Practitioners' perceptions on ethical aspects of managed care

Abstract

The environment of managed care has created ethical concerns for practitioners with respect to professional autonomy and ethical practice associated with clinical decision-making. Yet, knowledge and research in this area is limited. The primary purpose of this research was to investigate the influence of individual, organizational, and societal/market contextual factors on practitioners' perceptions of ethical aspects of the managed care environment. In addition, a secondary purpose was to investigate the effect of different data collection methods on response rates. The conceptual model developed for the study derived primarily from Cooper's framework for ethical conduct and principal/agent theory. This study was a cross-sectional, descriptive survey design using a mailed self-administered questionnaire. Data were obtained from a random sample of 700 nurse practitioners (NPs) in the state of Maryland with a response rate of 42.4%. Thirty percent of the sample (n = 210) was provided a disk-by-mail (DBM) option for responding. A slightly higher response rate was indicated for the DBM sample in comparison to respondents who only received the paper-and-pencil measure (45.8% vs. 42.4%). A majority of respondents indicated ethical concerns regarding individual autonomy (78.4%) and personal values/ethics being compromised (67.1%). Moreover, 80% of the sample perceived it necessary to bend managed care guidelines. Significant differences were noted for ethical concern ( p < .001), ethical environment (p < .001), ethical conflict in practice (p < .001), and autonomy (p < .05) in relationship to practice setting. NPs in a staff/group model HMO were less ethically concerned, perceived the ethical environment more positively, and had lower ethical conflict scores. Based on the multiple regression results, a path model was proposed and tested using structural modeling. The perception of the ethical environment, ethical concerns, and the importance of governmental regulation explained 44% of the variance in ethical conflict in practice scores. An idealistic moral philosophy, ethical concerns, ethics content in a continuing education program, and the percentage of the client population enrolled in managed care explained 12% of the variance in autonomy scores. The analysis provided initial support for the model, indicating the importance of ethical considerations in a framework of healthcare.