Update
Managed Care: Challenges Facing
Interdisciplinary Health Care Teams
by Ruth B. Purtilo
Interdisciplinary Health Care Teams
by Ruth B. Purtilo
Creighton University Center for Health Policy and Ethics,
Omaha, Nebraska. She has served as President of the Society for
Health and Human Values and the American Society of Law, Medicine,
and Ethics. She also was a founding member of the Society of
Bioethics Consultation.
In November of 1994, the New England Journal of Medicine ran an
Occasional Note entitled, "The Train is Leaving the Station."
(1) In it, the physician author reflects on whether he likes the
idea that he and his colleagues are aboard the "managed care express."
My comments are on another group of passengers--members of interdisciplinary
health care teams [IHCTs]. This article will explore some major challenges
teams are facing in the health care system's movement to managed care,
and reflect on compromises to cherished ethical goals of health care that
could result if the contributions of IHCTs are not fully and accurately
taken into account. My assumption is that while managed care approaches
are designed to deliver high quality health care, the definition of what
constitutes "quality" has not been fully determined. Without
that basic definition, other criteria may drive the decisions regarding
the direction taken by engineers of the managed care express. More importantly,
the contributions IHCTs may make could be overlooked or distorted.
This discussion will be limited to teams in which two or more health professionals
from different disciplines apply their skills to direct patient care.
Teams can serve many other functions, among them advocacy, education of
other health professionals, quality assurance, and community outreach,
to name some. However, patient care oriented interdisciplinary health
care teams serve two basic functions; one that can be called the moral
function and the other, the instrumental function. Both functions
are important in helping to foster the primary ethical goal of medicine:
to show respect for persons by providing high quality professional services.
(2)
The moral function characterizes IHCTs that engage in professional activity
directly, and are immediately geared to the good of the "whole patient."
Every interdisciplinary team has this moral function as its focus, but
some teams are characterized by instrumental functions directly
and immediately geared to accomplishing an important technical task. (3)
For instance, the cardiac catheterization team's work can be completed
successfully without any attention to a direct goal of fostering the person's
overall well being. Their activity as a team will include some moral functions,
but their conduct will be governed by the need to competently and efficiently
insert and secure the catheter.
In short, not all health care teams are equal in terms of the direct ends
they serve, though few are solely moral or solely instrumental enterprises.
Many have functions that fall somewhere on a continuum between the extremes
of serving moral or instrumental ends. This distinction is significant,
especially regarding the question of what constitutes quality in a managed
care environment.
Interdisciplinary Health Care Teams and Quality Care
Managed care plans operate within a system that integrates the delivery and financing of medical care and related health care services. Since managed care is about delivery and financing, it is reasonable to expect that usefulness in the new health care plans is being measured according to delivery and financing criteria. The language that governs current discussion about the criteria of usefulness in relation to these two criteria is that code phrase, "quality of care." Therefore, the future of interdisciplinary health care teams revolves around the compelling question: can IHCTs deliver quality care?
At the outset of this paper I suggested that the problem with answering that question lies in the imprecise definition of "quality" that currently governs managed care systems. At least three barriers meet IHCTs as they attempt to contribute to an understanding of quality which accurately conveys their perception of their contributions. The first is internal: teams which long have enjoyed camaraderie are becoming divided in their rush for survival in managed care alliances, an activity that deters them from the more fundamental and life saving task of searching for better understanding of team delivered quality care. The second is that tools presently utilized for measuring quality in the emerging managed care approaches are sometimes blind to the types of contributions IHCTs are making. The third barrier is that cost-effectiveness considerations are becoming disconnected from cost-saving ones, and team contributions are judged solely on money saved rather than quality proffered.
The Internal Threat of Team Divisiveness
Interdisciplinary health care teams today are becoming divided over threats to traditional team rules of success. One basic ground rule is that each player be highly skilled and responsible in carrying out his or her role. Flexibility among team members for assuming parts of another team member's role signals a highly skilled team, and such activity is decided play by play.
