Dr. Ari Hoffman serves as Collective Health's SVP, Product and Chief Clinical Officer.
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The world of bioethics is defined by four basic principles: autonomy, justice, beneficence and nonmaleficence. Healthcare practitioners use these principles as their guiding force when evaluating the merits and potential challenges of any given procedure, prescription or care plan.
Say you're a surgeon about to perform surgery on a patient. It’s your responsibility to consider questions like: Does this patient have autonomy during the decision-making process? Do they have the capacity to give informed consent? Is this procedure equitable, affordable and in alignment with evidence and guidelines? Is it for the good of the patient? Does the potential benefit outweigh the risks?
While benefits leaders don’t provide direct care to patients, using these principles to inform benefit design can help ensure we’re providing the greatest amount of good to the greatest number of people. Let’s explore these concepts and how to strike a balance between them.
Principle 1: Autonomy
American consumers are obsessed with choice. Whether we’re shopping for groceries or healthcare plans, we want every potential option to be presented to us because our culture equates autonomy with the freedom to choose. Promoting autonomy through the lens of plan design is thus two-fold. With an understanding and respect for that cultural mindset, leaders can grant employees ample choice regarding plans, in-network providers, etc. But that choice must come with transparency and comprehensive information on the options.
Most benefits leaders are probably familiar with the phrase “Narrow networks don’t sell.” However, the idea that more choice is inherently better disregards the facts that some providers or facilities aren't as high quality as others and that some consumer choices are not high value in healthcare. It's integral to acknowledge this because inappropriate services can cause both physical and financial harm.
As you work to grant your employees the autonomy they crave while ensuring the choices presented to them are viable (and valuable), don’t fall prey to the false notion that all choices are created equal. Be shrewd and deliberate when selecting options for your employees. Ensure they have access to the guidance they need to make informed decisions, and structure choice architecture around health and affordability.
Principle 2: Justice
As a benefits leader, you have a responsibility to ensure equitable access to care among the entire employee base. Fairly allocating and distributing healthcare resources, benefits and services is a must. Your ultimate goal is to create a plan that gives more to those with the greatest need so healthcare value is equitable, regardless of factors like gender, ethnicity, age and other characteristics. For example, can rural members access the care they need? What about hourly or seasonal workers?
Affordability is at once a significant challenge for employers and a major component of distributive justice. Equitable access to healthcare isn't possible when prices are unchecked. As inflation rages on and costs rise, benefits leaders must do everything in their power to keep costs manageable at the individual level.
Principles 3 And 4: Beneficence And Nonmaleficence
These final principles go hand in hand. Every benefits leader I know strives to design a plan that positively impacts health outcomes and minimizes the physical, emotional and financial challenges employees and their dependents may encounter. The problem is making it real at the population and individual levels. As such, beneficence and nonmaleficence are inextricably linked to one another and the principles of autonomy and justice.
We must weigh these principles against each other to design the best possible plan for our unique employee base. For example, a business that has historically prioritized autonomy above all else might be hesitant to scale back the drug options covered under a health plan, even though this decision would bring down costs. A benefits leader committed to a utilitarian approach (i.e., doing the most good for the most people) would have to consider whether the majority of employees would benefit more from a vast array of choices or lower costs.
There's no one-size-fits-all approach here. Nobody wants to ruffle feathers or disappoint their people, especially when it comes to vital offerings like healthcare. So we must constantly evaluate whether it’s more painful to disrupt the status quo or stick to it. My vote is for thoughtful change.
A Delicate Balancing Act
At this point, you’re probably wondering, “Okay, Ari, this is all well and good. But how do I weigh these principles against each other? How do I design a plan for my employees that strikes a balance between autonomy, justice, beneficence and nonmaleficence?” I hope this doesn’t come as a huge disappointment, but there’s no easy answer! The so-called "right" balance will be different for every company.
To determine the best path forward for your business, start by looking at your culture and core values. What's your business hoping to achieve? Maybe you're trying to cut costs wherever possible right now or there's a large population of rural employees you need to support. Do you know whether your employees are willing to pay extra if it means having more options to choose from? Lean on both qualitative and quantitative data to inform these decisions because a proactive approach will help you manage care in a way that ensures cost savings don't lead to worse outcomes or experiences.
The bottom line is this: buy value, not volume. Prioritize what’s important to your employees and your business at large, and build from there. This will help you do right by your workforce and ensure you’re upholding the fundamental principles of ethical plan design.
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