No Margin, No Mission

Health Care Organizations and the Quest for Ethical Excellence

Health care organizations and systems face the challenge of caring for individual patients, keeping down overall costs, and managing the inherent tensions between these two goals while competing for economic survival in the marketplace. Although some claim that managed care in the United States is "dead," there are still many challenges and opportunities for positive change within the U.S. health care system. The goal of this book is to combine ethical analysis and real-world experience to provide practical lessons about managed care. It directly addresses the universal ethical and political challenge: how can patients, providers and the public trust in the legitimacy and fairness of the organizations that provide health care in competitive systems? This book presents the results of a two-year national project to develop an ethical template for "exemplary" ethical performance, and then uses that theoretical structure to study the experiences of health care organizations that have attempted to design policies and programs that reasonably balance competing values in the marketplace. The Best Ethical Strategies for Managed Care (BEST) project was led by a team of investigators from Harvard Medical School, Harvard Pilgrim Health Care, and the National Institutes of Health. It involved the participation of eight large managed care organizations across the country. The researchers explored difficult questions with these managed care organizations such as: What are the best strategies for caring for vulnerable populations that can meet their special needs without dramatically increasing costs? And how and how much should a health care organization contribute directly to the community in which it operates?