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Health care reform to have impact on ethics
Effects will be revealed over time
One health care lawyer suggests that there will be a phased implementation of the health care reform bill, the Patient Protection and Affordable Care Act, which was passed in March.
"I think that health care reform . . . has been structured so that some of the positives come upfront; for instance, in states where you can currently exclude somebody based on pre-existing conditions under certain conditions that's going to be eliminated almost immediately," says Alan Lambert, MD, JD, sole practitioner in health care law in New York City.
"By contrast, some of the issues with respect to denial of certain types of coverage or the phase-in of taxes on luxury or high-benefit plans are phased in, or become effective, over a period of years," he tells Medical Ethics Advisor.
Even though, according to Lambert, almost every poll showed that a majority of Americans are insured and "appear to be happy with their health insurance to a large extent," the bill still passed.
"I think the issue that people are concerned about is that they would like to see other people insured, but they don't necessarily want to see that at the expense of giving up their own health benefits," he notes.
"Basically, the way that I see things evolving, starting with the electronic medical records, [is] the electronic medical records are going to be linked in to connect data through health information exchanges. And so, for instance, hospitals in the New York area that are going to their medical staff and trying to integrate, through a particular type of software, records that can be accessed in the hospital and the office, to maximize the exchange of information for efficiency purposes," Lambert says.
"But then, they're going one level further, and what they're doing is they're going to be collecting what they're identifying as patient safety and quality data, and they're going to take this data and ultimately filter it up through committees that are going to be organized to look to develop what is called 'best practices,'" Lambert explains.
Those best practices not a new term in the health care arena are going to determine what will be emphasized or prioritized in the delivery of medical care, he says.
"So, which diseases receive priority in terms of coverage for benefits, what types of medical care are considered cost-effective for treating the disorders, and so on . . . and basically, I think they may take a look, for instance, at certain categories of people and not necessarily just outright deny care, but say that it's not necessarily efficacious for particular people, let's say, to receive a kidney transplant, or a liver transplant, or other type of procedure," Lambert says.
Possible implications for ethics
Marc D. Hiller, DrPH, associate professor in the department of health, management and policy at the University of New Hampshire in Durham, NH, writes in an e-mail response that in the more immediate future, "passage of the health reform law could precipitate some elective and/or non-emergency services" to require a longer waiting period from the time an appointment is made to the actual time of service.
"However, it should not have a significant impact on rationing or not involve any denial [of] medically determined necessary medical care or surgery," he notes.
Passage of health care reform "makes the topic of possibly greater relevance to physicians and hospitals, who may see a surge in new (or first-time) patients being able now to enter the system and claim medical care through venues other than the hospital emergency room (as was the major source for care for the uninsured in the past)," Hiller writes.
The surge might prompt more training of primary care physicians and "other public health professionals involved in patient education and counseling, as was seen after the passage of Medicare and Medicaid in the mid-1960s," he writes.
Hiller notes that from a public health perspective and with more patients coming into the system, "it becomes more essential that more efforts be made both by public health professionals and primary care providers toward prevention. Prevention can be cost-effective and have a substantial impact [on] disease prevention that could result in lessening the need for added medical care visits, and equally if not more important in reducing the spread of communicable diseases among individual contacts and the public at large," Hiller notes.
Hiller notes that for ethics committees, "reform may not produce major new issues beyond those associated with ensuring that institutional policies remain sensitive to assuring fairness (particularly amid increased patient populations) and respect for individuals (particularly with regard to confidentiality and privacy as traditional medical records increasingly are being converted to electronic formats and require more substantial safeguard and protections. . . .)."
It will also be important to maintain a commitment to informed consent with patients.
He notes that ethics committees may pursue "ways to enhance the completion of advance directives [for] patients, as compliance with this practice continues to remain lower than ideal."
Hospital ethics committees might also, he writes, "develop and adopt medical futility policies to help assure that hospital resources are used most effectively in delivering needed and useful medical care.
"Also, depending on whether there are changes in reimbursement levels among the different health insurance options that might evolve, could conceivably lead to in some cases certain groups of patients [receiving] different levels of attention/services, i.e., in the same manner that some providers prefer privately insured patients vs. those of Medicaid," Hiller writes.
He also notes that health care reform could potentially lead to physicians having even less time to spend with patients, due to a surge in the demand for services.
Marc D. Hiller, DrPH of the Department of Health Management and Policy in the College of Health and Human Services at the University of New Hampshire, Durham, NH. E-mail: firstname.lastname@example.org.
Alan Lambert, MD, JD, sole practitioner, New York City. www.lamberthealthlawyer.com.