Considerations for ethical practice in managed care.

How does one maintain an ethical practice while facing the requirements and limits of a health care system that is dominated by managed care? Psychologists are increasingly raising such questions about ethical issues when working in or contracting with managed care organizations. The authors review the process involved in ethical decision making and problem solving and focus on 4 areas in which ethical dilemmas most commonly arise in a managed care context: informed consent, confidentiality, abandonment, and utilization management-utilization review. The need for sustained and organized advocacy efforts to ensure patient access to quality health care is discussed, as is the impact of managed care's competitive marketplace on professional relationships. Hypothetical examples of typical dilemmas psychologists face in the current practice environment are provided to illustrate systematic ethical decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Applied ethics for school-based consultants.

Rather than treat ethics as an ethereal, abstract, philosophical body of knowledge, the present authors focus on the practical aspects of ethics. Guidelines for exploring consultation situations and examples of some of the more common ethical dilemmas faced by school-based consultants are presented. These include matters of confidentiality, contract clarity, evaluation, client welfare, values vs techniques, and acknowledgement of personal limitations. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

In case of ethical dilemma, break glass: Commentary on ethical decision making in practice.

Psychologists are regularly confronted by a wide range of ethical challenges for which no clear solution is apparent. Although the "Ethical Principles of Psychologists and Code of Conduct" (American Psychological Association, 2002) is of some help when one faces such dilemmas, it cannot provide definitive guidance or all needed answers. The process of ethical decision making is reviewed, and the use of different models for ethical decision making is explored. Case examples highlight representative challenges faced by psychologist practitioners. Three invited experts provide commentaries in response to the points made and questions raised. They discuss ethical decision making from their perspectives and make recommendations to practitioners for how they can conceptualize and address the dilemmas they will face in their practices. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contrast-sensitivity testing with scanning-laser ophthalmoscope stimulation in normal, ocular hypertensive, and glaucomatous patients

This article reviews the history, growth, and evolution of managed care in mental health and substance abuse treatment. Specific issues described are stigma, the important social dimensions and chronicity of some types of mental illness and chemical dependency, and reliance on the public sector for care. Opportunities and challenges for occupational therapists in the rapidly changing mental health system are discussed, including the use of interdisciplinary teams, the importance of measuring functional outcomes of interventions, the need to develop clinical guidelines, the importance of the community setting and a continuum of services, ethical dilemmas, and the importance of assertive occupational therapy advocacy and involvement in health care reform.     

Mixed agency in military psychology: Applying the American Psychological Association ethics code.

Military psychology can diverge significantly from traditional psychological practice. Mixed-agency conflicts--those arising when a military psychologist's obligations to individual patients compete with obligations to the Department of Defense or federal regulations--can generate challenging ethical dilemmas. This article explores the notion of mixed agency within the military setting and addresses the most pertinent aspects of the American Psychological Association's (2002) Ethical Principles of Psychologists and Code of Conduct related to this ethical challenge. Case vignettes are presented as a means of illustrating key mixed-agency dilemmas and the effective navigation of these conflicts. The article concludes with several recommendations for military psychologists as they work to anticipate and effectively manage ethical dilemmas bearing on their dual identities as officer and health care provider. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An alternative to managed care: a "guild" model for the independent practice of psychotherapy

As health care is reconfigured by HMOs and managed care organizations, family therapists often have to decide whether or not to cooperate with the new power structures and their ways of doing things. The chief concern of many therapists is the ethical bind created when the managed care organization demands breaches of confidentiality or makes decisions about the course of treatment that may not, in the therapist's opinion, be in the best interest of the family. Associations of independent, nonmanaged care psychotherapists are springing up in response to these dilemmas. This paper describes the philosophical evolution and organizational development of one such association.     

Gag rules and trade secrets in managed care contracts. Ethical and legal concerns

Gag rules-clauses in managed care contracts that prevent physicians from disclosing information that the plan may find disparaging, but that could relate directly to the patient's health-have recently been the subject of ethical condemnation and legislative prohibition. Another serious problem in managed care contracts, trade secrets, or guidelines and quality assurance mechanisms that are imposed on physicians while their origins are shrouded in proprietary secrecy, have by contrast received little attention. Responses to these ethical challenges to the physician's integrity must involve individual physicians, managed care organizations, professional organizations, and public policymakers.     

Gender-related ethical dilemmas and ethics education.

After a summary of the current approaches to the ethics education offered in psychology training programs, various assessment techniques and results are presented. On the basis of the summary of the usefulness of such ethics education, three fictional ethical dilemmas involving sexual intimacy with a client, a dual relationship with a graduate student, and a biased child custody evaluation are examined from the perspective of gender. For each situation, possible ethical, unethical, and poor judgment responses are given. Suggestions are given on ways to educate or sensitize graduate students so that they will be prepared to recognize the dilemmas and face the issues involved. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological practice and managed care: Results of the CAPP practitioner survey.

