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Tuesday, 8 December 2009

Massachusetts Association of Health Plans Ethics Forum

Yesterday I attended a goodbye party for Dr. Marylou Buyse, who has been President and CEO of the Massachusetts Association of Health Plans (MAHP) since April 2001. MAHP is a trade association representing 12 Massachusetts health plans that together provide coverage for 2.3 million Massachusetts residents. Marylou is moving to Texas to become chief medical officer at Scott & White Health Plan.

When I first met Marylou in 2001, 6 months after she started working at MAHP, I proposed a cockeyed idea - that MAHP should sponsor a statewide ethics forum to bring together health plans and interested others to discuss ethical issues in managed care. Her immediate reaction was - "that's a great idea - let's do it!"

Anti-trust regulations are designed to prevent enterprises in the same economic sector from conspiring to create an anti-competitive cabal. Without an umbrella to convene public discussion, the kind of collaborative discussion and education I envisioned would run afoul of anti-trust law. MAHP stepped in, and Marylou became the godparent to a process that is still going strong.

The first forum, in March 2002, took off from two controversial cases about coverage for liver transplant for patients who were HIV positive. The twenty fourth forum - "Is Rational Public Conversation about End of Life Care Possible?" - was held three weeks ago. Other topics include: "Ethical Challenges in Managing Pharmacy Benefits: Can Good Management be good Medicine?" (2003); "Bariatric Surgery: Exploring the Ethical Issues" (2004); "The Ethical Dimensions in Public Reporting of Clinical Performance Data" (2005); "Ethical Challenges of Massachusetts Health Care Reform" (2006); "Medical Tourism – an Emerging Ethical Issue" (2007); and, "Virtual Visits: What are the values-related questions for health plans in promoting electronic visits in the information age?" (2008).

I've co-chaired the forum discussions - first with Dan Rome and then with Paul Fulton, both medical directors at Tufts Health Plan. A guest opens the meeting with a 5-10 minute overview of the area. The rest is discussion. In light of anti-trust concerns the forums don't involve action planning of any kind. We typically have 30 - 40 attendees, from health plans, government, NGOs, and industry. The discussions have been rich and thoughtful. The fact that so many busy people come to a 7:30 AM event is a vote of confidence in the value of the event.

In learning to write for publication and in mentoring younger colleagues the most useful question to raise is - "so what?" With regard to the MAHP Ethics Forum attendees have responded to the "so what?" question with reasons like these, which I've reconstructed from conversations I've had:
  1. "We're all in our silos with noses to the grindstone. It's helpful to step back and ask - 'what are the ultimate purposes for what we do?' Doing that helps me get back to what's most important in our work."

  2. "I take a lot of things in the insurance world for granted. The forums have led me to raise some useful questions about the work."

  3. "Raising questions isn't always popular. It helps hearing from colleagues who like to turn things upside down the way I do."

I've tried to stimulate other states to develop their own forums but so far I've struck out on that effort. Hospitals are familiar with ethics committees and ethics consults, but that kind of going back to first principles is new to the insurance world.

In our parting conversation Marylou suggested that we try to do the same thing in Texas. Lone Star State - here we come!


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