• The field of health care ethics embodies ethical principles that address risks in the areas of autonomy, access, informed consent, practitioner-patient relationships, and confidentiality.

• Ethical challenges and problems exist in both the traditional fee-for-service system and in the rapidly developing managed care system, although the incentives, risks, and oversight strategies differ in the two settings.

• Cultural competence and sensitivity are ethical issues.

12.1 Managed care organizations should be able to demonstrate that they recognize and have concern for the ethical risks created by managed care systems. Additionally, they should substantiate the use of safeguards that protect and maintain ethical standards and practices. These would include the following:

• a clear description of a plan, its benefits, and grievance procedures,

• accessible and responsive grievance, complaint, and appeals procedures,

• effective strategies to maintain confidentiality while meeting the needs of practitioners to coordinate care,

• culturally appropriate and gender-specific service practitioners in the network,

• consumer surveys and measures of consumer satisfaction,

• consumer representation on policy development and grievance resolution,

• continuous improvement protocols to promote better outcomes, and

• no contractual or other limitations for physicians and other practitioners concerning the discussion of clinically appropriate treatment options with patients and families.

12.2 A careful review of ethical issues in various settings, for example, managed care organizations, networks, and fee-for-service settings, is needed. The Substance Abuse and Mental Health Services Administration (SAMHSA), Health Care Financing Agency (HCFA), and Agency for Health Care Policy and Research (AHCPR) should develop a plan to examine ethical issues.

IOM (Institute of Medicine). 1996. Primary Care: America's Health in a New Era. Washington, DC: National Academy Press.