Practicing members of the American Psychological Association (APA) were surveyed regarding their work settings, activities, and greatest professional concerns in the managed care era. Results from 15,918 licensed psychologists indicated that half were full-time independent practitioners engaged principally in psychotherapy and assessment and another third were in part-time private practice. Four out of five reported a negative impact of managed care on their practices. Concerns about changes to practice and ethical dilemmas as a result of managed care policies were common to all settings. Relatively few differences were apparent between earlier and more recent generations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rights of clients, responsibilities of therapists.

Discusses ways in which ethical principles can be put into practice in the client–therapist relationship. Historically, ethical codes for therapists were drawn up to protect the professions from regulation by external agencies. Implicit in the ethical codes, however, is a model for the client–therapist relationship that fosters the goals of mental health. It is suggested that just as ethical codes have been given specific content in standards for providers of psychological services in human service facilities, ethical codes can be given specific content in the client–therapist relationship. It is recommended that therapists take responsibility for incorporating ethical standards into their practices so that clients' rights will be an integral part of therapy. Four illustrative situations are presented: providing clients with information to make informed decisions about therapy, using contracts in therapy, responding to clients' challenges to therapists' competence, and handling clients' complaints. (63 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethical dilemmas in psychologists accessing Internet data: Is it justified?

Many psychologists search the Internet for both personal and professional information. Although various guidelines have been proposed for psychologists regarding therapeutic services provided over the Internet, few address the ethics and efficacy of gathering information about clients, students, or employees on the web. As quickly as guidelines are written, new technologies create new challenges. With the advent of social networking sites and numerous free and paid data search engines, unique dilemmas have arisen. The ready access of voluminous personal information raises perplexing questions for clinician psychologists, instructors, supervisors, and employers. An overarching consideration addressed in this article is whether in the course of one's professional activities it is ethically appropriate to conduct intentional Internet searches for information about patients, students, or employees. We discuss ethical dilemmas such as right to privacy, trust, confidentiality, informed consent, boundary violations, and best interest of the client, student, or employee. Next we provide a list of some extant electronic sources of information and offer case examples. The article concludes with recommendations that we hope will generate further dialogue and research on these perplexing issues and provide guidance on balancing situationally appropriate flexibility with the need for adopting wise parameters of professional behavior in regard to social networking activities and Internet “investigations.” (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Decisions and justifications by community mental health providers about hypothetical ethical dilemmas

OBJECTIVE: Community-based treatment of persons with serious mental illness requires providers to become involved in clients' personal lives to a greater degree than does hospital-based treatment. The study examined attendant ethical dilemmas, especially for staff who lack professional training or work in rural communities. METHODS: A total of 95 staff members from five community mental health centers read 14 vignettes describing ambiguous ethical dilemmas involving professional role boundaries or client confidentiality. Twenty-seven staff members were from rural agencies, and 68 from urban-suburban agencies; 60 were direct care staff, and 35 were supervisory. Participants were asked to make and justify a more conservative or a less conservative decision in response to each dilemma. RESULTS: Years of experience as a mental health provider and previous ethics training correlated positively with staff having experienced more situations similar to those in the vignettes; however, these variables were not related to the decision made or the type of ethical justification for it. When the analysis controlled for experience and previous ethics training, staff made fewer conservative decisions in boundary dilemmas than in confidentiality dilemmas. Compared with nonrural providers, rural providers had experienced more boundary dilemmas and made fewer conservative decisions in response to them. CONCLUSIONS: Boundary problems occur frequently in community-based services, especially in rural settings, and may or may not be handled conservatively. With the expansion of case management and other in vivo services, better understanding of ethical risks and informal practices will help improve services and provide appropriate training and supervision of staff.     

Ethical ambiguities in the practice of child clinical psychology.

This article presents results from a survey of ethical beliefs about practice dilemmas unique to clinical work with children and adolescents. Survey data suggest that identical practices are not always ethically equivalent, particularly when the developmental status of the client is varied. The survey also reveals widespread ambiguity about what constitutes ethical practice, as manifested both in individual uncertainty and in the absence of group consensus. Ethically guided clinical practice is presented as a far more complex undertaking than adherence to a single set of professional standards. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Meaning vs. medical necessity: Can psychoanalytic treatments exist in a managed care world?

