American Military University Week 7 Addressing Ethical Issues IECs Discussion From Chapter 12, Darr (2011, p 306) writes “institutional ethics committees (

American Military University Week 7 Addressing Ethical Issues IECs Discussion From Chapter 12, Darr (2011, p 306) writes “institutional ethics committees (IECs) should assess prospectively and retrospectively the ethical issues raised in competition, marketing, and managed care. They should review the ethical implications of competitions as it affects their patients, organization, and community”. Consider yourself a member of the IEC. Identify two ways to ensure ethical issues are properly addressed.300 words two sources CHAPTER 12
ETHICS IN MARKETING AND MANAGED CARE
n the 1920s, President Calvin Coolidge stated that the business of America is business. This
statement remains true and the United States is the bastion of free-market, democratic
capitalism. Unique among its enterprises are health services organizations. These enterprises
differ in purpose, type of service provided, orientation, and motives. Health services
providers are often faith-based and have not-for-profit tax status. Health services organizations
are unique because they are intimately involved with several professions and provide services
that have significant emotional and psychological dimensions. Health services organizations
are social enterprises with an economic dimension, rather than economic enterprises with a
social dimension.
The elements of marketing—product, place, promotion, and pricing—have been applied to
health services. Here, again, health services differ significantly. Unlike marketing in traditional
business enterprises, which seeks to create demand, health services marketing seeks to meet a
demand, perhaps unrealized, for its services. The distinction between business enterprise and
health services has become less clear since the 1980s. Health services organizations have
engaged in marketing for many years. Any type of community outreach is an implicit form of
marketing. Historically, marketing occurs in several ways, including community health days,
disease screening, well-baby clinics, and press releases from the provider. The milieu of the
competitive marketplace, however, began to require that marketing become systematic,
focused, and much more aggressive.
I
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NEED VERSUS DEMAND
Opinions vary when the role of marketing in health services is assessed: Is demand being
created or is it being met? Important to answering this question is disagreement about the types
of health services demand that are meritorious (in itself a value-laden concept). Few would
disagree that it is important to create consumer demand for hypertension or colorectal cancer
screening. The desirability of such efforts is tempered by calculating costs and benefits.
Depending on the population and the disease, screening may be unacceptably expensive when
measured by the number of true positives found and the morbidity and mortality prevented.
Screening may be done even when it is not cost-effective, for reasons of political correctness
or to further a feeling of well-being in a population.
Both price and nonprice competition may increase demand. Competition in the business
sector is generally deemed to be desirable, but its desirability is less clear in health services.
This is true because services are duplicated and because competing for physicians, staff, and
patients is costly. Despite acceptance of competition, disagreement continues as to whether the
demand created is appropriate.
In addition, conditions requiring medical intervention may be treated with different
Darr, K. (2011). Ethics in health services management, fifth edition. Retrieved from http://ebookcentral.proquest.com
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Copyright © 2011. Health Professions Press, Inc.. All rights reserved.
therapies. Coronary artery bypass surgery or angioplasty for individuals who have had mild
heart attacks is an example of an expensive therapy that patients may be able to avoid. One
study found that patients given the most elaborate tests and treatments were two or three times
more likely to suffer a second heart attack or die within 30 days than were those diagnosed and
treated with noninvasive therapies, such as exercise stress tests and drugs that dissolved blood
clots. It has been estimated that 400,000–600,000 Americans could avoid angioplasty each
year at a cost of $20,000–$25,000 per procedure.1 The benefits are obvious.
Similar treatment controversies are found in diagnoses such as prostate cancer. Following
early detection using the prostate-specific antigen test, the standard therapy has been to treat all
malignant prostate tumors aggressively with surgery or with radiation therapy. As a result, men
who would neither die from nor likely even notice small prostate tumors endure treatment that
often causes complications such as incontinence, impotence, injury, and sometimes death.