One aspect of managed care that threatens these ground rules is Patient Focused Care (PFC). PFC appears to be team-friendly because someone follows a patient throughout the continuum of care-such as from the hospital to home or nursing home--consistent, on the face of it, with the moral function of IHCTs. However, the PFC idea involves "cross training" of personnel, or de-emphasizing traditional professional boundaries. It suggests that professional "expertise" can be taught in a short course to someone who will provide it less expensively, and that no subsequent compromise of quality will result. No well working team, moral or instrumental, rests on such an assumption. From the teams' perspective, cross training to provide for greater flexibility of services appears to sacrifice quality. In the end, PFC runs directly counter to the premises of a well working team. Rather than beginning by changing team structure, a better approach would be to concentrate on understanding what constitutes quality, then closely assessing the unique expertise of each profession and protecting those functions that lead to quality.
The potential derailing of the traditional assumption that expertise is essential to quality, combined with the anxiety created by restructuring health care, is resulting in entrenchment of professional boundaries rather than enhancement of the spirit of mutual cooperation and adventure this period of change could foster. The surer road would be for IHCTs to make themselves indispensable by virtue of their contributions, but humans tend to act more conservatively and self-protectively when threatened. One untoward effect of the internal strife is neglect--which will become moral complicity--caused by focusing on the wrong task.
Having looked at the internal threat, we turn to another kind of challenge, that of measurement tools which inadequately measure quality of care.
The Threat to Quality Because of Inadequate Methods of Measurement
How will quality be measured in an era of managed care? Every indication is that health services research data, particularly outcomes data, will be used. This is designed to identify optimum treatment, distinguishing that from simply more treatment or more expensive treatment; then data from pooled evidence regarding outcomes will be used to further restructure health plans. This strategy deserves high commendation. But since so much rests on the findings generated by it, a major ethical challenge is to assure that it is an adequate tool for assessing that quality indeed is being measured.
There is reason to doubt that outcomes methodology can assess a team's moral contributions. The emphasis on morbidity and mortality in outcomes approaches will measure instrumental functions more easily. Take the example of transplant teams. The surgeon's contribution will weigh heavily in affirming the instrumental value of this type of team. Nurses' contributions also will have high instrumental value because they deliver medications and monitor patients for changes in physiological status. Medical technologists, pathologists and radiologists will rate high as well. Less significant (though not totally insignificant) from an outcomes measurement standpoint is that these same professionals also may assume a moral role of, say, attending to patients' anxiety about how much their interventions are costing or the effects of the transplant on a patient's ability to enjoy past pleasures. But now consider team workers whose functions are more directly "moral": social workers, who skillfully guide the golden thread by which numerous disparate services are woven together for patients over many months, or chaplains, who minister to the spiritual and religious needs of patients and families. Their moral functions may lead patients to remember the social worker or chaplain with special gratitude as the ones who made the entire ordeal survivable, but the surgeon's or nurse's contributions as team members with unique technical capabilities will be measured higher on an outcomes profile. Patient satisfaction scales could help to alter the present higher valuation of technical over moral functions, but such scales are only imperfectly developed, or not used at all in managed care systems.
In short, IHCTs whose interdependence is not characterized by strong instrumental functions, and professional groups whose members are not skilled in providing highly technical instrumental functions on IHCTs, are more likely to be judged low in terms of outcomes and may be trimmed before the importance of their moral functions can be assessed fully.
Another way reliance on outcomes criteria may affect the opportunity for IHCTs to have their contributions assessed fully is that many health professions disciplines do not have a history of measuring therapeutic success [quality] according to outcomes methodology. Every health professions group is rushing to gather data today, but it could take years of using this methodology to demonstrate their contributions conclusively. Their neglect to collect this type of data may signal unpreparedness and lack of rigor, but more likely, the disjuncture lies in factors other than negligence. For a task as important and momentous as determining which services will be reimbursable in the future, prudence and wisdom would dictate that similar standards of measurement be applied to all groups before decisions are made.
The charge to IHCTs is to engage in delineating accurate descriptions of "quality," as they perceive it, and to show how these particular benefits can be measured in outcomes approaches. The barriers discussed above could lead to decreased quality if teams do not persevere in defining the scope and nature of quality.
The Threat to Quality Occasioned by Reliance on Cost Savings Alone
Finally, let's look at challenges that will arise if cost savings considerations alone replace cost effectiveness ones in managed care systems.
