ACA shifts liability to patients: Bioethicists must be "watchdogs" to ensure ethical care
Unethical practices are concern
The ethical justification for the Affordable Care Act (ACA) is distributive justice, with the goal of making health insurance available to more Americans, notes Dennis M. Sullivan, MD, director of the Center for Bioethics at Cedarville (OH) University.
"This has clearly succeeded, at least in part, but at the cost of a loss of autonomy. Is it worth it?" he asks. "Now, more than ever, there is a strong need for bioethicists."
Ethics professionals must be advocates, both for physicians who want to be compassionate clinicians, and "to defend the human dignity of the patients who get lost in the shuffle," says Sullivan.
Ensure hospitals "play by the rules"
As the implementation of the ACA continues, medical ethicists must serve as "watchdogs" at the organizational level, urges Philip M. Rosoff, MD, director of clinical ethics at Duke University Medical Center in Durham, NC.
Bioethicists can play a major role in ensuring that healthcare institutions "play by the rules," says Rosoff — staying fiscally solvent while not sacrificing patient care.
"They can also scrutinize activities that may serve to aggravate already existing inequities between patients," says Rosoff. These include patients’ ability to pay for their care and the quality and amount of insurance they carry.
"One could imagine that the habit of many institutions to treat so-called VIPs differently — bigger and nicer rooms, better food, more customized care — could become more exaggerated," says Rosoff.
This could further marginalize many populations already at risk. "It would also serve as a very poor example of fairness and equity to trainees, young physicians and nurses, and, of course, the public," adds Rosoff.
For institutions in dire financial straits, this approach could be seen as an opportunity to improve the bottom line. "I would hope that bioethicists could monitor these activities, and perhaps serve as calm voices — a conscience, even — to minimize their appeal," says Rosoff.
Patients face higher costs
The cost of care remains an ethical concern, especially in light of higher out-of-pocket expenses for insured patients. "Presumably, high-deductible plans, coupled with an ever-expanding number and scope of co-payments, is to lessen the cost of the overall premium that is paid," says Rosoff.
However, this means some people will avoid or delay needed care. Thus, health care institutions could be faced with patients presenting with more advanced disease, which could have been treated simply and more cheaply if therapy had been initiated earlier.
"For some people, this could be both a life-endangering procrasti-nation and a threat to their fiscal solvency," concludes Rosoff.
Shifting financial responsibility to patients is presumably aimed at keeping plans affordable, with some modicum of coverage for major medical problems. "I suppose that the only way to determine if the goals are being reached — meaning inducing more responsible use of health care by people with high-deductible plans — is to see if that actually happens," Rosoff says.
If a delay in seeking treatment necessitated much more high-priced diagnostic and therapeutic interventions, however, this could easily offset the amount saved by the insurer upfront.
"It is unclear to me that this strategy will spur more health-related responsibility by the newly insured," says Rosoff.
Outcomes remain to be seen
The fact that many preventive services are now completely covered balances, at least in part, the increased out-of-pocket expenses for patients. "Whether the ACA will actually result in better health outcomes and reduced health care costs remains to be seen," he says.
The World Health Organization statistics indicate, for example, that the United States is 43rd in the wld in infant mortality. "It will take a long time to see if better access to insurance will help decrease the infant death toll, especially among minorities," says Sullivan. Here are some other ethical concerns involving the ACA:
"Mandated EMRs have been met with widespread disapproval by patients and doctors alike," Sullivan notes.
Increased emphasis on efficiency and numbers may be detrimental to patient care.
"Current trends favor volume over quality, decreasing the time that a doctor spends with each patient to hear the main complaint and to do a good review of systems," says Sullivan. This increases the reliance on blood tests and X-rays, driving up costs.
The ACA does not address tort reform.
"Defensive medicine and its contribution to high costs will continue," predicts Sullivan. "With the doctor-patient relationship deteriorating, this exacerbates the problem of litigation-minded patients."
Dennis M. Sullivan, MD, Director, Center for Bioethics, Cedarville (OH) University. Phone: (937) 766-7573. E-mail: [email protected].
Philip M. Rosoff, MD, Director of Clinical Ethics, Duke University Medical Center, Durham, NC. Phone: (919) 668-9025. Fax: (919) 668-1789. E-mail: [email protected].
