c. 1999 Religion News Service

UNDATED _ The weeks are running out for 8-year-old Jason Martin. He has a deadly brain tumor, and one last hope _ a new cancer-fighting drug being tested several hundred miles away.

The Martins, a family of modest means, have health insurance through a managed care organization. But the regional treatment center is outside the network of providers, and the organization has refused to cover the costly experimental-drug therapy.

With Jason’s story hitting the press, an appeal by the parents has landed on the desk of Dr. Stanley, a medical director with a solid commitment to delivering high-quality, appropriate care. What should he do?

The account _ though a fictional case study _ is the kind that has turned public wrath on what has become America’s dominant system of privately insured health care. Indignation has swelled over decisions by managed care companies to deny bone marrow transplants to women with advanced breast cancer, and other medical procedures to other desperate patients.

Now, a report by a Roman Catholic think tank _ which used the Jason Martin case study _ has cast a somewhat more charitable light on judgments rendered by people like Dr. Stanley.

Under the auspices of the Woodstock Theological Center in Washington, a 54-member panel of health care practitioners and industry leaders has been checking the ethical pulse of the system. The two-year study has yielded a mixed moral diagnosis of managed care and its survival as an institution worthy of public trust.

The 42-page report says managed care”may hold out a hope of providing a new vision for sustainable, efficient, socially responsible and ethically sound health care delivery in the United States.”It immediately adds,”We are a long way from that vision.” For managed-care executives, the document prescribes a meticulous method of ethical questioning that probes the claims of various”stakeholders,”including patients, doctors, employers who sponsor health plans and, in the case of for-profit systems, shareholders.

In the late 1980s, only a small portion of the insured population was enrolled in managed-care plans or other health maintenance organizations (HMOs). At the end of the 1990s, the majority of privately insured Americans receive part or all of their health care through such arrangements.

In traditional,”fee-for-service”health plans, insurance companies typically paid for whatever tests or treatment the doctor ordered, and otherwise pulled aside from health care delivery. The essential difference today is that managed care companies are intimately involved in managing the relationship between patients and providers, often second-guessing doctors or inducing them to curb costly procedures.

What provoked the rise of managed care was a dire need to control medical costs, in part through promoting healthy habits such as low-fat diets and regular exercise, notes Jesuit Father James L. Connor, the Woodstock center’s director.”It wasn’t purely greed,”he said of the motivation.”It was to stop the runaway costs of health care, which were clearly getting out of hand.”Managed care, Connor said, has helped squeeze the fat out of the system, although public and political pressures have already led to a loosening of the grip on costs.

A virtue of managed care is its insistence on patients taking responsibility”for their own, God-given health,”he said.”It’s also been a reminder to doctors that excessive testing and medications, without any consideration of costs, is irresponsible.” Proliferating medical technologies have heightened the cost dilemma, along with what some consider the essentially moral challenge of equitably and prudently allocating health care resources.

Managed care organizations have responded by imposing the terms of treatment, thus intruding, inevitably, upon the doctor-patient relationship. Frequently care companies have left the impression of acting entirely out of bottom line, financial motives. That suspicion has even stalked nonprofit care systems.

A widely diagnosed ill of managed care is the way it has demoralized many clinicians. Connor alluded to stories of middle-aged doctors pulling off the shingle out of frustration with managed-care bureaucracies.”There are some very good physicians who are now fishing in Florida. They’re saying, `I’m sure as heck not going to have a 22-year-old kid, just out of business school, on the other end of the line, telling me what I can and cannot do for my patient.” The Woodstock center’s new document is intended as a guide through what it terms the”ethical maze”of managed care. The 54 signers include leaders of managed-care organizations such as Kaiser Permanente, giant employers such as Ford Motor Company, industry groups, hospitals and medical institutions. Ethicists and policy analysts also took part.

It is probably the first time such a widely represented group has deliberated so extensively on the morality of managed care. The seminar convened four times in the past two years.

Members ranged from doctors who at least initially viewed managed care as”the devil incarnate”to executives who believe they are doing”God’s work in allocating scarce resources in a better way,”said Brookings Institution economist Margaret M. Blair.

Blair, who had the main hand in drafting the consensus document, said participants wound up agreeing on ethical procedures. Indeed, while public attention has dwelled on yes-or-no decisions in contested cases of managed care, the report gives greater ethical import to the value-laden process of arriving at those decisions.

The heart of the document, titled”Ethical Issues in Managed Health Care Organizations”(Georgetown University Press), is the composite case of Jason Martin. The drama is in the medical director’s mulling of questions spotlighting often-colliding values and priorities.

For example, Dr. Stanley’s managed care organization has a policy of not covering experimental treatment (like the drug therapy giving hope to the Martins) or treatment outside the network of providers (where they want to go). Would granting an exception in Jason’s case create a harmful precedent?

Would more patients insist on exotic and unproven procedures, possibly escalating the cost of employee health plans? Would employers pass on the charges to their workers, or trim health benefits to hold down costs?

The organization’s oncologists have begun testing the same cancer-fighting drug, though less promisingly than at the regional center. Would a choice to send the family outside the network betray a lack of confidence in Stanley’s own staff?

Furthermore, have Jason’s parents really weighed the slender chance of success against the burden of further treatment and the hardship of separation during what might be their son’s final days? The regional center is 400 miles away and Jason’s father would have to stay behind at his job.

During seminar meetings, participants acted the parts of these and other”stakeholders.”In the end, Stanley decides to cover the experimental treatment _ but only within the network. He also decides to tap the regional center’s physician as a consultant.”It came down to a gut feeling, based on limited evidence he had, that Jason might have a chance to get an additional 24 months of life with the new therapy,”the report explains.

Blair, a senior fellow at Brookings, said seminar participants couldn’t agree on such weighty questions as whether the profit motive should play a role in health care decisions. But she added,”Everyone was able to concede that managed care could be a good system, if it has built-in safeguards and procedures that push toward fairness.” The ethical fortunes of this system, Blair suggested, may ultimately depend how many real-life Dr. Stanleys are out there in the brave new world of managed care.

DEA END BOLE