set, and a successful and smoothly running operation planned.
4. Integrated funding of independent providers. This inherits many of the disadvantages of fragmented care especially if the providers are encouraged to compete with one another. In fact, the latter arrangement is totally inimical to a progressive scientific community of health care professionals among whom realistic standard setting and the fair evaluation of innovations is fostered.