Will bundled payment models incentivize undertreatment?
Bioethicists can help guide institutions
New bundled payment models included in the Affordable Care Act (ACA), which assign a fixed, negotiated fee to cover a set of treatment services, are expected to reduce overall healthcare expenditures.
"Bundling, however, is not entirely benign," says Jason Morrow, MD, PhD, a palliative care specialist on the faculty of the Center for Medical Humanities & Ethics, part of the School of Medicine at the University of Texas Health Science Center at San Antonio.
One reason is that bundled payments have the potential to incentivize undertreatment. "A shift towards accountability and value-based purchasing offers a potential ethical remedy," says Morrow.
Rewarding health systems that are reimbursed through bundled payments and achieve meaningful population-level outcomes is "a powerful way to align marketplace incentives with the overall mission of healthcare, which is to improve the health and productivity of our at-large population," says Morrow.
There is an inherent conflict between any for-profit insurance system and good medical care, says Neil J. Farber, MD, FACP, professor of clinical medicine at the University of California, San Diego. "Yes, they need to keep costs down and make a profit," he says. "But you can’t withhold medical care from patients to keep down costs."
It’s not difficult to imagine physicians feeling pressure from plan administrators to reduce the number of costly diagnostic tests ordered. "Physicians need to resist that pressure," says Farber. "You can’t restrict tests simply because it’s expensive to the ACO [accountable care organization]. That is not acceptable."
Some patients with high-deductible plans are likely to delay seeking medical treatment. "This would certainly diminish the potential health benefits of having mandatory insurance," says Morrow. "But a high-deductible plan is better than no plan."
To make care more affordable for the likely ill, Health Insurance Marketplace plans are charging higher premiums for the likely well, says Paul T. Menzel, PhD, professor of philosophy emeritus at Pacific Lutheran University in Tacoma, and affiliate professor of bioethics and humanities at University of Washington in Seattle.
"When you are putting everybody in the same pool, you have to split the cost," he explains. Thus, some people pay more in order to cover individuals who would otherwise be priced out of the insurance market by their high-risk status. "You can’t have it both ways," says Menzel. "You either have to subscribe to the common pool’ idea, or you have to put more tax subsidy into it."
The underlying ethical conviction to cost-sharing is that those who are well need to share the burden of those who are ill.
"If you don’t prohibit plans from dropping people who start incurring costs, you will have terrible cases of medical bankruptcy," says Menzel. "A frighteningly high percentage of bankruptcy cases in any given year are from medical expenses."
Morrow believes the potential shortcomings of the ACA are no worse than the shortcomings of the previous system.
"If our country is going to continue to rely on an insurance model for healthcare coverage — a model that has historically struggled to accommodate high-risk or high-cost pools — then universal coverage is the most ethically sound and cost-effective strategy," says Morrow.
This means some people will be at a financial disadvantage. "But we are a better society to have made some significant attempt to reduce the number of uninsured," says Menzel.
Bring issue to forefront
Potentially unethical practices involving new payment models won’t come up during ethics consults. "These are sort of hidden’ ethical issues, if you will," says Farber. In order to call attention to these, bioethicists can first familiarize themselves so they can speak with authority to physicians and administrators.
"There are white papers on the ethical traps involved [in the new payment models]," says Farber.1,2 Bioethicists can also cover the topic during grand rounds. "An ethicist in a healthcare concern has to be independent from any kind of pressure — that is the sine qua non of an ethicist," says Farber. "They have to feel free to bring up these kinds of issues to help guide the institution."
Bioethicists can continue to articulate the ethical imperatives at stake in healthcare delivery and consumption, says Morrow, "and, importantly, persuade clinicians, local leaders, and even consumers."
- DeCamp M, Farber NJ, Torke AM et al. Ethical challenges for accountable care organizations: a structured review. JGIM 2014; 29:1392-1399.
- McCullough LB. An ethical framework for the responsible leadership of accountable care organizations. Am J Med Qual 2012; 27:189-194.
Neil J. Farber, MD, FACP, Professor of Clinical Medicine, University of California, San Diego. Phone: (858) 657-8000. Fax: (858) 657-8066. Email: firstname.lastname@example.org.
Paul T. Menzel, PhD, Professor of Philosophy Emeritus, Pacific Lutheran University, Tacoma, WA. Email: menzelpt@plu.
Jason Morrow, MD, PhD, Assistant Professor of Medicine, University of Texas Health Science Center at San Antonio. Email: MorrowJ3@uthscsa.edu..