Academic journal article The Hastings Center Report

Justice and Managed Care

Academic journal article The Hastings Center Report

Justice and Managed Care

Article excerpt

Four Principles for the Just Allocation of Health Care Resources

The American health care system has long been criticized for its injustice. The absence of universal coverage and the reliance on employer-based health insurance and patient ability to pay create financial barriers that limit access and produce high levels of under- and uninsured. Further, the diffuseness of decisionmaking within the American health care system precludes a coherent process for allocating health care resources.[1] The growing dominance of managed care organizations raises both expectation and apprehension about improving the justice of the American health care system. How can we evaluate the justice of a managed care organization's allocation of resources? What set of criteria can we use to determine when managed care's denial of benefits is just or unjust?

Two Dimensions of Justice in Health Care

Issues related to justice in health care can be divided along two dimensions: access and allocation.[2] Access refers to whether people who are--or should be--entitled to health care services receive them. Allocation refers to determining what resources should be devoted to health care, at three distinct levels.[3] At the social level, allocation refers to the proportion of Gross National Product, the government budget, or a company's revenues that should be devoted to health care. At the service level, allocation refers to what health services people should be guaranteed as part of a basic benefits package, or which services should receive the highest funding priority. At the patient care level, allocation refers to which specific patients should obtain naturally or socially scarce services, such as organ transplantation or in-patient psychiatric care for depression. Managed care organizations are involved in allocation at both the service and patient care level.

Access and allocation are related. One of the main allocating decisions is whether to use resources to increase the number of people entitled to specific services or to expand the range of services provided. For instance, the Oregon Medicaid reform plan opts "to assure everyone basic health care rather than to offer a larger but unevaluated collection of benefits to some of the poor while excluding others from anything but emergency services."[4] Nevertheless, access and allocation are conceptually distinct: After we decide that people should have access to health services, it is always a further question to delineate precisely what services they will be guaranteed.

While some managed care organizations have accepted some responsibility to ensure access for the uninsured,[5] whether managed care organizations--and those who fund them--have such an obligation and how far such an obligation extends are complex and unresolved issues. Conversely, the fair allocation of resources at the service level is an obligation all parties, including managed care organizations themselves, agree they have.[6] The very nature of managed care financing and delivery makes defining benefits inescapable; receiving a fixed budget to provide services for a defined population necessitates judgments about what services should be guaranteed and what should be left to members' discretion. Indeed, an advantage of managed care is that there finally is a natural locus in the American health care system for service level allocation decisions. What constitutes a just allocation of health care resources at the service level for managed care organizations?

Principles for the Just Allocation of Health Care Resources

There have been many different substantive methods proposed for the just allocation of health care resources, including cost-effectiveness, age-based rationing, the prudent insurer method, and the fair opportunity method.[7] Yet even their proponents acknowledge that these substantive methods have serious philosophical and practical problems that constrain their use for the just allocation of resources. …

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