In July 2016, Jennifer Brown, a graduate student at Southwest State School of Public Health, had been asked to staff an Ethics Advisory Group (EAG) meeting at Mountain Health Insurance Company, a large, regional nonprofit health insurance company where she was employed as a summer intern. The mission of Mountain Health was “to improve the health of the people we serve and the health of society.”
Jennifer had been working with the ethics program director, Robert Jones, to review and update the program’s ethical guidelines to reflect emerging ethical challenges in the financing and delivery of health care. This meeting was the first time that Jennifer had been given the responsibility of identifying the ethical issues that EAG should consider and what values should be applied in determining how Mountain Health should address them.
The topic for the meeting represented a timely example of an emerging ethical challenge. The group was to discuss whether the company should respond to rising demand for low-cost, highquality surgical and diagnostic procedures in hospitals in other countries, dubbed “medical tourism” in the national press, by contracting with some international providers for specific procedures as part of its efforts to develop lower priced health insurance products.** The number of Americans traveling internationally for medical care grew from roughly 150,000 in 2006 to close to 1.4 million expected in 2016; the dollar value of overseas medical spending by Americans was over $100 billion by 2015. Top country destinations included Costa Rica, India, Israel, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thailand, and Turkey. The top conditions included cosmetic surgery and dentistry (much of which is not covered by traditional health insurance) as well as cardiovascular and orthopedic surgeries, cancer, reproductive/fertility procedures, and weight loss procedures. Private facilitators helped patients make arrangements with providers and arranged for travel, which often included recuperation in a resort of the host country.
The Ethics Advisory Group of Mountain Health
The EAG was founded several years earlier to strengthen Mountain Health’s capability to make ethical tradeoffs between the best interests of individual patients and the need to maintain affordable, high quality health insurance for its enrollees (i.e., the people who had health insurance products through Mountain Health). The EAG’s goals were to increase the company’s capacity to identify and address ethical issues affecting all dimensions of health plan policy and operations. Amid the managed care “backlash” of the late 1990s, when popular sentiment turned sharply against “managed care” insurance plans that used cost containment measures such as sharply restricted choice of doctor or hospitals, or mandatory utilization review for high cost procedures, Mountain Health wanted to ensure that its benefit design (including coverage and cost-sharing features), medical management, and provider network contracting decisions were morally defensible and transparent to the public.
The EAG included Mountain Health
The EAG included Mountain Health administrative staff, insurance plan enrollees, physicians and hospital representatives from the company’s provider network, employer-purchasers, and ethics leaders from local universities and industry associations. The ethics program director generally prepared background material and summarized the plan’s ethical concerns. The EAG then convened to discuss the issue; following that meeting, the director wrote a report with recommendations on how Mountain Health should ethically address the situation. That report was posted on the company’s public website to foster transparency and trust with the company’s enrollees (those who are insured by Mountain Health, either by paying premiums by themselves or sharing the cost of the premium with their employer) and the public at large.