Health Care Distribution

7


Health Care Distribution






Professional Profile



When I graduated from a hospital-based radiography program many years ago, signing the application for the American Registry of Radiologic Technologists (ARRT) examination seemed like a mere formality. I was focused on taking the registry examination, so I gave little thought to signing the promise to adhere to the professional code of ethics. The imaging and radiation sciences professions have become much more complicated than I ever imagined when I became a radiographer. I could not envision the role that ethics would play in the delivery of imaging services over the life of my career.


My first encounter with an ethical dilemma occurred when I was a radiography student. A young couple brought their toddler son in for an abdominal radiograph. The father carried the child and very gently laid him on the table. The boy looked like a victim of child abuse, bruised and battered. Cancer was actually the culprit, and the radiograph was a follow-up to an intense radiation therapy regimen. The radiologist’s interpretation of the radiograph suggested that more radiation therapy might be needed. The parents announced there would be no further medical intervention, and they carried their son out of the hospital, against medical advice. Many technologists were appalled and very critical of the parents. I remember thinking how much harder it would be to say “no more” than to cling to the tiniest shred of hope for your child.


I had another distressing experience just a few years later that I will never forget. I was summoned to do a stat portable chest examination on an older man. He was uncooperative, noncommunicative, and obviously very uncomfortable. I finally had to be very firm with him to get him to lie still and take a deep breath while I made the exposure. A few minutes later I returned to the unit with his radiograph, only to learn that he had expired. I felt angry that the doctor had ordered an imaging procedure for a patient so close to death, but mostly I was angry with myself for being gruff with a patient during what turned out to be his last moments on earth. It was a terrible feeling and a painful lesson.


The uncharted territory of new technology and advances in medicine changed ethical issues for me from words on paper into new processes for my daily work routines. Witnessing a patient’s written consent suddenly meant more than pausing long enough to scribble my name on a form handed to me by a doctor while on my way to the break room. The waiting room sign-in sheet vanished. Gone are the view boxes in the main hallway where patients walked to the dressing rooms. Now fusion imaging technology and molecular imaging are blurring the lines between health care disciplines and creating areas of overlapping responsibility. Emerging areas of advanced practice are ushering in even higher levels of obligation and ethical responsibility.


Understanding the foundations of ethical decision making is the first step toward appropriate professional practice. Knowing the limits of your scope of practice, state laws, and institutional policies will keep you headed in the right direction. Let experience serve as your guide, and always listen to your inner voice. When in doubt, ask for clarification. As the delivery of imaging and radiation services becomes more sophisticated, addressing the ethical implications continues to expand as an important component of clinical practice.




ETHICAL ISSUES


The ethics of health care distribution affects both imaging professionals and patients. The United States spends more on health care than any other nation. Despite increased spending on health care, the national health status has not always improved. Thus reform of the health care environment, services, patients’ rights, and the imaging professional’s changing role are topics that must be addressed. The ethical challenges inherent in health care are changing, and imaging professionals must be prepared to change. Changes require critical thinking, flexibility, and a continued desire to provide high-quality imaging services.



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).






Fairness Theory


The fairness theory tries to tailor health care distribution to balance the dignity and equality of all persons with the inequality of their needs and circumstances. The most important consideration in this theory is the ways in which advantaged and disadvantaged people receive care and who makes these decisions. Inequalities in health care distribution are frowned upon. “Identifying how these differences affect the person can easily lead to subordinating the dignity of the individual to the convenience of the society.”2



Within the fairness theory, the equality of patients as individuals is weighed against differences in their needs and circumstances. This weighing leads to a number of difficult questions. Do pediatric patients who come from financially disadvantaged homes have a right to an imaging examination their parents cannot afford? Should imaging procedures on individuals with mental disabilities be limited because of these patients’ limited intellectual and financial resources? The fairness theory answers yes to the first question and no to the second. All patients are equal under the law and equal in human dignity, and regardless of whether they are unequal in means and resources, they still have the right to health services. However, difficulties arise in the determination of the degree to which a patient is disadvantaged.



Utilitarian Theory


As noted in previous chapters, utilitarianism recommends the provision of the greatest good (in this case, health care services) for the greatest number. Under utilitarian theory, imaging departments look at patients as a group and not as individuals and seek to provide the most care for the most people. A utilitarianist would say that if a vascular laboratory can accommodate five uncomplicated procedures in one day, it should perform them instead of two long procedures. More patients are served in this way, and thus the greater good for the greater number is achieved. However, utilitarianism creates a number of problems. Individuals may have difficulty maintaining autonomy as the utilitarian theory is implemented.





Practical Wisdom and Distribution


The practical wisdom theory of distribution states the following2:


Justice or distribution is accomplished through application of practical wisdom (right reason) to meet the demands of human dignity in the social circumstances of the time. Justice thus involves respecting human dignity and satisfying human needs and recognizing human contributions within the system and in ways that are characteristic of the system.



In other words, to serve the patient, imaging professionals must use practical wisdom to assess individual needs, ability to pay, scarce resources, and resource distribution. How are rights balanced with scarce resources? Who makes these decisions?



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).





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.




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.



Feb 27, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Health Care Distribution
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