Watchful waiting with active surveillance (WWAS) is a more desirable alternative. WWAS
entails closely monitoring the progression of small, slow-growing tumors and initiating
treatment only as necessary.2 Added to quality of life benefits is that of a marked decrease in
costs compared with active treatment. WWAS is especially desirable for men who may not
live another 10 years, such as those older than age 75, or those with severe heart disease or
diabetes.
More subjective situations contrast with the objective need to intervene when coronary
artery disease is present. Cosmetic surgery is often cited as an example of an “unnecessary”
medical service. It is claimed that face lifts, tummy tucks, silicone implants, and Botox waste
medical resources—regardless of payment source—and that these “resources” should be used
for other health problems. This is a subjective definition of need. Reasonable persons could
differ as to what patients need and how or whether the demand that arises from that need
should be met by the healthcare system. Perhaps interventions such as cosmetic surgery should
not be defined as health services, but rather as consumer services similar to hair styling,
exercise and yoga classes, laser vision correction, and bodybuilding.
Epidemiologic studies should be used to develop data about populations. These data
reveal the incidence and prevalence of diseases as well as psychological and physical
concerns of the population that may fall outside traditional definitions of disease. The real
problem in terms of assessing need and demand arises when those judging such data apply
their personal value systems to determine how important the “problem” is. These judgments
cause the process to be less than objective, whether it affects decisions in determining what to
study or what is to be done with the results. In turn, these decisions affect the choice of
regimens and decisions about whether to provide treatment. More important, however, they
diminish or thwart the autonomy and decision making of individuals.
The debate about need is most heated when the ethics of marketing is included. This is
especially true when marketing is to be used to affect demand or to encourage persons to seek
elective procedures. Physical or psychological conditions about which an individual is either
unaware or unwilling to seek treatment represent potential demand. Conditions for which no
help is sought because of financial barriers also represent potential demand; examples are
dental care, hammertoes, hemorrhoids, and mental health services.
Troubling in this debate is the suggestion that meeting potential, consumer-driven demand
Darr, K. (2011). Ethics in health services management, fifth edition. Retrieved from http://ebookcentral.proquest.com
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is unethical. The constitution of the World Health Organization defines health as “a state of
complete physical, mental, and social well-being and not merely the absence of disease or
infirmity.”3 This broad definition includes as beneficial all efforts to improve physical, mental,
and social well-being. It is instructive to consider wellness (prevention) activities. The
possibilities for organizational involvement are almost limitless because every facet of life
could be affected to improve general health and prevent medical problems. Beyond wellness
activities are questions of how to treat demand for services that may seem foolish to some.
Should persons be denied cosmetic surgery because others judge such procedures to be trivial
or because what they seek to correct is not life threatening? Currently, such infringements on
individual autonomy are greater than the public will accept.
It is not clear how and by whom need and demand are to be judged. Despite the presence
of the occasional hypochondriac or patient with Munchausen’s syndrome, demand for medical
services should be accepted as rational. When typical patients hear about new medical
problems or treatment and diagnostic possibilities, they respond rationally. The “worried
well” are not clinically ill but are concerned about their health and quality of life. Their
decisions about elective procedures are personal cost–benefit analyses. It is when publicly
funded programs use cost–benefit analyses to make macroallocation decisions that services
may become unavailable. Oregon’s example of prioritizing health services in its Medicaid
program is instructive and rational when political decisions determine the services available.
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Responsible Marketing
How does the health services organization market to patients and potential patients in ways that
are consistent with its ethical obligation to avoid creating unnecessary demand, but which
simultaneously find and serve those who might need services? In its Principles and Practices
for Marketing Communications in Hospitals and Health Systems, the Society for Healthcare
Strategy & Market Development (SHSMD) of the American Hospital Association (AHA)
includes a marketing communications checklist.4 The checklist has 12 areas for organizations
to consider in marketing communications. Examples include “Does the product or service
being promoted add genuine value for the patient?,” “Does the communication set realistic
expectations?,” “If quality measures are highlighted, are words such as safe, high(est),
effective, painless, best, and top quality used with caution and only when they can be verified
and objectively substantiated?,” and “Is the language in the communication readily
understandable by the audience for which it is intended?” Separate sections provide guidance
on price information, endorsements and testimonials, use of physicians in marketing, social
media, and blogger advertising, among others. In sum, the SHSMD advisory encourages
marketing communications that are truthful, fair, accurate, complete, and sensitive to the
healthcare needs of the public.
