BIOMEDICAL ETHICAL CHALLENGE

In the 1940s, the patient’s needs came first regardless of the cost. Health care’s obligation was to serve and meet the needs. By the 1960s, cost was becoming a greater concern and diagnostic related groups (DRGs) were developed to control resource allocation. In the 1980s, the prospective payment system (PPS) further expedited a fairer and more equitable system of health care distribution.

In the 1990s, President Bill Clinton stated the following¹:

We must set and keep our sights on three goals: controlling rising health care costs, covering every American with at least a basic health benefit package, and maintaining consumer choice in coverage and care. Putting people first in health care calls for a fundamental reform of the system. It requires that we combine an appropriate and revised governmental role with reliance on the private sector to provide care and to compete to serve every person in this country. But that competition must take place under a restructured set of ground rules that foster competition to provide the best care at the best price, not to avoid covering the less healthy and to raise prices fastest for the sickest.

As we enter the 21st century, the ethical dilemma of fair and equitable health care distribution remains. Health maintenance organizations and preferred provider organizations, which are discussed later in the chapter, have had the opportunity to provide more care for more people. Whether they have fulfilled this goal is questionable.

As the public becomes more aware of new imaging technologies and their diagnostic importance, the medical imaging community has been affected profoundly by the health care distribution dilemma. Patients may respond to advertisements in the mass media by asking for these expensive new procedures. As such advertisements become more prevalent, questions regarding the ethics of health care industries marketing to target patients become more complex. Patients may feel entitled to the benefits of new technologies and may make demands on physicians and institutions to facilitate their needs. The reimbursement process, however, remains controversial. The patient, provider, and third-party payer must come to terms with the availability of services and the amount of reimbursement available for those services.

RIGHTS AND HEALTH CARE

Before a right to health care can be discussed, the terms “right” and “health care” must be defined. A right in this context means a just claim or an entitlement. Americans tend to believe that all people deserve health care as a matter of course, but this may be a simplistic notion. Should all people, regardless of whether they pay for their health care, are homeless, or are financially irresponsible and cannot afford health care, be able to claim routine health care as a right?

The second term, health care, encompasses many elements. It may be perceived as a practice, a commodity, an approach, or a collective responsibility. Health may be described as a condition or frame of mind. All these definitions help inform a discussion of health care.

To answer the ethical question of whether a right to health care exists, medical professionals should ask whether health care is an element in autonomy and self-determination. Self-determination requires patients to participate in their own health care. Patients need knowledge, awareness, and continuing education regarding what they can do to maintain health to be full participants in their care. This is as important in the health care process as the provision of health care services. However, self-determination also requires patients to take responsibility for their health. Smokers who have chronic respiratory problems require many health care services, including chest studies, sinus radiographs, computed tomography (CT) scans, and other procedures. However, do such patients not bear some responsibility for their poor health? Should other patients suffer delayed access to imaging examinations because of the examinations required by patients who have not participated in their own health care? Should society pay the health care costs of those who do not take care of themselves?

SCARCITY AND DISTRIBUTION

Society is under many demands to provide health care for all citizens. The increasing costs of health care and the demands of a growing population place other stresses on an increasingly overburdened health care system. Nevertheless, many perceive a need for resources for the distribution of health care services to come from public as well as private sources because “society is under an obligation to the individual to promote the common good.”²

Resources in health care are increasingly expensive and scarce. “A sound theory [of] distribution, then, must provide for priorities and a system of allocating resources that at least regularizes expectations in the light of what is politically and economically possible.”² Society, patients, and providers must make difficult decisions to aid in this distribution.

DISTRIBUTION ALLOCATION GROUPS

Questions regarding health care resource allocation can be divided into three groups: macro-allocation, meso-allocation, and micro-allocation.³ Macro-allocation questions ask how big the health care budget will be, who will pay for it, what end it serves, whether there is a right to this care, and what standards will be used to determine these factors. Meso-allocation questions ask how the health care budget will be divided, what health care needs will be addressed, how they will be prioritized, who will deliver these services, and what limits will best serve the efficient meso-allocation of health care. Micro-allocation questions ask who should get what share of the health care budget, whether the present distribution is equitable, how rationing of services is determined, and what factors should be used in the triage of patient needs (Figure 7-1).

DISTRIBUTION THEORIES

Prioritizing, or triage, is an ongoing decision-making process in health care. The determination of which patient is the most important, is in the most critical condition, has the greatest need, or has the best opportunity for a positive outcome is an evaluation process necessary for the distribution of limited resources. Triage, however, is much easier to practice at an administrative level than at eye level with a dying patient. Triage seems to be a practical method to bring justice and fairness to distribution, and society may see it as such, but it presents ethical conflicts.

The prioritization of patient needs influences imaging modalities. For example, breast imaging is often scheduled under pressure by patients and physicians after a lump has been found. Many breast imaging suites examine patients every 15 minutes all day long, and many of these patients have to wait for diagnostic examinations after discovery of an abnormality. Prioritizing these patients according to their needs is difficult. A number of theories have been advanced to aid the triage process (Table 7-1).

Distribution Decision-Making Criteria

According to Armstrong and Whitlock, there are six criteria—need, equality, contribution, ability to pay, effort, and merit—that will aid the health care professional in ethical problem solving when a fair distribution of scarce resources is required.⁴ These criteria, modified for imaging, are explained as follows:

1. Need. Need seems to be an obvious and useful criterion; however, this is complicated by whose perception of need is used to make the distribution decision. The imaging patient may determine that a much more expensive procedure is needed than the physician has ordered. Thus need is not always the best criterion to use in allocation dilemmas.

