Ethical Decision
Chapter 4
Healthcare Marketing Ethics Considered
Healthcare ethics refers to moral standards of clinical and administrative conduct that affect healthcare stakeholders. Stakeholders are people, groups, and organizations that “hold a stake” in an enterprise and are affected by the conduct of people in that enterprise. In the case study, stakeholders included the patients who underwent the hand therapy, the coder who was told to bill for the treatment, other salaried providers and staff at the SportsMed clinic, the three physicians who had previously owned the clinic, the clinic’s leadership team, the employees of AMU, AMU itself, and the general public.
In everyday life, individuals’ personal moral codes guide their behaviors and actions. At times, people must seriously consider whether actions they are contemplating violate those codes. Exhibit 4.1 categorizes example behaviors/actions in one of four quadrants to illustrate their legal/ethical status. (While Exhibit 4.1 is substantively in the public domain, it is possibly based on ethics professor and management consultant Verne Henderson’s (1982) concentric circle model, which illustrates how ethics may be conceptualized in business.) Behaviors/actions may be unethical and illegal, ethical and legal, unethical but legal, or ethical but illegal. Stealing drugs is wrong; providing a patient with expert care is right. However, controversial topics, such as assisted suicide and expediting a celebrity’s organ transplant, provoke debate. Whether these latter two examples are right or wrong is not as clear.
Beginning with the Hippocratic Oath, healthcare is governed by ethical codes of clinical conduct. Each of the clinical professions has a specific professional code of eth- ics that spells out ethical/professional standards of conduct/behavior for its members. Examples include:
the American Medical Association’s (AMA) Code of Medical Ethics for physicians (www.ama-assn.org), and
the American Physical Therapy Association’s (APTA) Code of Ethics for the Physical Therapist (www.apta.org).
Administrative and managerial professionals in the healthcare environment also have specific professional codes of ethics. Coding and marketing professionals are two examples:
◆ For coders, the American Health Information Management Association (AHIMA) not only has a code of ethics but also outlines expectations for ethical decision making in the workplace (www.ahima.org). AHIMA’s framework is reproduced in Exhibit 4.2. Moreover, AHIMA provides case studies to assist its members’ ethical decision making in the workplace. The case studies illustrate work situations in which ethics had a role and show how the professional addressed the situation.
◆ For healthcare marketers, the American College of Healthcare Executives (ACHE) provides a code of ethics and a process to assist with ethical decision making (www.ache.org).
While AMA and APTA focus on clinical behaviors and AHIMA and ACHE center on administrative and managerial conduct, they share four fundamental ethical standards: justice, fidelity, beneficence, and autonomy (Beauchamp and Childress 2001). Think about the characters in the case study, and identify the courses of action they should take. What factors should Mariana keep in mind as she communicates with the reporter? What considerations do the standards of justice, fidelity, and beneficence require of her?
Healthcare Marketers and ethical behavior
The justice standard addresses the importance of properly and appropriately communicating the issue so that it is handled ethically and fairly. The philosopher John Rawls (1971) introduced the concept of procedural justice as the adoption of a fair procedure to bring about an equitable outcome. He illustrated his concept using a simple example of allocating slices of cake. If one person is told to cut a cake and let others choose their slices first, the person will cut equally sized slices so that he is assured an equal share (Rawls 1971, 84). Hence, a fair process effects a fair outcome. Healthcare marketers often make decisions in which fairness plays a role because they influence how stakeholders—employees (internal) and the general public (external)—are treated.
Along with a fair process, the manner in which employees are treated in interaction affects employees’ behavior (Dessler 2009). Interactional justice refers to how people are treated (interpersonal justice) and how much information is given to them (informational justice). If she follows this standard, Mariana will consider what she shares with the local television reporter and be mindful of her need to be fair to AMU employees.
Coding professionals should:
1.Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.
2.Report all healthcare data elements (e.g., diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.
3.Assign and report only the codes and data that are clearly and consistently sup- ported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.
4.Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator).
5.Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.
6.Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations and official rules and guidelines.
7.Facilitate interdisciplinary collaboration in situations supporting proper coding practices.
8.Advance coding knowledge and practice through continuing education.
9.Refuse to participate in or conceal unethical coding or abstraction practices or
procedures.
10.Protect the confidentiality of the health record at all times and refuse to access
protected health information not required for coding-related activities (examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).
11.Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
The fidelity standard is about loyalty and faithfulness to duty. With regard to this standard, Mariana’s job is to ensure that her communications are accurate and true, but again, she must carefully consider AMU employees’ rights as well. Additionally, authors Eva Winkler and Russell Gruen (2005, 109) elaborate on the fidelity standard to propose that organizational ethics include managers’ responsibility to be compassionate regarding healthcare delivery, respectful to their employees, public spirited, and mindful of their organization’s resources. This standard also extends to healthcare professionals as corporate citizens (Cellucci and Wiggins 2010, 27). They are loyal to their discipline and mindful of the environment and community in which they live.
