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 might 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

Patients should never be denied emergency care and treatment due to their inability to pay or inadequate insurance coverage, says Marianne L. Burda, MD, PhD, a Pittsburgh, PA-based ethics consultant and educator. 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.