Spring Health Uninsured Share Policy

Spring Health Uninsured Share Policy Ethics

Scarcity ethics nursing

Imagine two possible extremes of either zero safety net at all, or every consumer receiving identical care regardless of ability to pay. A mixture of the two extremes may actually maximize care, but require inequity in burden of cost. But that also adds an inherent level of unfairness if the result is treating people differently who have the same ability to pay, so there seems to be no perfectly fair solution to the inherent scarcity of medical care. Even aspirin costs money to refine and ship. Education costs time and skill the expert could spend earning income somewhere else. These factors all came up in an actual, ongoing discussion our Governing Board of partners has been having, trying to deal with an increase in walk-ins by new uninsured or Medicaid claims at our general practioners / family medicine clinic in suburban Dade County. Were health care unlimited, and were all consumers to voluntarily engage in only the most health-promoting behaviors, then there could perhaps be a fair distribution of health care based on need alone, except this also may require a list of unrealistic considerations.

The situational factors that contribute to this ethical dilemma include a health care system that involves cost due to scarcity, as well as a limited number of providers in our region, some of whom have been reducing new Medicaid and uninsured coverage coincident with a growing demand by those patients, some of whom engage in lifestyle or behavior choices that aggravate preventable conditions that drive up cost for all consumers. If providers are to respect every individual "unrestricted by considerations of social or economic status, personal attributes or the nature of health problems" (American Nurses Association, 2001, 1), this requires someone cover the cost or everyone only gets the very minimum possible to all consumers, the result is less care for either those who can afford it, for those who cannot, or return for providers.

Health Springs LLP. is a private, for-profit partnership family practice in the Dade County town of Miami Lakes. The mission outlines the objectives partners agree to: "Every individual deserves equal dignity and respect. Providing optimal health care requires collaboration. Individuals should have a medical home and be the cornerstone of their team of health care experts. We act to achieve the earliest possible detection and prevention of disease, including education and the resources to choose the life style and health care options that maximize health and well being, including the health of others." The firm as yet has no formal policy about what share of new uninsured, uninsurable or Medicaid caseload to take on compared to insured patients, and what such a policy might look like provoked this discussion.

Stakeholders in our practice comprised the active M.D. And LPN partner practitioners, three semi-retired senior partners and also the full- and part-time employees who bear their own shares of an increasing combined group workload. Consumers both existing and new bear the price and results of our ability to dispense care, and thus the affected parties include in a general sense our local care system and consumer population at large, including the taxpayer. One of the M.D.s mentioned a recent study she had read claiming this was growing more prevalent across the industry for several years now (Cunningham and May, 2006) and others mentioned more recent corroborating evidence (e.g. Esert, Durfee, Welsh, Moore, Mehler and Gabow, 2009, p. 122). As far as value orientations are concerned, these professionals entirely conform in practice and principle to either AMA or ANA codes of ethics but generalizing about their individual social or political values would be speculative beyond comments made in this particular discussion. As for the consumer base, their education and income levels vary across the spectrum of below federal poverty income to retired and independently wealthy, and so commenting on their value orientations would be premature absent any type of questionnaire or research. A widening circle of counterparties extends the farther the effects of such a policy are taken into account. The partners in the firm must bear any increased costs not covered in price. If costs can be shifted from uncollectibles or lower-reimbursement caseloads into price for insured clients, then the insurer pool at large bears some of that cost, although if those costs increase individuals' effective premiums, then that share is borne directly by those customers. Increased caseload regardless of payer affects all employees' workloads, and while partners may receive higher earnings for more hours, without increased pay, heavier workloads are a de facto pay cut for hourly staff. Of course affected are the uninsured clientele we either must turn away or shift those costs from.