The beneficence standard refers to the professional duty to benefit others. This principle is based on the Hippocratic Oath, which states that physicians must apply all measures required to benefit the sick and do no harm (Goldberg 1963).
The autonomy standard is based on the premise that people are able to make informed decisions that respect and consider the well-being of others. This principle was one of the foci of the Belmont Report, which included ethical principles and guidelines for the protection of human research subjects. The report was published in 1979 by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research after controversial studies such as the Tuskegee syphilis experiment were made public and the ethical standing of such research was called into question.
Healthcare Marketers as Critical thinkers and Creative problem solvers
The concepts that guide ethical behavior and decision making for healthcare professionals help them think critically and solve problems creatively. As AMU’s public relations officer, Mariana has ethical frameworks she is obligated to consider as she fulfills her responsibilities. First and foremost, the problem must be defined correctly.
The ethical dilemma in the case study varies among the different characters. For the physicians at the clinic, the ethical principles pose potential conflicts. The physicians are to do no harm, respect patients’ autonomy and rights, faithfully treat patients to heal their hands, and be honest. If Medicare denies payment for the treatment, patients probably will stop going to the clinic for therapy. If the patients stop going to the clinic and receiving hand therapy, the likelihood of any improvement is practically nil. Continued hand therapy may bring about some improvement. By noting in patients’ records that they were improving, the physicians acted in accordance with the principles of fidelity and beneficence (their duty to heal) but possibly counter to the principle of autonomy (honesty).
The coder’s dilemma points out the value of the ethical principles as well. The coder is responsible for coding practices and values accuracy in patients’ information. The
patients’ records indicate contradictory information, and thus it does not appear to be accurate and true. Moreover, the coder, as a professional, has an obligation to act.
Mariana also must strike an ethical balance. Her position obligates her to give the reporter accurate and true information but also to adhere to the standards of procedural and informational justice to ensure that the clinic’s employees are treated fairly.
When the coder discovered the inconsistencies in the patients’ records, she may have asked herself whether she had addressed each AHIMA standard appropriately. For instance, the patients’ records indicated contradictory information regarding improvement. She followed AHIMA standard #4 by asking the provider about the conflicting notes. However, she was told to bill Medicare for the treatments anyway and was not provided documentation to support such billing. The coder followed AHIMA standards when she subsequently reported her concerns about the inconsistent documentation in patients’ records to Medicare.
Jacqueline Glover, professor in the Center for Bioethics and Humanities at University of Colorado Denver, offers an ethical decision-making process for health information managers dealing with challenging ethical problems. While specifically designed for health informatics professionals, these steps also apply to decision making by healthcare marketing administrators such as Mariana. Glover’s (2006) process includes seven steps:
1.What is the ethical question? In the case study, Mariana learns that Medicare is investigating fraudulent practices. Because of her position in the marketing department of the hospital, her responsibility to be mindful of ethical standards is framed by her communications with the media. Thus, for Mariana, the ethical question is, what information is appropriate to share with the media?
2.What are the facts? The facts in the case study are twofold: those that are known and those that are being gathered. Mariana needs to be mindful that certain facts are known, Medicare is investigating the situation, and the patients’ documentation is contradictory as well as that the leaders of the hospital (e.g., human resources director, CEO) will pursue the investigation.
3.What are the values? Mariana’s concerns are to provide accurate information while being mindful of justice (treating employees fairly and with respect) and her responsibility to be loyal to the hospital and community (corporate citizenship).
4.What are my options? In the case study, Mariana could do nothing and refuse to talk with the reporter, but her job is to communicate with the media under her supervisor’s counsel to ensure the accuracy and appropriateness of the information she shares.
5.What should I do? Mariana should tell the truth; she should talk to the media and offer accurate information regarding the case. Nonetheless, she must be careful not to discuss the coder or the physicians specifically because they have employee rights.
6.What justified my choice? If Mariana carries out her job as she should, her choice will be justified by adherence to and respect for the ethical principles of justice, fidelity, beneficence, and autonomy in the healthcare environment. Her actions will not be justified if she chooses to disclose information about clinic personnel without due process, ignore the television reporter’s text message, or give misleading information.
7.How can I prevent this ethical problem? Mariana’s primary role is communication. She could contribute significantly to future in-house communications designed to educate hospital employees about ethical standards and institutional integrity.
William Nelson, former chief of the Ethics Education Service in the National Center for Ethics in Health Care, offers an ethical decision-making tool based on the concept of procedural justice. Similar to Glover’s, Nelson’s (2005) model is a step process:
1.Clarify the ethical conflict, first by determining whether the conflict is actually an ethical one. A healthcare professional should be able to identify what the ethical issue is. If he/she cannot, the problem should be referred to another person. For example, if the question is “purely legal,” he/she should consult with the healthcare organization’s attorney (Nelson 2005, 11).
