'Buy one get one free' healthcare Is it unethical or just undignified?

Consumer web sites such as LivingSocial, Groupon, Loclly, and Ebates are popping up in millions of e-mail inboxes across the United States offering everything from sushi dinners and massages to car washes and now, healthcare.

It appears that these daily deal web sites are becoming more and more popular. In fact, according to reports, Groupon recently turned down a $6 billion buyout from Google in lieu of its own initial public offering (IPO). It also appears that some physicians are now getting in on the coupon frenzy. The popularity of these daily deal sites is no longer limited to free yoga classes and restaurant deals, as the medical community is jumping on board with deals ranging from cheap dental cleanings to laser eye surgery.

When it comes to offering healthcare at a discounted rate, ethical issues can come into play. "I find the concept of offering discounted healthcare troublesome because it reinforces the notion that healthcare is a commodity like TVs or X-Boxes and that healthcare should be distributed according to the ability to pay as opposed to a basic, personal, individual need or basic human right," says Linda MacDonald Glenn, JD, LLM, assistant professor in the Department of Medical Education, Alden March Bioethics Institute, Albany (NY) Medical Center.

Additionally, there are possible legal ramifications. Matthew K. Wynia, MD, MPH, FACP, director of The Institute for Ethics and Center for Patient Safety American Medical Association, Chicago, says, "Before addressing ethics, there are potential legal issues in offering some types of discounts. In particular, I would talk to a good lawyer before offering a discount program or coupon for any service that is covered by insurance, including Medicare," says Wynia. Otherwise, providers might violate self-referral or kickback laws.

Glenn adds, "No other civilized nation looks at healthcare in this way; no other country allows medical centers to be for-profit institutions with shareholders, where the profits are the main consideration as opposed to patient care. The United States ranks number 38 in the world in healthcare, right before Slovenia and right after Costa Rica."*

Offering discounted healthcare could provide more access to individuals who are uninsured or underinsured, but it is akin to giving fast food coupons to those on food stamps, says Glenn. In the short term, it solves an immediate problem, but in the long term it is neither healthy nor good policy.

Ethically, the primary obligation of clinicians is to ensure equal high quality care for every patient, regardless how or what they are using in paying for the care, Wynia says. "Physicians must strive to provide care equitably, period. So, for example, if a discount program or coupon were to drive excess volume over a short period of time, and thereby reduce the quality of care that can be delivered, it would be ethically problematic," he adds. Barring adverse effects on quality of care, some ethicists agree that coupons or limited time discount offers are more undignified than they are unethical.

Where does the ethics board come in?

Because of tremendous growth in group coupons all over the United States, in the for-profit sector, an ethics committee could see using daily deal coupons as a way of providing healthcare for those who might not otherwise be able to afford care, which is not a bad thing. Glenn says, "The ethical problems arise at a broader national level."

An ethics committee might have a say over the use of these coupons if there is an ethical issue or reason that arises within the organizational ethics, says Lisa Anderson-Shaw, DPH, MA, MSN, clinical director, Clinical Ethics Consult Service, assistant clinical professor, University of Illinois Medical Center, Chicago, says. "For example, if the organization offers discounts, but only for services or practitioners that are not meeting their professional expectations, this might be something that the ethics committee might be involved in, but not alone; the organization's administration would be important in such cases, as well."

An ethics committee could play a role in addressing these sorts of marketing strategies and keeping them inside ethical bounds, just as they might play a helpful role in many other marketing endeavors, Wynn says.

In the first quarter of 2011, there were more than 2,500 medical, health and dental offers published on daily deal sites in the United States, which is an eight-fold jump over the 300 offered during the same period only one year ago. There are many theories of why there was such a tremendous surge in this market. "I think this really has to do with the economy," Anderson-Shaw says. "Extreme couponing is very popular among consumers, and there really have been no problems that I am aware of by using coupons for groceries, etc. In fact, it has really helped many people who have limited income during this recession."

Because of this trend, it is possible that many people see healthcare-related services in the same way. "Many folks have to pay out of pocket for healthcare services, and a coupon/discount can be very helpful to them, but the issue at hand is if the discounted care or service is of a lesser quality than those who pay 'full price' or have insurance pick up the bill," says Anderson-Shaw.

While these deals are appealing to consumers, some medical organizations believe that the wrong message is being conveyed. Consumers taking advantage of offers might pay too much attention to the low prices and not enough to the quality of care or the provider's track record. "I believe this is a valid concern, especially if the patient — aka the 'consumer' in market terms — doesn't feel as if he or she has a choice, because of lack of health insurance," says Glenn. "It certainly can create a power imbalance between the patient and provider, where the patient feels they are helpless and totally at the mercy of the provider." Anderson-Shaw says that the healthcare industry almost always has been part of a fee-for-service/free-market industry; even prior to insurance, payment for a doctor's fee was in whatever monies or goods that could be shared, such as food and services. "So, I don't think offering coupons or discounted healthcare, in and of itself, is unethical. For example, many private offices and healthcare organizations offer 'back-to-school specials on school physicals or even free school physicals through the health departments," she says.

The threat might be more related to the quality of the services as opposed to the discount for the service, and quality is something that is better measured through consumer word of mouth, by looking up the practitioners information online to see if and what kind of feedback has been left for that person. "Consumers of healthcare are as consumers in other areas of life, however, healthcare practitioners must be licensed, and institutions that hire them must do background checks, and the like, to ensure a level of competency that is acceptable and legal for their profession, Glenn adds.

Don't expect this discounting trend to stop anytime soon, sources say. Glenn says, "It is because of free market/for-profit approach that healthcare costs have skyrocketed out of control. Because healthcare is currently being treated and viewed as a commodity, we will continue to see more of these offers."