2. Equity. The concept of equity rarely serves well as an effective criterion for allocating health care resources. Each imaging patient may require a different type and number of imaging examinations depending on his or her health. It would make no sense to expect each patient to have an equal type and number of examinations.

3. Contribution. The consideration of contribution requires a determination of what an individual might be expected to give to society at a future date. Does the imaging patient have the ability to contribute something useful? Should younger imaging patients be given priority over the elderly? Is there an ethical means of evaluating these future contributions?

4. Ability to pay. Decisions based on ability to pay are of limited benefit in making allocation decisions based on the individual situation. Imaging professionals recognize the values of compassion and giving, and denial of health services based on the imaging patient’s inability to pay is counter to the fundamental belief in generosity and charity. However, the ability to pay may be considered a compelling criterion for consideration when decisions involve elective treatment and the imaging patient was able to choose his or her health plan. At this point the third-party payer may determine the allocation of resources.

5. Patient effort. The imaging patient’s effort may be a useful criterion for patients who fail to heed medical advice or do not make an effort to help themselves. It would be reasonable to consider the value of repeating imaging procedures on a person who continues high-risk behaviors after being warned by a physician to discontinue them. Patient effort may be a controversial criterion because of the complexity of withholding and limiting resources.

6. Merit. The best criterion on which an imaging professional could base an ethical allocation determination might be merit. Merit is the potential to benefit from the additional investment of limited health care resources. The criterion of merit requires that decisions be based on data or evidence. Do the data support the successful outcome of a vascular imaging procedure? Conflicting data and sources may complicate a merit-based decision.

The preceding criteria are useful in dealing with ethical dilemmas in allocating imaging resources. They raise important questions when choices are necessary, and they provide the imaging professional with an awareness of what imaging administrators face when solving distribution dilemmas (Figure 7-2).

TRADITIONAL CARE

Traditional care allows patients to choose their own physicians and facilities for health care services; however, a patient must be able to pay for those services. Each individual must have traditional insurance or be able to pay for the services. The more choices allowed to the consumer, the greater the cost of insurance. Traditional care provides high-quality health care for those with traditional insurance coverage and those who can pay for these services, but uninsured persons and those unable to pay find it difficult to obtain high-quality services.

Inequity of service, escalating health care costs, and demands from society have caused the U.S. health care system to become more sensitive to market forces. These factors have led to the development of managed care.

HEALTH CARE DELIVERY MODEL AND MANAGED CARE

Imaging professionals must understand the health care delivery model of managed care so that they may address the challenges that reforms in health care distribution have presented to imaging services. Managed care is an all-encompassing term that includes any type of system to coordinate the care and treatment of patients. Managed care is designed to provide better access, improved outcomes, more efficient use of resources, and controlled costs for the patient.⁵ More simply, managed care is any type of delivery and reimbursement system that monitors or controls the type, quality, use, and costs of health care.⁶ The aim of managed care is to reduce unnecessary or inappropriate care and reduce costs (Box 7-1).⁷

BOX 7-1

WHAT IS MANAGED CARE AND HOW DID IT EVOLVE?

Managed care is a fusion of the two functions that historically were regarded as separate, the financing of medical care and the delivery of medical services.

1880s to 1960s

Managed care is not a new concept. Prepaid plans existed as early as the early 1800s, when employers paid physicians a few cents per employee to take care of the needs of all their factory employees. In the 1920s and 1930s, doctors and hospitals took care of patients through prepaid plans with payment by employers. Providers were not happy with this system, and hence the traditional fee-for-service or indemnity plans (like Blue Cross and Blue Shield) emerged. These dominated the health care market until the 1970s, when the increasing cost of health care prompted more incentives for managed care and the government decided to help reform the health care system through legislation.

1970 to 1990

The HMO Act of 1973 provided federal money to spur the growth of HMOs. However, America was not ready for managed care at that time and few employees signed up for this option. As the cost of health care continued to grow, in the mid to late 1980s, employers expressed concerns that their health care costs were preventing them from being competitive in the international market. Big business started listening when managed care offered some solutions in the form of new types of HMOs that gave employers more choices and physicians a larger measure of autonomy, while still achieving the goals of lower costs, use of practice guidelines, and coordination of care among providers.

Several different HMO versions emerged, and they began to be recognized under the umbrella of managed care organizations. As managed care became more common, the cycle of trying to appease consumers and providers and being unable to control costs accelerated.

State legislation attempted to rein in the managed care organizations. However, the Employee Retirement and Security Act (ERISA), although intended to protect employee pension plans, also affected health care and prohibited states from regulating managed care organizations. Managed care organizations had virtually no or very limited liability when they made medical decisions to deny care.

Early 2000s

In the early 2000s, the U.S. Supreme Court decided three different cases that opened the door for consumers to sue managed care organizations when they make erroneous medical decisions. State tort laws as well as state regulation of managed care organizations now apply. Unfortunately, this ability to litigate against managed care organizations also contributes to higher health care costs.

Emergence of Risk Managed Care

In response to the problem of state and federal insurance mandates and the resultant continuing trend of cost increases, a supportable solution emerged from the Institute of Medicine (IOM) and its reports on medical errors. The solution is based to a large extent on evidence-based risk managed care. This concept uses guideline-driven protocols, monitoring of provider standards, and financial incentives for provider compliance. Risk managed care is often referred to in terms of quality and patient safety. The IOM sees risk managed care as an improvement over managed care because medical decision making is aboveboard and subject to increased scrutiny and scientific validation.

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