Cost effectiveness criteria, applied correctly, are among the signal strengths of a managed care system. Several recommendations being made about how this goal can be reached have direct bearing on the future of IHCTs. Cross training was discussed earlier. Down scaling the level of professionals involves replacing physicians with persons trained in other health fields, the assumption being that this practice automatically will cut costs because of relative scales of earnings. (4) This view could mean a secure future for disciplines at the low end of the salary scale, with IHCTs composed of fewer physicians becoming more and more the norm. At the same time, another plausible scenario would be to substitute barely qualified or unqualified persons with appropriate skills, for many types of professionals. For example, a health plan just above the average cost in its bid for a contract may be able to stay in the playing field by substituting an assistant for a physical or occupational therapist. Most patients would never guess. The cost savings motivation for administrators to substitute this level of service may be compelling, especially if there are enough such patients to make an appreciable difference financially. A rival plan, seeing the savings, would follow suit, and a cumulative effect would occur. Because of the way outcomes data are generated, it would take many patients to establish what aspects of care, if any, had been compromised. From the IHCT point of view, team members responsible for this instrumental function would be at risk simply on the basis of cost savings rather than their ability to contribute to high quality.
Down sizing is the practice of cutting the numbers of professionals on a service to save money. Most patients won't know that fewer specialty trained nurses on the intensive care unit team will result in such overload for the remaining nurses that adequate, but only minimally adequate, nursing interventions are possible. Everyone who has worked on IHCTs knows that in this case, not only nurses (and nursing care) suffer. Other members are compromised by a stressed link in the chain of interdependent functioning, often to the point that efficiency and quality both are compromised seriously. (5)
In short, the legitimate desire to weed out costs in the system must be weighed against unintended side effects that compromise positive values sought in the cost effectiveness thrust of managed care. Changes made on the assumption that the use of less costly disciplines, or cutting back numbers, will be cost effective will be unsuccessful in the long run. The real contribution of various IHCTs and the relevance of their contributions to a fully developed concept of quality will be possible only if hasty cutbacks are avoided.
What Should Members of IHCTS
(and Everyone Else) Do?
The challenge of coming to a more complete understanding of quality health care, and of understanding IHCTs appropriate role in its delivery, is a task for the whole society. Policy makers and professionals in the health care system can take leadership in coming to a full understanding of quality care in the emerging era of managed care. Some suggestions of specific tasks for health professionals on IHCTs have been made in this paper.
More importantly, however, this is the time for going back to the basics. Health care and the professional delivery of health care services rests on the ethical foundation of respect for the inherent dignity of persons. Any goal, process, procedure, structural arrangement, policy or practice that detracts from that foundation diminishes the value of this age old endeavor. The definition of quality care, who should deliver it and why, must begin with this basic orientation.
This article began with a train story and I think it fitting to conclude with another: If you have seen the powerful film, Gandhi, you probably remember how the young Gandhi, an Oxford trained lawyer, takes a case in South Africa. Upon arrival he buys a first class coach seat on the train and begins to review his portfolio. The conductor enters, and seeing that Gandhi is an Indian, announces that he must leave his seat. Gandhi is dumfounded. When he argues with the conductor that he in fact has a ticket for that seat he not only is removed from the compartment, but unceremoniously thrown from the moving train. Later, discussing the baffling incident with his lawyer colleagues in Durban, he is told that he was thrown from the train because he had broken the rules--the rules of the game in apartheid South Africa. In a moving scene he concludes that the rules are wrong! They are wrong because they contradict God's rule--we are all equally children of God; they are wrong because they disregard the high ideals of culture and civilization; and they are wrong because they undermine the possibility for community right here and how.
There are many positive dimensions in our health care system, but there are current and potential challenges. In the long run, managed care approaches must meet criteria that will show them to be consistent with our highest religious, cultural and community ideals.
REFERENCES
1 Williams, Burton J."Occasional Notes: The Train is Leaving the Station."
New England Journal of Medicine 331, no. 19 (1994): 1316-17.
2 Purtilo, Ruth.
"Interdisciplinary Health Care Teams and Health Care Reform."
Journal of Law, Medicine and Ethics 22, no. 2 (1994): 121-26.
3 Casell, Eric.
"The Sorcerer's Broom: Medicine's Rampant Technology."
Hastings Center Report 23, no. 6 (1993): 32-39.
4 Wright, Richard A.
"Community-Oriented Primary Care: The Cornerstone of Health Care Reform."
Journal of the American Medical Association 269, (1993): 2544-47.
5 Purtilo, Ruth. op. cit.
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