The ethical considerations related to the problem in a functional sense have to do with conforming with the ANA code of ethics for nurses, as well as the firm's mission to treat everyone with equal dignity and respect, and maximize care and public health. The most obvious conflict arises treating all patients "unrestricted by social or economic status" (American Nurses Association, 2008, p. 1), given many interpretations that "the primary ethical principle of justice" (American Nurses Association, 2008, p. xviii) is the underlying foundation of this Provision. If justice includes respecting patients' self-determinacy (Bandman and Bandman, 2002, 97-98), then this probably also includes fairness about who pays for others' individual care especially if some conditions are more or less preventable. This is all complicated by Provision 3 if the nurse "promotes, advocates for and strives to protect the health, safety and rights of the patient" and also if "shaping social policy" as per Provision 9 (Fowler, 2008, p. 143) conflicts with a policy restricting access. On the other hand if the firm becomes less competitive, or if providers have to bear extra cost, the best qualified workers and partners may go elsewhere and eventually the firm could fail entirely, which would reduce access to care for far more people, more abruptly, than a proactive, forward-looking policy if other alternatives are available. In such a case preserving public health could entail preventive care for the firm itself, if we maximize care by remaining sustainable enough to take indigent patients at all.

The most difficult question was how to prioritize individual utilities of health and cost, especially if many conditions are preventable, but at the same time wealthier consumers' costs represent a lower share of their total income, especially if that is partially spread over a pool of millions of insurance consumers. Even insured consumers access different levels of care while paying the same premiums, and so within our insured caseload there remained effective price inequity. One possible model for comparison was regulated public utilities, where investors (in our case, providers) are guaranteed a "fair" rate of return compared to investments of similar risk, in which case we then would have had to find a way to measure the risk of finding comparable employment, and costs of moving to a new job for the various stakeholders. If taking on an unsustainable indigent caseload was the best way to maximize total health, this seemed to suggest we should just give away care until we went out of business. This exaggeration revealed very clearly how important our ability to distribute health remains beyond maximizing turnover of the highest-paying accounts. The economic sustainability argument has merit beyond stakeholders' personal interest, in maximizing possible care and also continuity of care. This suggested expansion might actually be the best way to balance all these competing claims, and the stakeholders tabled decision pending a cost-benefit analysis of expanding providers and caseload altogether. As far as the ANA code is concerned, Provision One seemed to take precedent within the group of patients we already see.

Non-ethical considerations related to the problem include future decisions that affect all stakeholders like national or state law mandating insurance or public budgets, and macroeconomic conditions underlying individuals' ability to pay. These policy decisions have yet to make it through court and even were such law passed today, the effects in the field would take until 2014 (Cogan, 2011, p. 355). If all individuals will have to have insurance, then our taking policy may not be necessary at this time. On the other hand the date those changes would take effect seems distant enough that action becomes necessary soon if we are to maximize care both in direct application and also via ensuring firm sustainability and competitiveness.

Utility takes many definitions in this dilemma. Individuals' access to care provides health, which also likely encourages happiness, but also takes some disutility of investment in for example exercise or foregone preferences. Some people have more time than others, for another example. The viable actions we considered were unrestricted access on first-come, first-served imposed rule basis, or prioritizing lower-reimbursement accounts for clients who reduced comorbid lifestyle choices like smoking or inactivity. Expanding the practice was viable if expensive at first but would spread cost over a larger pool. Preserving patients' rights seems to come before stakeholder net income perhaps but only to the point where that becomes unsustainable for the practice. The list of ethical relationships continues to include procurement and communicability, behond the space for the present report.

There is probably no way to include all stakeholders in this decision since that group includes future applicants as yet unidentified, other providers and the consumers at large. If a policy of insured to uninsured is enacted at Health Springs, consumers will decide for themselves how long to remain on wait lists if at all, or to engage in priority points behaviors if such policy is implemented. Likewise employees and partners will decide for themselves if other opportunities deliver more utility than remaining with our partnership after such policy takes effect or not. Partners have clear interest toward maximizing their own revenue and rational consumers generally want to pay only for their own expenses with the consideration that many of them also probably value altruism to some degree and realize the benefits of reducing disease in the aggregate society. Individuals all have biases toward themselves if they are suffering and want immediate access to care, or at least priority as demonstrated by high continuity of care for existing clientele. Employees are biased toward avoiding job loss and apparently, some other providers apparently have biases against taking on new uninsured. We have an interest in maximum performance for all these complementary inputs and a bigger firm may be an asset rather than an obstacle.