General practice guidelines cannot take into account individual circumstances that make a particular case a legitimate exception. Because of their clinical expertise and judgment, physicians are in a unique position to determine whether a particular case is an exception to practice guidelines. Physicians should inform patients of such beneficial interventions, whether or not the insurance plan would cover them. Without such information, patients cannot decide to appeal the coverage decision or pay for an intervention out of pocket. On the other hand, physicians should not advocate for patients when interventions are only marginally beneficial and an exception to the guidelines is not justified, but should explain to the patient why the intervention is not recommended at this time.
Physicians can help ensure that managed care institutions are ethically responsible.
It makes little sense to hold physicians to ethical responsibilities without giving attention to the responsibilities of managed care organizations that constrain and influence the actions of individual doctors. If the organizational context is not ethically sound, physicians may be placed in the bind of having ethical and professional responsibilities that are extremely difficult to carry out. Physicians and professional societies can help managed care organizations establish practice guidelines and standards for utilization review. Physicians can help evaluate published studies critically and provide expert judgments. Professional organizations like the ACC can play an important role in recommending practice guidelines, particularly as new knowledge about cardiology procedures is published.