Ethical Challenges in Managed Care: A Casebook

By Karen Grandstrand Gervais; Reinhard Priester et al. | Go to book overview

17
Quality Care for Elderly
Nursing Home Patients

CASE STUDY

The Tamarack Health System owns a large delivery network that includes physician practices, clinics, hospitals, nursing homes, and a hospice and home care company. Over the years, it has intentionally created a values-driven organizational culture. All managers and employees are schooled in the meaning and application of the system values of caring, quality, dignity, and stewardship. Their performance evaluations are focused on the extent to which they implement these system values in their actions and decisions.

Tamarack has a contractual arrangement with the OptiHealth Health Plan that enables physicians of OptiHealth to practice in Tamarack's health care facilities. OptiHealth is a staff model HMO (that is, an HMO whose physicians are salaried employees) that has a large Medicare contract. Dr. Wilson, a geriatrician employed by OptiHealth, has several Medicare-covered patients in one of Tamarack's nursing homes. Recently, OptiHealth initiated cost-containment measures to lower physician use of laboratory services. According to plan data, laboratory use rates among its physicians, particularly for its Medicare enrollees, are significantly higher than the rates of other physician groups. To incline physicians toward greater restraint, the health plan has implemented new practice guidelines designed to discourage laboratory tests that are not medically necessary for Medicare enrollees.

Mrs. Erickson, a ninety-year-old woman, is one of Dr. Wilson's patients. She was admitted to Tamarack's nursing home from another long-term care facility over a year ago. Her admitting medical problems included stage-four decubitus sores, arthritis, scoliosis, paralysis following a stroke, and dementia. Upon admission, she was poorly nourished.

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