With more and more insured employees covered by behavioral managed-care organizations (MCOs), psychoanalytically oriented practitioners are confronted with the dilemma of trying to deliver meaning-based treatments in a medical-necessity setting. Like many psychoanalytic dilemmas, resolution requires an appreciation of the situation from the perspective of the other, that is, understanding health care from the perspective of the employer. On the basis of his experiences as a case manager, the author specifically suggests the importance of understanding (1) that the medical necessity standard requires distinguishing health care from growth experiences; (2) population as well as patient needs; (3) four reasons why psychoanalytically oriented clinicians are not popular with payers and vice versa. Supported by vignettes, clinical experiences, and literature, some specific recommendations are presented for analytic clinicians which might allow for less frustrating interactions with the healthcare system. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The ethics of managed care: Part 3--Toward a common vision

A common set of values is one of the primary unifying elements of any systematized group. The moral crisis in health care today has more to do with value dis-integration than economic dis-array. The use of resource allocation mechanisms like managed care expand the needs of conscience with those of man-willed choice. If health professionals are to meet the ethical challenges of "managed care," they must start by reminding themselves of what the scientific and ethical commitments both promise and imply.     

Ethical dilemmas in pain management

Pain management is becoming an increasingly important component of comprehensive wound care. Choices for the best approach in managing the elderly patient with painful wounds can pose ethical dilemmas. Ethical principles such as autonomy, beneficence, and non-maleficence are explored through a case presentation. Suggestions for addressing these ethical dilemmas are examined.     

Roles of advanced practice nurses in oncology

Managed care is a process of health-care management that integrates financing, cost-containment strategies, and business principles with the delivery of health care. Managed care's rapid transformation of specialty practices, such as oncology, is redirecting classic nursing functions toward market initiatives that value the design of care/case management systems and the implementation of multidisciplinary "patient-centered" care models. As health-care systems continue to evolve, advanced practice nurses (APNs) are redefining their roles and enhancing their skills to meet the demands of the marketplace. Advanced practice nurses are defined as registered nurses who have met advanced educational and practice requirements and are prepared at the graduate level. This paper will identify the four established APN roles: nurse practitioner (NP), nurse anesthetist, nurse midwife, and clinical nurse specialist (CNS), as well as highlight the nurse practitioner and clinical nurse specialist as the leadership APN roles within oncology practice. The adaption to managed care has identified new functions and created opportunities for these APN specialties that are being viewed both competitively by other oncology health-care providers and creatively by managed-care organizations. The integration of these emerging roles within the new advanced nursing market and their contributions to oncology care are also discussed.     

Medical management of obesity

CONTEXT: Since the initiation of managed health care, little information has been available on whether family planning agencies are seeking ways to serve (and obtain reimbursement for serving) the growing number of clients who are managed care enrollees. METHODS: A 1995 mail survey sought information from a nationally representative sample of publicly funded family planning agencies about the agencies' involvement with managed health care plans and related clinic services, policies and practices. Completed surveys were received from 603 agencies, for an overall response rate of 68%. RESULTS: One-half of all publicly funded family planning agencies had served known enrollees or managed care plans. One-quarter (24%) had served managed care enrollees under contract, while others sought out-of-plan reimbursement for services provided to enrollees (13%) or used other sources to cover the cost of these services (12%). Family planning clinics administered by hospitals and community health centers were more likely than other types of clinics to have contracts to provide full primary-care services to managed care enrollees, whereas Planned Parenthood affiliates were more likely to have contracts that covered the provision of contraceptive care only. Clinics administered by health departments rarely had secured managed care contracts (10%), and only 36% reported even serving managed care enrollees. CONCLUSIONS: The challenges presented by managed care, and agencies' responses to these challenges, vary according to the type of organization providing contraceptive care. Family planning agencies need to seek relationships with managed care organizations based on those services that their clinics can best supply.     

Managed care: rationing without justice, but not unjustly

Three ethical criticisms of managed care are often voiced: (1) by "skimming the cream" of the patient population, managed care organizations fail to discharge their obligations to improve access, or at least, to not worsen it; (2) managed care organizations engage in rationing, thereby depriving patients of care to which they are entitled; and (3) by pressuring physicians to ration care, managed care organizations interfere with physicians' fulfillment of their fiduciary obligations to provide the best care for each patient. This article argues that each of these criticisms is misconceived. The first rests on the false assumption that the health care system includes a workable division of responsibility regarding access that assigns obligations concerning access to managed care organizations. The second and third criticisms wrongly assume that we in the United States have taken the first step toward assuring equitable access to care for all, articulating a standard for what counts as an "adequate level of care" to which all are entitled. These three misguided criticisms obscure the most fundamental ethical flaw of managed care: the fact that it operates in an institutional setting within which no connection can be made between the activity of rationing and the basic requirements of justice.