Synopses & Reviews
Review
"This book is written in a manner that makes it easy to read and understand. It is a must read for employers in all industries who must choose health care coverage plans for their employees. This book would be beneficial to companies of all sizes. It also is an excellent resource for employees who want to understand how health care decisions are made. I applied an ethical framework to this difficult subject. Although I am a 20-year-old veteran of the health care industry, I did not have a complete understanding of coverage plans until I read this book. It is a wonderful, timely resource that I intend to share with my colleagues." ---AORN JOURNAL (Association of Oerioperative Registered Nurses)
Review
"It is a must read for employers in all industries who must choose health care coverage plans for their employees." ---Association of Perioperative Nurses (AORN) Journal
Review
"""This is a very useful tool for providing benefits decision makers with a
practical framework on which to base their decisions. It offers
examples that illustrate what is faced every day by plan providers and explains the logic and rationale applied by others in similar circumstances. In a sense, it is a benefits executive support network ...without the effort of having to reach out to that resource on a case-by-case basis. It can also serve as an outstanding resource for training and education related to plan design."" -- Rick Martino, Sr. Vice President, HR & Administration, The March of Dimes Foundation
""Ensuring Fairness in Health Care Coverage provides an excellent summary for employers who want to maximize the value of their health plan decisions for both the business and the employee. This is a valuable resource for businesses of all sizes in making fair and meaningful decisions on health care coverage for their employees."" -- Jack Mahoney, Corporate Medical Director and Director Global Health Planning, Pitney Bowes
""Some health plan administrators have spent restless nights over how to make coverage decisions that respect both their ethical obligations to patients and their business obligations. The guidance in this book will provide them -- and patients -- a roadmap to more restful sleep.""-- Paul M. Schyve, M.D., Senior Vice President, Joint Commission on Accreditation of Healthcare Organizations"
Synopsis
"Choosing a health care plan that is both ethically sound and financially prudent is one of the biggest challenges facing businesses today. Many people think that high-quality, compassionate health care plans are prohibitively expensive. But in reality, purely cost-driven decisions end up costing businesses more in the long run. Fair health care coverage decisions are actually good for business! Studies show that employees who see their benefits as fair are more likely to stay with their employer, be more productive, and refrain from legal action. Fairness is the best policy -- but employers are uncertain how to reconcile doing what is right with doing what is cost-effective.
Ensuring Fairness in Health Care Coverage provides employers with a solid ethical framework for making even the most challenging benefits decisions. Based on a study by the Ethical Force Program, led by the Institute for Ethics at the American Medical Association, this book enables employers to make difficult decisions about the fairness -- and perceived fairness -- of the health benefits they provide, such as:
Whether to provide benefits to domestic partners.
Whether to give lower coverage for mental than for physical illnesses.
Whether to charge employees who smoke or who are obese more for health care coverage.
How to differentiate between the various types of health care coverage -- from HMOs to Health Savings Accounts -- and how to determine which will benefit the most employees.
Whether to index employee contributions to their salaries, with higher-paid employees paying more for the same benefits.
This groundbreaking book provides five ethical guideposts to help employers make such decisions. The guideposts were developed by the Ethical Force Program’s extensive interviews with a national expert advisory board representing the perspectives of all major participants in the health care system, including employers, insurance companies, physicians, patients, and regulators, followed by focus groups to further refine the principles. As this book explains, fair decision making should be:
Transparent -- being completely open and honest about what decisions are made and why
Participatory -- including employees in the decision process
Sensitive to value -- providing coverage that is both efficient and effective
Consistent -- avoiding favoritism
Compassionate -- offering flexibility for special circumstances
Authors Matthew Wynia and Abraham Schwab show how to apply these guideposts to practical dilemmas employers face every day. Using real-world examples from their extensive research, they bring the principles to life and provide concrete steps for taking action on sensitive and complex issues. Their analyses of case examples, showing how employers have dealt with specific problems, are particularly enlightening.
Creative and compassionate, Ensuring Fairness in Health Care Coverage will help employers design and administer plans for the benefit of their employees and their businesses."
