Expert Still Wrestles With How To Use Medical Resources Fairly

Thirty years ago, when psychiatrist James Sabin, M.D., joined Harvard Community Health Plan (HCHP), the organization was in the vanguard of a movement its advocates hoped might become a model for a reformed American health care system.

Along with Kaiser Permanente and Group Health Cooperative of Puget Sound, HCHP pioneered a vision of prepaid medical care within a staff-model HMO, seeking equitable and ethical allocation of resources for a defined population.

It was a vision that challenged the dominance of the model of private-practice, fee-for-service medicine and offered a remedy—so its adherents believed—to the idiosyncrasies and inequities (and the rising costs just then making themselves felt) inherent in that model.

In time, Sabin would become associate medical director at HCHP, and then associate director of the health plan's fledgling teaching program.

“I thought an HMO-based teaching program ought to address the question of how can societies best address the issue of providing access to—and at the same time setting limits for—a fundamental human good? And how can that process be done in a way that is clinically informed, ethically justifiable, and socially acceptable?”

Today, the notion of prepaid managed care as the antidote to America's health care problems appears to have been sidelined by the anti-HMO“ backlash,” and HCHP has separated into Harvard Vanguard Medical Associates, a clinician-governed multispecialty group practice, and Harvard Pilgrim Health Care, a not-for-profit health plan.

But the questions that intrigued Sabin then still animate a career devoted to exploring how medical resources can be ethically allocated across a population. And he has continued to expound the founding visions of managed care, while physician colleagues have come to regard “ethics” and“ managed care” as mutually exclusive.

As director of the Harvard Pilgrim Health Care Ethics Program and co-founder of the Center for Ethics in Managed Care, sponsored by the Department of Ambulatory Care and Prevention and Division of Medical Ethics at Harvard Medical School, Sabin is responsible for a nationally recognized, organizational-ethics program.

Navigating by `Ethical Compass'

Sabin leads periodic meetings of Harvard Pilgrim's Ethics Advisory Group, which includes members, employer representatives, clinicians, and staff, and helps provide an “ethical compass” for the company's business and clinical decisions. In 2004 the group suggested principles and guidelines on a number of important issues facing the health plan, including the risks and advantages of bariatric surgery, the use of preexisting-condition exclusions in benefit plans, the movement toward increased patient cost sharing and“ consumer-directed” plans, and the proper collection and use of data that identify members' race and ethnicity in programs intended to reduce disparities in health care.

Setting Limits Fairly, written with Norman Daniels, was published by Oxford University Press in 2002. No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence, written with Steven Pearson and Ezekiel Emanuel, was published by Oxford University Press in 2003.

In 2002 Sabin received the American Association of Community Psychiatrists' Moffic Award for Ethical Practice in Public Sector Managed Behavioral Healthcare.

Throughout, of course, Sabin has always treated patients with mental illness, and he emphasized that his interest in organizational ethics and his training in psychiatry are far from antithetical.

“I think our profession has an inherent connection to the domain of ethics,” he told Psychiatric News. “In our clinical work with patients, we are hearing in deep ways about values, and our role is to understand and bring about constructive movement for individuals, families, and groups. So as clinicians we are dealing with the core activities that the field of ethics deals with.”

Much of what Sabin means when he refers to ethics is centered on the understanding that health care is a finite resource, and hence one that is rationed—either fairly or unfairly. As he wrote in Setting Limits Fairly, “Because resources are limited, all societies must set limits to care and establish priorities about how resources will be used—whether they acknowledge doing so or not.”

It is a notion that has not found easy acceptance in America, and thus it may not be surprising that Sabin's collaborative work with Daniels has been more widely received in Europe than in the United States.

“For some, rationing means taking an otherwise healthy person and turning off the ventilator,” he told Psychiatric News.“ But what it really means is hard-nosed attention to the most cost-effective way of providing care. That's the thing that needs to be done day in and day out—making difficult decisions about whether a small marginal benefit warrants a significantly larger cost.

“By and large we have avoided those questions at the program level, with the exception of a number of Medicaid programs and organizations like Kaiser, which are explicit about looking at the evidence and making decisions about how to practice.”

Insurers Became Activists

Thirty years ago, he said, the insurance industry largely performed a“ pass-through,” or middleman, function, paying hospitals and physicians for services rendered to enrollees. When costs began to escalate, however, policymakers expected insurers to take a more active role in making determinations of value and worthiness of expenditures—a movement that formed the basis for managed care.

But, Sabin said, insurers took on this task with “zero public education about the need for managed care and zero political leadership in articulating the underlying problems.” And while there were organizations that had decades of experience in ethical, population-based health care, there were others that practiced what Sabin called“ 1-800-Just Say No.”

The result was an enormous backlash against managed care that tarnished the entire movement.

Today, Sabin sees a “third wave” in the insurance industry marked by the effort to pass decisions about limit setting down to the patient, through higher deductibles and tiered formularies.

“We have essentially said for the moment that we cannot effectively set limits in health care as a society, so we will ask individuals to decide for themselves what is worthwhile through significantly increased deductibles,” he said. “Where this goes remains to be seen. On the up side, some of the population may become much more discerning and thoughtful consumers of health care, bringing about a kind of public education that the political process has failed at abysmally.

“At the other extreme, people of limited financial means may simply forego medically important care and risk a decline in well-being. If this happens, their plight is likely to trigger a backlash against this approach.”

`Perfect Storm' Developed

The American political process has failed in other ways to lead an informed discourse about ethics and medical care, Sabin said. A case in point is that of Terri Schiavo, which he called “a perfect storm for ethics and public policy” because several factors came together in a way that led to a“ stunningly muddled” discourse.

“Part of it was the media's focus on a painfully bitter difference of perspective within the family,” Sabin said. “And part of it was a political process that corrupted efforts to understand Ms. Schiavo's medical condition, a process that went wildly out of control.

“One good thing perhaps is that it seems the public had a fairly high degree of revulsion at the political posturing and showed good sense in distinguishing between the tragic personal situation and the disgraceful political maneuvering. But for the most part, deep moral issues got lost when the political process picked up on the personal situation and exploited it for partisan political gain.”

Indian Project Under Way

Today Sabin is extending his interest in ethics and medical care overseas to India, where he is working with colleagues investigating the ethical and social aspects of the effort to roll out antiretroviral medicines for AIDS.

The goal of the Values and Access to Medicines Project is to improve the effectiveness and equity of international, national, and local programs that deliver antiretroviral treatment for HIV/AIDS in developing countries. The project builds on efforts to identify, in the context of the U.S. managed care system, a systematic approach to values in the provision of pharmacy benefits.

Sabin said that although this new endeavor might seem to be a far stretch from the practice of psychiatry, in fact it feels like familiar territory.“ What attracted me to psychiatry in the first place was that it seemed like an area where one could help individuals make the most of their lives and at the same time engage with the deepest and most central existential issues at the individual and societal levels.

“That's proven to be true,” he continued. “In one sense what I've done is unusual, but to me it feels almost like a linear application of the core values and activities that psychiatry is all about.”▪