Managed care ethics : the legitimacy of fairness of rationing new health technologies in the treatment of cancer in the private health care sector in South Africa

Allies, Shaun Brandon (2008-12)

Thesis (MBA)--Stellenbosch University, 2008.

Thesis

ENGLISH ABSTRACT: The cost of medical care, in particular the cost of cancer care, has seen significant increases globally in the last few years. These cost increases in part are a result of tremendous advancements in new health technologies to diagnose, treat and care for cancer sufferers. The development of these highly specialised treatment modalities is not expected to slow down in the next few years, as potentially new treatments are already in the pipeline. On the other hand, cancer is becoming more prevalent. affecting more people worldwide. The condition remains life threatening, causing patients to become dependent and desperately hopeful of their requested treatments. Managed care, which includes the processes of rationing, has been implemented by medical aid schemes in the private health care industry in an effort to curtail the escalating costs of health care. Currently medical aids in the country are under immense pressure to comply with financially demanding legislation as well as to increase their membership risk by keeping contributions low and subsequently improve access to private health care in the country. Notwithstanding the fact that rationing might be justified from an economic perspective, the implications of transposing free market principles into an almost sacred health care environment challenges current morals and ethics in this arena. The price consciousness in cancer care is almost creating a scenario where clinical reasons are becoming subservient to fiscal reasons or, put differently, it is placing a price tag on human lives. In its true glory, the rationale of rationing is to challenge the individual patient needs against that of the bigger medical aid society. The distributive justice principles of rationing are creating immense conflict between the virtue-based, principle-based and contemporary ethics, which are currently governing medical practice in the country. As a result rationing creates serious vexing funding decisions with long-ranging effects. Its against this background that the study further consider the implications of managed care and rationing as it creates serious questions about the fairness, decision-making power and authority of managed care organizations. The implication of this is that the treating physician seems to have lost all autonomy and control in trying to treat and care for his cancer patient. Hence the perception that managed care does not act in the best interest of the vulnerable and desperate cancer suffering patient. As a result of th is view of managed care it becomes important to ensure the fairness and or legitimacy of managed care and rationing decisions. Therefore, the final section of the study considers the fair and just rationing of medical care as well as setting limits that are morally and ethically acceptable, in a cancer related setting. The studies of Daniels and Sabin are utilized extensively in particular the suggested criteria required by managed care organisations to ensure their rationing decisions are fair and legitimate. The implications of this and the assurances to cancer sufferers in a medical scheme is that the decisions to fund new health technologies are based on a process that is transparent and collaborative and that cost consideration of treatment has merit if it is made within the confines of this process.

AFRIKAANSE OPSOMMING: Die koste van mediese sorg, en spesifiek die koste van kankersorg, het in die afgelope paar jaar wereldwyd aansienlik toegeneem. Hierdie toename in koste is gedeeltelik die resultaat van geweldige vooruitgang in nuwe gesondheidstegnologiee om kankerlyers te diagnoseer, te behandel en vir hulle te sorgo Daar word nie verwag dat die ontwikkeling van hierdie hoogs gespesialiseerde behandelingsmodaliteite oor die volgende paar jaar sal afneem nie, aangesien nuwe behandelings steeds geregistreer word. Aan die ander kant is die voorkomssyfer van kanker besig om toe te neem, en be"invloed dit mense oor die hele wereld. Die toestand is steeds lewensbedreigend, en veroorsaak dat pasiente afhanklik van en desperaat vol hoop is vir die nodige behandeling. Bestuurde sorg, wat die proses van rantsoenering insluit, is deur mediesefondsskemas in die privaat gesondheidsorgbedryf ge"lmplementeer in 'n poging om die stygende koste van mediese sorg te verminder. Mediese fondse in die land is tans onder geweldige druk om aan finansieel veeleisende wetgewing te voldoen en om hulle lidmaatskaprisiko te verhoog deur bydraes laag te hou en gevolglik toegang tot privaat gesondheidsorg in die land te verbeter. Ondanks die feit dat rantsoenering moontlik vanuit 'n ekonomiese perspektief geregverdig kan word, daag die implikasies van die omsetting van vryemarkbeginsels in 'n amper heilige gesondheidsorgomgewing huidige morele waardes en etiek in hierdie veld uit. Die prysbewustheid in kankersorg skep amper 'n scenario waar kliniese redes ondergeskik aan fiskale redes gestel word of, om dit anders te stel, dit plaas 'n prys op mense se lewens. In sy volle glorie is die rasionaal van rantsoenering om die individuele pasient se behoeftes teenoor die van die groter mediesefondssamelewing te stel. Die beginsels van verdelende regverdigheid van rantsoenering skep enorme konflik tussen die deug..gebaseerde, beginselgebaseerde en kontemporere etiek wat tans die mediese praktyk in die land beheer. Gevolglik skep rantsoenering ernstige, moeilike befondsingsbesluite met effekte oor die lang termyn. Oit is teen hierdie agtergrond dat die studie die verdere implikasies van bestuurde sorg en rantsoenering moet oorweeg, aangesien dit ernstige vrae rondom die billikheid , besluitneming en outoriteit van bestuurde sorg maatskappye lig. By implikasie beteken dit dat die geneesheer wat die pasient behandel, feitlik aile beheer verloor het om die pasient vir aile praktiese doeleindes optimaal te behandel. Oaarom die persepsie dat bestuurde sorg nie in die beste belang van die kwesbare en desperaat kanker pasiente is nie. As gevolg van die persepsie van bestuurde sorg, raak dit meer belangrik om die bilikheid en regverdigheid van gesondheid sorg besluite te verseker. Met dit in ag genome, oorweeg die finale deel van die studie die bilikheid en regverdigheid van mediese rantsoenering so-ook die set van perke wat eties en moreel aanvaarbaar is, in 'n kanker verwante agtergrond. Die werke van Daniels en Sabin word in aansienlike detail hersien in besonder hul voorgestelde kriteria wat vereis word deur bestuurde sorg organisasies om te verseker hul besluite ten opsigte van rantsoenering is redelik en regverdig. Die implikasies hiervan en die versekering tot kanker Iyers in 'n mediese skema is dat die besluite om nuwe gesondheidstegnologiee te befonds, is gebasseer op In deursigtige en samehorende proses en dat aile koste oorwegings vir behandeling meriete het, indien dit is gemaak is binne die raamwerk van hierdie proses.

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