The emergence and widespread use of social media has added a dramatically new and
potentially problematic dimension to health services marketing. At this writing, it is estimated
that 250 hospitals are using YouTube, Facebook, Twitter, or blogs in outreach to their service
areas. Some hospitals are using Twitter to show live surgical procedures. In one instance, the
Twitter broadcast is enhanced by tweets from a physician observing the procedure and
Darr, K. (2011). Ethics in health services management, fifth edition. Retrieved from http://ebookcentral.proquest.com
Created from apus on 2020-07-14 11:50:38.
providing live commentary. Should a complication arise, the hospital will cut away from the
live broadcast and substitute a video from a similar procedure. This raises ethical issues
because it will mislead the public about the procedure’s risks. In addition, concerns have been
raised about patient privacy.5 Social media offer great potential for service recovery,
responding to and sharing positive feedback, and learning how other health services
organizations use those same tools. An argument against using social media is that the
organization cannot control what is being said about it on these various sites. But the comments
are being made regardless and the organization will benefit from becoming part of the
conversation. By knowing what is being said, the organization can improve its services and
respond to concerns and complaints from users. Nonetheless, ethical issues abound in the
interactions that can come from social media. The organization is obliged to ensure that
responses to social media interactions meet basic requirements established by the AHA and
are consistent with its own values.6
If profit and return on investment are their primary reasons for being, organizations will
have a very different view of responsible marketing and appropriate competition. This is the
difference between giving the public whatever it wants and tempering desires and potential
demand with judgments about value and usefulness. This view of the patient includes elements
of paternalism, but it should be consistent with the organization’s mission statement.
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Demarketing to Avoid Bankruptcy
Chief executive officer (CEO) Chris Hines had finally gotten down far enough in the stack of papers on her desk to get to last
month’s emergency department (ED) activity report. She had already digested the grim news about the continued financial
hemorrhage affecting Community Hospital. The current deficit was $500,000—and it was only the fourth month of the fiscal
year. Because Community Hospital served largely inner city patients, many of whom were uninsured or whose care was paid
by a chronically underfunded Medicaid program, there seemed to be little hope that the financial situation would improve.
Hines knew that more than 40% of Community Hospital’s admissions come through the ED and that about half of those
admissions arrived by taxi, private automobile, or on foot. The other half arrived via the city-owned ambulance service. Hines
had tried to implement a plan to increase elective admissions, and thus improve the payer mix, by encouraging her attending
physicians to admit their private patients to Community. Her effort failed. Next, Hines tried to work with city officials to
implement a new ambulance routing system that would give Community a chance to improve its financial condition.
Unsympathetic city officials refused to help.
Hines knew that Community Hospital’s endowment would carry the hospital for approximately 3 more years, but that the
institution would have to close if it were not breaking even by then. Because the city was uncooperative, Hines concluded that
the key to survival lay with reducing the number of uninsured and Medicaid patients admitted through the ED.
Hines spoke with several marketing consultants, one of whom offered to do pro bono work for Community Hospital. He
seized on the idea of “demarket-ing” the ED. He reasoned that it was the fine reputation enjoyed by Community Hospital’s ED
that was largely responsible for the 50% of ED patients who arrived by means other than city ambulance. He listed the
following ways the ED could be made less attractive to potential patients: reducing ED staffing to a minimum; closing the
parking lot near the ED; reducing housekeeping services so that the physical plant would be dirty and unkempt; deferring
nonsafety-related maintenance; changing triage policies, procedures, and staffing to increase waiting time for nonemergency
patients; using staff who were most likely to be rude and inconsiderate; and encouraging rumors that closure of the ED was
imminent.