2.Identify all affected stakeholders. In the case study, the ethical issues raised many concerns. Medicare’s investigation of fraud brings the hospital’s integrity into question, and the physicians’ actions incite financial issues and concerns. Furthermore, any actions taken must consider the public—community members’ perception of the hospital as doing no harm and acting ethically. Mariana must be mindful of procedural justice and honesty regarding all stakeholders to ensure that communications via the media are accurate, timely, and true.
3.Understand the circumstances surrounding the ethical conflict. The financial arrangement between AMU and the clinic’s physician leaders may be a basis of the conflict in the case study. The situation may also be cause for speculation: If Medicare finds that fraud is occurring in the SportsMed clinic, could it be occurring in other AMU clinics? Or, why did it occur in one clinic and not the others? These questions are to be addressed by AMU’s leaders. It would not be appropriate for Mariana to lead the fact-finding mission, given her job responsibilities. She is in charge of communications regarding the investigation.
4.Identify the ethical perspectives relevant to the conflict. Mariana is expected to uphold the standards of fidelity and justice and communicate appropriately. For the other leaders (i.e., the attorney, the CFO, and the CEO), fiduciary responsibility is pertinent as well.
5.Identify different options for action. Mariana could do nothing; communicate too much information; or—obviously the best choice—act ethically by communicating the facts, engaging in future actions decided by AMU’s leaders, and responding to external events (Medicare’s investigation) as well as internal policies (audits of the clinic’s operations).
6.Select among the options. The following epilogue demonstrates this step: Medicare found that the clinic had indeed engaged in fraudulent practices, and the government agency took legal action. One of the three original physician owners retired from the profession, announcing that he wanted to “spend more time with family.” AMU renegotiated its contract with the other two physician leaders, who agreed to forgo their profit share and receive only a salary. AMU paid Medicare the monies owed plus a penalty. Regarding AMU policy, the human resources department—in close counsel with the hospital’s attorney—designed in-house training and implemented it with Mariana’s assistance. Via the in-house newsletter, Mariana communicated that all employees were to participate in a four-hour workshop on ethical decision making to learn how to address ethical issues. She also communicated with the media, staying mindful of employee rights as well as the need to share accurate information. She reported that Medicare had concluded that the coding practices were inaccurate and that AMU was taking steps to ensure that this infraction was addressed appropriately. In addition, AMU planned to conduct more frequent audits of its departments and clinics without advance notice. The coder who informed Medicare of the fraud resigned from the clinic, citing that other employees were not as kind to her as they had been in the past, and accepted a job in a neighboring town at a physician practice not affiliated with AMU.
7.Share and implement the decision. Mariana did not communicate with the media until she received direction from AMU’s leaders. She then replied to the television reporter, stating that the investigation was underway and that she would be communicative after AMU gathered the facts. Mariana remained the “go to” person for media inquiries throughout the investigation and subsequent activities.
8. Review the decision to ensure it achieved the desired goal. AMU regularly trains its employees in ethical practices and conducts more frequent audits of its departments and clinics. It offered to transfer the coder to another AMU facility, but she did not accept the offer.
Healthcare Marketers and ethics assessed
Persons in positions of responsibility and power may find themselves in challenging situations similar to the events at the Atlantic SportsMed clinic. ACHE offers a self-assessment tool designed to help leaders identify their ethical strengths and note areas for improvement. This exercise is reflective, not one to share or to use to rank others. The assessment questions address one’s thoughts and beliefs regarding leadership and relationships with the community, patients and their families, the governing board, colleagues and staff, clinicians, buyers, payers, and suppliers. The topics and situations addressed by the self- assessment are outlined on ACHE’s website.
Ethical Decision Making Scenario:
You are the marketing officer at Sullivan’s Island Medical University. Three employees work in your department—you, the marketing director (your boss, who oversees all marketing/public relations duties), and the marketing media officer (your colleague, who oversees all communications to external audiences). You oversee all in-house communications (i.e., for audiences inside the medical school). Currently, you are writing articles about new residents who have just arrived at Sullivan’s Island Medical University for their surgical rotations. Your articles will be published in the in-house newsletter Take Note in a recurring section titled “Welcome to Our New Docs.” The articles about the new residents include their educational background and some personal information, such
as marital status, the names and ages of their children, and their hobbies. To prepare for your interview with resident Patricia Gray, you google her name and find her Facebook page. The photos, captions, and comments on her page indicate that she is a big partier; in several of the photos, she obviously is drinking alcohol. One photo shows her pouring champagne on the head of another woman. Another shows her holding a beer can in one hand and giving the thumbs-up signal with the other. Moreover, she uses profanity throughout her posts.