Ethicists abhor denying care of poor to make up for poor reimbursements

California lawsuit reveals two standards of care

Morally reprehensible. Truly tragic. These are the phrases physicians, professional association executives, and government officials are using to describe how the modern health care system prevented a pregnant woman from receiving anesthesia during labor.

A lawsuit brought by a mother who was denied an epidural during childbirth because she did not have private insurance has shed light on a failing reimbursement system for poor Californians.

The lawsuit, filed in January, asks for unspecified monetary amounts for pain and suffering from Northridge Hospital Medical Center in Los Angeles and an anesthesiologist who works there. Anesthesiologists contract with the hospital but are not employees. As a group, the physicians decided not to accept reimbursement from the state's Medicaid system, called Medi-Cal, for epidurals because the reimbursement is too low to make the additional bureaucracy worthwhile, says Barry Silberman, the attorney representing the hospital's anesthesiology group.

The lawsuit includes at least six other accounts from women - all on Medi-Cal - who also were denied epidurals during childbirth. The common anesthesia is administered to women during childbirth to allow the mother to remain awake while blocking pain in the lower half of her body.

Medi-Cal reimburses $57 for the insertion of an epidural and approximately $14 for every 15 minutes that an anesthesiologist monitors a patient. Private insurance companies, however, pay $175 to $300 for the procedure and an additional $35 to $60 for each 15-minute increment.

The alleged denial of anesthesia is morally reprehensible, says David J. Birnbach, president of the Society for Obstetric Anesthesia and Perinatology in Richmond, VA. "My own personal belief is that it is not fair to have two standards of care - one for patients who have insurance and one for patients who don't have insurance," he adds.

Problem runs deeper than the surface

But what may appear to be an isolated incident involving one anesthesiologist's crusade to "right a wrong" could be a problem "that runs deeper than the ethics of one single physician," says John C. Lewin, MD, CEO of the San Francisco-based California Medical Association.

"By keeping the amount physicians receive for treating Medi-Cal patients well below the national average for nearly a decade, the state of California has, in effect, relegated its poorest and most vulnerable patients to nothing less than third-class health care status," adds Lewin.

Lewin points out that the state has failed to legally abide by its obligations over the past nine years and is acting in an unethical manner itself. The state legislature, Department of Health Services, and administrative officials have not ensured "fair and adequate" compensation of physicians treating Medi-Cal patients, notes Lewin.

The result, Lewin says, affects both patients and physicians. According to the association, less than one-third of all Medi-Cal eligible children are receiving preventive health screens and immunizations. In addition, emergency department use among Medi-Cal patients is almost double what it should be.

Those statistics influence physicians, as well. In fact, 70% of physicians have placed limits on the number of Medi-Cal patients they can see, Lewin notes. "Medi-Cal reimbursement rates are so low that many doctors who see a majority of Medi-Cal patients are no longer able to cover even basic office staffing costs," he adds.

The state legislature has allocated up to $35 million in additional funding for fiscal year 1999, but only for certain procedures and services. "It amounts to less than a 10% increase in reimbursement levels for physicians," Lewin notes. The procedure the anesthesiologist group at Northridge is protesting, Lewin points out, would still not receive increased reimbursement under the proposed budget.

Hospitals, and hospital ethics committees, should provide education for physicians and other caregivers on how to appropriately take a stand on social issues. "The caregivers need to provide care due to their moral and ethical obligations, but the patient should not bear the brunt of any ill-feelings," says Lewin.

Procedure exacerbates problem

The Los Angeles County Medical Association also agrees that the problem lies in the reimbursement levels. "The consensus is that in spite of the horrible public relations impact of the Northridge incident, the fundamental problem is that payments to anesthesiologists under Medi-Cal are woefully inadequate," says Frank Clark, executive vice president of the association.

Adding to the problem is the nature of the procedure, Clark adds. "The problem is exacerbated with epidurals, since the physician can't leave the patient alone, and the patient may be in labor for hours. I am sure this is what prompted the inappropriate solution of charging [patients for the procedure] - a practice that is clearly illegal under California law," says Clark.

Clark also believes that the incident is not isolated, adding that "there is an army of federal and state investigators trying to find out how widespread the practice is, and soon we should know what they find out."

Clark suggests that although the issue of ethics in this particular instance has not been specifically addressed, there is still a lesson for other hospital ethics committees. "I would think that as a minimum, hospital ethics committees should promote a culture within the institution of obeying the law."

There is, however, one caveat to that advice, Clark concedes. "Ethical principles beyond the law should be promoted, as well, realizing that they will run headlong into economic considerations, which is not an easy problem in these days of rationed dollars."