Challenges in researching racially sensitive topics in HMOs.

When research designed to close the disparities gap is conducted in real-world health care settings, unique sensitivities may arise, particularly when race is the focus of interventions. Researchers encountered this issue in the course of a randomized trial investigating the influence of ethnic identity (EI) among African American (AA) study participants. The study was conducted by the research programs at three health maintenance organizations (HMOs) and the University of Michigan Center for Health Communications Research, as described in this issue of the journal (Resnicow et al., 2009). This commentary describes the research partnership's concerns for the racially sensitive nature of the study and the precautions undertaken to mitigate them. The research study's experiences may be informative and insightful for health plans and research centers invested in health disparities research.

Community-based participatory research: partnering with communities for effective and sustainable behavioral health interventions.

The present issue contains one of the first studies published in Health Psychology-by Resnicow and colleagues-that uses elements of community-based participatory research (CBPR) (Resnicow et al., 2009). The authors engaged community partners (three health maintenance organizations or HMOs) to develop and implement a fruit and vegetable promotion intervention (Tolsma et al., 2009). African American HMO patients (the intervention targets) participated in formative work (i.e., focus groups) on survey items and intervention content and in survey pilot testing. A diverse group of researcher and nonresearcher expert stakeholders (e.g., African American health plan staff; consultants with expertise in Black identity theory, on which the intervention was based) was engaged in major project decisions regarding the measures and intervention design.

Principles versus procedures in making health care coverage decisions: addressing inevitable conflicts.

It has been suggested that focusing on procedures when setting priorities for health care avoids the conflicts that arise when attempting to agree on principles. A prominent example of this approach is "accountability for reasonableness." We will argue that the same problem arises with procedural accounts; reasonable people will disagree about central elements in the process. We consider the procedural condition of appeal process and three examples of conflicts over coverage decisions: a patients' rights law in Norway, health technologies coverage recommendations in the UK, and care withheld by HMOs in the US. In each case a process is at the center of controversy, illustrating the difficulties in establishing procedures that are widely accepted as legitimate. Further work must be done in developing procedural frameworks.

Confronting trade-offs in health care: Harvard Pilgrim Health Care's organizational ethics program.

Patients, providers, and policy leaders need a new moral compass to guide them in the turbulent U.S. health care system. Task forces have proposed excellent ethical codes, but these have been seen as too abstract to provide guidance at the front lines. Harvard Pilgrim Health Care's ten-year experience with an organizational ethics program suggests ways in which health care organizations can strengthen transparency, consumer focus, and overall ethical performance and contribute to the national health policy dialogue.

Hospital ethics committees: is it time to expand our access to managed care organizations?

Hospital ethics committees provide important services to their institutions, often including review of clinical cases for which an ethical issue or dilemma has been recognized.Traditionally, such case reviews or consults by the ethics committee may be called by the patient and/or family and institutional healthcare providers. Recently, managed care organizations have requested an ethics committee case review at a Chicago area institution. This article will explore whether or not the time has come to expand hospital ethics committees access to managed care organizations.

Ethical evaluation of "retainer fee" medical practice.

This article examines the reasons that some physicians have recently opted to reduce the size of their practice rosters to allow more time for each patient in exchange for a retainer fee from patients. These physicians also offer supplementary, nonmedical amenities to patients as part of their service. Because physicians have reduced the size of their practice rosters and have increased the price tag for their services, some patients have lost access to their care. We have tried to assess the ethical propriety of such a change in the design of medical practices by weighing plausible, ethically relevant arguments favoring and opposing RFMP. Physicians are ethically obligated first and foremost to promote and protect the health of their patients. RFMP fulfills this duty directly by ensuring prompt and ample professional time for the care of patients. It does so indirectly by allowing time for physicians' continuing education, which in turn should upgrade the quality of care. It also advances the ethical goals of autonomy as it allows patients to choose their own physicians and to spend their money as they please. On the other hand, these ethical positives are offset by the cost of retainer fees that may exclude access of patients to their physicians' care. Even if ethical tradition obligates physicians primarily to patients under their specific care, as professionals and as private citizens, they also have a responsibility to support the health of the entire community. RFMP does little to advance this cause, except that by optimizing the conditions under which their own private patients receive healthcare, they call attention to shortcomings in prevailing public healthcare policies, which by comparison fall short of that standard. An assumption that health is not properly a market commodity, and that all people should receive healthcare on equal terms, would expose RFMP to moral reproof. From an ethical perspective, we find sufficient cause for concern and caution in this innovative style of practice. Nevertheless, the weight of arguments presented here does not seem to justify unequivocal moral condemnation of RFMP. As neither pro nor con views seem to have settled the ethical question, definitive moral judgment on RFMP will probably depend on the outcome of future experience and ongoing evaluation. The implications of RFMP for any future healthcare system are not clear, at least to us.

Ethical differences between socialized and HMO systems.

A visiting scholar from the School of Philosophy of Leeds University, England, was invited to participate in a seminar at the Section of Bioethics of Drexel University School of Medicine, which discussed (a) ethical differences between socialized and HMO systems, (b) physician-assisted suicide, (c) reproductive technology, (d) triage and rationing, and (e) organ donation and sale.

Ethics orientation as a mediator of organizational integrity in health services organizations.

Increasing scrutiny of ethical misconduct by federal and state agencies has prompted health services organizations to adopt codes of ethics and institute legal compliance programs. However, there is little understanding of the impact of ethics programs or the manner in which program elements act to enhance organizational integrity. This study examined the effect of five ethics program elements on organizational integrity and the mediating role played by ethics orientation in this relationship. It found that program elements influence organizational integrity by engendering among employees a values orientation, a compliance orientation, or both. Furthermore, program elements that induced both orientations have a larger impact on integrity. These findings have important implications for health services managers involved in designing and implementing an ethics program.

Ethical climate in managed care organizations.

Managed care organizations employ nurses as medical utilization reviewers; however, little is known about the ethical climate of these organizations. This study describes different ethical climates in which utilization review nurses work and the implications of these differences for nurse administrators. The nurse participants, although demographically similar across three managed care organizations, perceived distinct ethical climates across the organizations. Nurses were employed to make complex decisions regarding medical care utilization; however, none of the organizations had an ethics committee to help nurse reviewers in this decision-making process. The need for such committees, as well as clarification of a consistent and deliberate ethical climate by nurse administrators, is discussed.