The consultant knew that there might be repercussions beyond the ED, but Community was desperate, and he believed
extreme action was necessary.
A first question is whether Hines and her managers ignored other steps to improve the financial
condition of Community. Examples include closing the ED rather than demarketing it (a more
honest solution); undertaking other, more remunerative medical care activities to offset ED
losses; or opening less costly primary care clinics to care for the worried well and other
Darr, K. (2011). Ethics in health services management, fifth edition. Retrieved from http://ebookcentral.proquest.com
Created from apus on 2020-07-14 11:50:38.
nonemergent medical problems.
Even if such options were available, however, a demarketing strategy raises two ethical
issues. First, the steps contemplated are likely to negatively affect the quality of care in the ED.
Beyond staffing and the physical aspects directly affected, the psychological impact on ED
staff, with its ripple effect on inpatient care, will reduce employee morale and ultimately the
quality of care. Such actions violate the principles of beneficence and nonmaleficence and the
virtues of caring and honesty.
A second ethical principle to be considered is justice. People in the community are caught
between the city bureaucracy and the efforts of Community Hospital to remain financially
viable. They may have little choice but to endure the indignities and reduction in quality of
service resulting from the demarketing strategy. Deliberately adding insult to injury should give
all concerned great discomfort. A dimension of justice and the virtue of fidelity deplore the
unfairness associated with forcing ED staff to work under such conditions. They will bear the
brunt of angry patients and the dilapidated, depressing environment of the ED.
That the declining financial condition of Community Hospital might eventually result in the
same changes in the ED does not justify taking them as recommended by the consultant.
Desperate managers may consider desperate acts, but the actions being recommended are not
morally justifiable.
Copyright © 2011. Health Professions Press, Inc.. All rights reserved.
FUTURE OF COMPETITION
A theory in political science suggests that, over time, enemies begin to take on one another’s
attributes. This concern is troubling to the not-for-profit sector of the health services system,
which views itself as holding and furthering values different from and superior to those in the
for-profit sector. These individuals fear that competition for market share and the focus on
financial considerations and economic survival will cause them to lose sight of their
humanitarian and charitable motives.
In this regard, payment systems are especially significant. The advent of reimbursement
using diagnosis-related groups for hospitalized Medicare beneficiaries was the opening round
of what is proving to be a continuing reassessment of payment schemes. Competition and costcutting are furthering the shift from fee-for-service to various forms of fixed payment.
Physician and organizational providers are becoming aligned in relationships that add a
significant amount of complexity to traditional ethical problems and raise new ones as well.
Physicians are beginning to push back against the various pressures on them, however. Many
are limiting the number of Medicare and Medicaid patients in their practices, refusing to
accept assignment from managed care and managed care organization (MCO) fee schedules,
and establishing boutique practices to serve fee-for-service patients exclusively. Hospitals
have less flexibility, but market conditions may allow them to negotiate better reimbursement
schedules with MCOs.7
Some writers suggest that the pressures of fixed-fee reimbursement will lead to an
adversarial relationship between patients and health services organizations (and, perhaps,
physicians) and that the interests of patients will be subordinated to the demands of efficiency
and economic survival. Such results are possible under any payment system or ownership, and
Darr, K. (2011). Ethics in health services management, fifth edition. Retrieved from http://ebookcentral.proquest.com
Created from apus on 2020-07-14 11:50:38.
they will occur whenever caregivers and managers lose sight of their reason for being. Doing
more with less is not at variance with efforts to operationalize the principles of respect for
persons, beneficence, nonmaleficence, and justice, as well as several of the virtues. It remains
for all who organize, plan, and deliver health services to keep these values in mind.
COMPETITION AND HUMAN RESOURCES POLICY
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