About the Author
Matthew K. Wynia, MD, is Director of The Institute for Ethics at the American Medical Association and Executive Director of the Ethical Force Program. He is also a clinical assistant professor at the University of Chicago and the 2006 President of the American Society for Bioethics and Humanities. He lives in Chicago. Abraham P. Schwab, Ph.D. was a Senior Fellow at the Institute for Ethics at the American Medical Association at the time this book was written. He is currently an assistant professor of philosophy at Brooklyn College. He lives in New York City.
Table of Contents
"Foreword
vii
Acknowledgments
xi
Part I: The Issues and Principles of Fair Health Care Decisions
Chapter 1
What's Fair? An Introduction to Fairness Issues
3
Foundations
5
Audience
7
Form and Function
8
The Stages of Health Care Coverage Decisions
9
Where to Apply the Five Ethical Guideposts
11
Legal Ramifications
13
The Ethical Guideposts Reflect Overlapping Ethical Principles
13
Next Steps
15
Chapter 2
Why Worry? The Business Case for Fair Decisions
16
The Five Ethical Guideposts for Making Fair Decisions
23
The Business Case
26
Two-Step Decisions
29
Abuse or Misuse of the Ethical Guideposts
30
""Give Him an Inch and He'll Take a Mile"": The Importance of Balancing the Ethical Guideposts
32
Will the Guideposts Really Work?
33
Conclusion
36
Chapter 3
Why Is Health Insurance for Employees My Problem, Anyway? A Brief History of Health Insurance Coverage in the United States
38
Health Insurance in the United States
42
Tensions Within Managed Care
48
The Ethical Role of Businesses in Providing Health Insurance Coverage
52
The Basic Terminology of Health Insurance Coverage
54
Part II: The Five Ethical Guideposts of Fair Decision-Making
Chapter 4
A Clear Choice: The Decision-Making Process Should Be Transparent
63
Why Transparency Is Important
65
Transparency Is Critical in Times of Transition
67
Transparency and Communication Barriers
71
Why Wouldn't an Employer Be Transparent?
72
Maximizing the Transparency of Your Decision-Making
73
What's the Business Case for Transparency?
75
Transparency as the Foundation of Fairness
76
Case Studies
78
[bpConclusion
90
Chapter 5
Get It Together: The Decision-Making Process Should Be Participatory
92
Improving Decision-Making Through Employee Participation
94
The Business Case for Employee Participation
97
Offering Employees the Opportunity to Participate
100
Why Wouldn't an Employer Be Participatory?
102
Case Studies
105
Conclusion
110
Chapter 6
You Can Count On It: The Decision-Making Process Should Be Consistent
111
Why Wouldn't an Employer Be Consistent?
114
What's the Business Case for Consistent Decision-Making?
117
Case Studies
118
Conclusion
129
Chapter 7
The Value Equation: The Decision-Making Process Should Be Sensitive to Value
131
Judgments of Value
134
Centers of Excellent Value
139
Determination of What? By Whom?
140
Why Wouldn't an Employer Be Sensitive to Value?
142
Case Studies
143
Conclusion
149
Chapter 8
Stay Flexible: The Decision-Making Process Should Be Compassionate
150
Types of Compassion
153
What Is the Business Case for Compassion?
156
Measuring and Balancing Compassion
157
Why Wouldn't an Employer Be Compassionate?
157
Case Studies
159
Conclusion
164
Chapter 9
Putting It All Together: Ensuring Fair Decisions
165
The Five Ethical Guideposts of Fair Decisions
167
Summarizing the Business Case (Once More, with Feeling)
172
Consistent, but Not Transparent?
174
Using Resources like HEDIS;rm, and Knowing Your Limits
175
Conclusion
175
Afterword
177
Appendix A: The Expert Advisory Panel on Benefits Determination
183
Appendix B: Steering by the Rearview Mirror: Factors That Shape Employee Health Plans
185
Appendix C: Selected Resources
213
Index
221
About the Authors
226"