An Ethical Evaluation of the PACE Program

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Cox, Austin
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Managed care organizations , Program for All-Inclusive Care for the Elderly , Healthcare , Ethical practices , Physicians and patients
The World Medical Association’s physician oath declares that “the health of my patient will be my first consideration,” and that “the interests of the subject must always prevail over the interests of science and society.”1 We all would hope that our physicians uphold these ideals, but the rise of managed care organizations (MCO) has greatly undermined a physicians’ capacity to do so. Since the inception of MCOs the physician has experienced conflicts-of-interest that have led to increased responsibility to the group at the expense of the individuals’ care. You may ask: why should I care? Because your physician may have denied or failed to inform you of a beneficial treatment because it is not covered by your insurance company. This paper will focus on the ethical stature of a new type of managed care system called the Program for All-Inclusive Care for the Elderly (PACE). PACE is a progressive MCO in Chattanooga with a revolutionary delivery system. Their major goal is to provide good healthcare to the highest-risk patients – urban citizens who are poor, frail, and elderly. This means they cater to inner-city elders of the lowest socio-economic bracket. A literature search yields extensive discussion of PACE’s financial structure yet no discussion about its ethical practices. My goal is to explicate the potential conflicts of interest and determine whether PACE has adequate mechanisms for resolving such conflicts. To do this I will adapt the arguments for and against distributive justice in Managed Care Organizations (MCO) to the PACE program. To aide my literature based research I carried out interviews with physicians, nurses, social workers and chaplains at PACE, Chattanooga to gather some firsthand accounts of PACE’s ethical practices. The goal of my thesis is to determine if the PACE structure contains adequate measures to alleviate the conflict between obligations to participants and obligations to protect the financial well being of the program. I have isolated three important mechanisms built into the PACE structure for combating conflicts between the physicians’ obligation to the patient’s best interest and to the financial stability of the program. Despite the many arguments for and against distributive justice in the managed care setting, I will argue that PACE is adequately equipped to alleviate the tension. PACE’s unique structure allows the physician to manage the fundamentally opposed goals of maintaining a healthy trusting patient-physician relationship while simultaneously protecting the financial viability of the program. To understand the arguments for and against PACE’s ethical decision-making process, it is necessary to have a basic understanding of its structure.