Underinsured patients will need cost-effective options

Less expensive alternatives should be considered

It's a "tremendous victory to have something approaching universal access" as a result of the Patient Protection and Affordable Care Act, but the resulting increase in underinsured patients will pose ethical challenges for providers, according to Joseph J. Fins, MD, MACP, chief of the Division of Medical Ethics at Weill Cornell Medical College and director of medical ethics at New York Presbyterian Hospital-Weill Cornell Center in New York City.

The fact that patients are insured should not be taken as a guarantee that they are adequately insured, he explains. "There are people who, by virtue of the mandate to buy health insurance, will buy the cheapest insurance they can afford, which comes with higher deductibles," says Fins. "The fact that they are insured doesn't mean they are protected against under-treatment. So the next policy challenge is not just access to care, it's access to sufficient care."

Practicing evidence-based care and trying to avoid waste saves the patient money and provides better care, he argues. "This is a clarion call for patients and doctors to talk about the various ways of working up medical problems," he says. "Patients may be able to avoid dire choices promoted by underinsurance."

On the other hand, Fins underscores the importance of not breaching professional standards to save patients money, such as ordering an X-ray instead of a magnetic resonance imaging or CT scan for the evaluation of back pain in a cancer patient. "Care of patients comes first, and finances come second," he says. "Just as cost containment is never a malpractice defense, underinsurance is not an excuse for bad medical care."

There may be legitimate alternatives in which evaluation can be performed in a less costly way, but it is unacceptable to deviate from the standard of care if this puts the patient at risk, warns Fins. "I think we have to appreciate now that families unfortunately have to sometimes make choices," says Fins. "Physicians need to be aware of that, because if they don't speak about the cost of care, they may prescribe things that are not followed-up on. There may be a problem with non-compliance."

Fins observes that the scope of this problem is larger than it appears. He notes that health service investigators have described under-insurance as "a moral hazard."1 Research has shown that the metric of out-of-pocket costs, by which under-insurance is tracked, underestimates the scope of the problem because the under-insured delay, defer, or avoid care when a more fully insured patient would seek it.

"So by the time an underinsured patient gets to the point of seeking care, a diagnostic or therapeutic inadequacy has already occurred," he explains. "The opposite is true with patients who are very well insured, say without a deductible, who will over-utilize services."

Inability to pay

Marianne L. Burda, MD, PhD, a Pittsburgh, PA-based ethics consultant and educator, says that patients should never be denied emergency care and treatment due to their inability to pay or inadequate insurance coverage. Physicians have an ethical obligation to do the following, says Burda:

  • ensure that the tests, treatments, or procedures they recommend to their patients are medically indicated and not unnecessary or a result of practicing defensive medicine;
  • consider whether there is a less expensive alternative that is comparable to a higher-priced test, medication, or treatment and will obtain the same result, such as an older generic medication or a different diagnostic test;
  • fully inform patients of all care and treatment options including doing nothing, risks and benefits associated with each option, and the costs of all options;
  • advocate for underinsured patients to get needed medical treatment covered;
  • provide some free or discounted care to patients.

"If they are unable to do so for a particular patient, they should help the patient locate financial assistance, or free or reduced sources of the needed medications, tests, and treatments," says Burda. For example, physicians can refer patients to social workers or agencies in their community that can work to locate and secure these resources.

  • work with patients to design affordable payment plans that do not delay patients receiving needed care.

"Insurance discounts to costs of care should apply. Underinsured or uninsured patients should not be charged full costs for care, as they are the least able to pay these prices," says Burda.


  1. Abraham JM, DeLeire, Royalty AB. Moral hazard matters: Measuring relative rates of underinsurance using threshold measures. NBER Working Paper No. 15410; Issued in October 2009.


  • Joseph J. Fins, MD, MACP, Chief, Division of Medical Ethics, Weill Cornell Medical College, New York City. Phone: (212) 746-4246. Email: jjfins@med.cornell.edu.
  • Faith T. Fitzgerald, MD, Professor, Internal Medicine, University of California--Davis School of Medicine, Sacramento. Phone: (916) 734-2177. Email: faith.fitzgerald@ucdmc.ucdavis.edu.
  • Rosalind Ekman Ladd, PhD, Visiting Scholar in Philosophy, Brown University, Providence, RI. Phone: (603) 788-4864. Email: rladd@wheatonma.edu.

Limited resources will pose ethical challenge

More time with patient is key

Physicians want the best for their patients, but part of their ethical challenge is to advise patients how to use their limited resources wisely, according to Rosalind Ekman Ladd, PhD, a visiting scholar in philosophy at Brown University in Providence, RI. "This is a problem that is not going to go away," she says. "Even if we were to assure that 100% of Americans have health insurance, there would still be critical ethical questions to confront: How much health care? What kinds of health care?"

One answer that is commonly heard is that everyone should be assured a decent minimum of health care, notes Ladd. "But what does that include? Heart and liver transplants are usually understood to go beyond the minimum, but what about MRIs and CT scans that are useful but very expensive?" she says.

Various schemes have been proposed to achieve a fair system of allocation, notes Ladd. "Some states pay for all childhood vaccinations because it is in the public interest and is very cost-effective," she says. "In 1972, the federal government agreed to fund kidney dialysis for anyone who needs it, but it was a decision based more on emotional impact than careful comparison and planning."

An attempt at rational allocation of resources was made in Oregon in 1994 when a committee of citizens determined how to prioritize the services that Medicaid would fund. "It was a frank acknowledgment that resources are limited, but it continued to provoke controversy and was eventually abandoned," Ladd says.

More time with patients

"A lot of Americans consider, I need an MRI' as a chief complaint," says Faith T. Fitzgerald, MD, professor of internal medicine at University of California, Davis School of Medicine in Sacramento. "That is part of the American psyche, and also a mark of respect from the patient. If you don't order a test they want, they think, You're saying I'm not worth it.'"

While most practicing physicians saw indigent patients before the managed-care era, this has become much more difficult as doctors are typically overwhelmed with existing patients, says Fitzgerald. "If you see patients who don't have any money and you have to pay to support a private practice, you will go out of business. That means there is one fewer doctor to see patients, whether or not they have insurance," she says.

The physician's ethical obligation to care for the patient is "the basic core of the oath," says Fitzgerald, but most modern oaths have the addendum, "I will serve my individual patients and serve humanity." This means that physicians are professing to two things that the current system does not allow to occur simultaneously, she says.

"You may do one or the other, but you can't do both," she says. "Caring for the individual patient may bankrupt the ability to care tomorrow for other individual patients." Fitzgerald says the answer likely lies in the growing movement for cost-conscious care, and an increase in the ability of physicians to spend time with patients.

Time-pressured physicians are now seeing even patients with complex multisystem diseases in 15 minutes, she says, and might order needless diagnostic tests as "a kind of proxy for care, but at vast expense." Each physician should be given enough time with the patient to decide whether or not expensive tests are actually necessary, argues Fitzgerald.

Medical students might observe physicians ordering diagnostic tests because this is quicker than spending time with the patient, and mirror these habits in their own practice, she warns. "There is a danger that what they may be taught is good medicine is largely test-based, that good medicine is what you get in the way of studies on the patient," Fitzgerald says. "Doing something gets paid for; thinking does not. And I believe it is the ethical obligation of physicians to think."