By JULIE MINDA
Health care reform is expected to have an impact on virtually every aspect of the nation's health care delivery system. Providers are beginning to plan how best to meet the promises and challenges of health care reform, and ethicists say that organizational ethics should be part of this conversation.
Ministry providers have "a chance to be ahead of the game," said Kirk Hanson. "Having a clear understanding of the organization's values will help the Catholic health care system deal with the great number of questions that are arising under health reform." Hanson is executive director of the Markkula Center for Applied Ethics at Santa Clara University in Santa Clara, Calif. The center partners with and consults for Daughters of Charity Health System of Los Altos Hills, Calif.
The Patient Protection and Affordable Care Act signed into law in March 2010 includes provisions designed in part to encourage the integration of health systems, expand access to preventive care, cut down on health care fraud, expand the health care workforce, improve care quality and efficiency, link payment to quality outcomes, encourage innovation and increase the availability of home care and community care. Provisions are rolling out over the next several years.
Ministry moorings
Transitioning to this new system of care is requiring health systems and facilities across the continuum to evaluate every aspect of their operations in light of health care reform's goals and implementing regulations.
During this period of change, systems need to adapt in a way that is consistent with their organizational mission, Hanson said. They need to define their values and ensure those values are operational enough to act upon.
Ron Hamel, CHA senior director of ethics, said it is important for ministry providers to ensure that they are grounded in an organizational ethics approach, one that looks proactively at decisions made throughout the organization through the lens of mission and values. "Ethics must permeate the organization," Hamel said.
John Wallenhorst, vice president of mission and ethics at Bon Secours Health System of Marriottsville, Md., described organizational ethics as being a methodical and intentional way of making decisions. He said it challenges people to be thoughtful and discerning — approaches that are important in a period of rapid and far-reaching change.
Shifting locus of care
Hamel said that both the locus of care and the people who are providing that care are shifting, and ethical discernment is needed in this transition. He said more care is being delivered in the community rather than at the hospital, and this trend likely will continue under health reform. "This moves ethics questions out of the hospital and into the clinics," he said.
John Gallagher, corporate director of ethics at Cincinnati's Catholic Health Partners, concurred, adding that more care will be delivered by home care specialists in patients' homes.
Hamel and Gallagher said health systems should be applying organizational ethics to their nonhospital operations and staff. They should be asking what concerns often arise in those settings and how those concerns could be prevented through changes in policy, for instance.
New and different partnerships
With health reform calling for new types of partnerships among players in the health care system — accountable care organizations, for instance — health systems are considering new styles of relationship with other health care providers, physician groups, insurers and others.
"We'll be asked to enter into new and unconventional partnerships in the years ahead, and that will require us to think creatively from an ethics point of view about how to enter into that relationship in a way that benefits the community and does not dilute who we are," said Bon Secours' Wallenhorst. "We'll be looking at how to partner with other people in a way that effectively maintains our Catholic identity
and organizational ethics is one important way of focusing on our mission and Catholic identity."
Philip Boyle, vice president of mission and ethics for Newtown Square, Pa.-based Catholic Health East, said, "We're looking at: Who do we partner with and under what set of circumstances and what kinds of partnerships — it's all issues of cooperation." Many such questions relate to whether the affiliations are in accord with the Ethical and Religious Directives for Catholic Health Care Services.
Many of the partnerships are likely to be with physicians and physician groups. "These increasing relationships with physicians — that has some challenging dimensions," said Wallenhorst. "The challenge is to be discerning about why we're doing the partnering and then how to engage the physicians with our ways of doing organizational ethics."
Some have argued that sales and mergers will increase under health care reform. A preventive ethics approach and moral analysis will enable providers to reflect on the details of the deals in light of questions related to mission and values. Systems grounded in an organizational ethics approach already take this tack when entertaining such deals, noted Hamel.
Hanson of Markkula noted that it was a flurry of hospital deals happening in the 1990s and early 2000s that originally heightened Catholic health systems' interest in organizational ethics in the first place.
Quality care
Care outcomes are in the spotlight under health care reform, particularly since government payers increasingly will be reimbursing based on the quality of care delivered.
St. Joseph Health System of Orange, Calif., applies Lean management concepts developed in the automotive industry to health care delivery in order to identify systemic concerns and address them quickly. And this is true for its organizational ethics approaches as well. The system has been using organizational ethics to look at care patterns and address issues that arise frequently. For instance, through an Ethics Improvement Project, it put in place protocols so that decisions on life-sustaining treatment would be made in a more timely and effective manner — and in a way that is in line with ministry values — in ICUs.
Applying such approaches proactively and across the organization also can help systems improve care processes that have been contributing to frequent patient readmissions. For instance, said Gallagher of CHP, hospitals may realize that people with end-stage chronic obstructive pulmonary disease are returning frequently for readmission. Hospital leaders in this case might reflect on whether it makes sense to put in place new procedures to ensure these patients are better prepared for post-discharge care.
Potential cuts
Some experts have said that health care reform may lead to decreases in some categories of hospital revenue. For instance, Hamel explained, some have said that with more preventive care practices in place under reform, patients will be healthier and require fewer hospital services, which could mean a drop in inpatient revenues for hospitals. On the other hand, more preventative services could identify more conditions in people who then may seek more care both inside and outside of the inpatient environment.
Under another scenario, hospital revenues could drop if states continue to experience budget struggles and then look toward Medicaid reimbursement cuts to balance their budgets.
If revenues do drop, under whatever scenario, hospitals will need to determine how to manage the shortfall. They should apply an organizational ethics approach when making the decisions, Hamel said. For instance, they'll need to ask: If some services must be cut to improve finances, what cuts would be in line with the hospital's mission, who might be impacted and how might the hospital lessen the impact.
Hamel said, particularly in this era of change, it should be clear to Catholic health systems and facilities that a preventive, organizational ethics approach is a must. "You can't sit back and think that organizational ethics is optional. To not take that approach would be to disregard an important reality — and that is that ethics pervades everything, and we need to do it.
"Otherwise, it's like putting blinders on," he said.
Health Progress series examines intersection of ethics, reform
In the July-August issue, Health Progress debuted a series on ethical perspectives on health care reform. The inaugural articles delve into myths about reform and into ethical questions surrounding an individual mandate for purchasing health insurance.
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