Question

Patient A is seen for a similar diagnosis as patient B, but patient A has a different insurance plan than patient B, which provides less coverage for medical services. Should patient A be treated differently than patient B? If they are treated differently, would this be a legal issue or an ethical issue?

Answer 1

Ans) Yes surely, it has happened in many cases & is to be considered a legal & ethical issue to be concerned.

- When financial considerations intervene in decision making for the individual patient, the clinician is forced off of well-trodden clinical pathways, leaving uncertainty about what is best for the patient. In instances where physicians are forced to compromise the standard of care, there is a potential reduction in quality. Such instances will occur until there is universal access to a basic standard of care. If the art of medicine is applying the science of medicine to the context of the patient, the artful physician will provide the best care possible under the circumstances. The following are proposed as guidelines.

• Physicians should explicitly ask about financial concerns rather than ignore the problem or wait for patients to raise the issue first. As with other sensitive questions physicians ask, patients may react with anxiety or discomfort, but the information they provide is important to the care plan. If financial considerations will affect the delivery of medical services, it is better to know sooner rather than later. This will enable the clinician, before embarking on an extensive work-up, to consider the ramifications of transferring a patient with a particular medical need to an indigent care facility versus retaining the individual with a goal of providing care at lower cost.

• Physicians need to be knowledgeable about the resources available at their institution and in the community for the medically indigent, so they can maximize services that aid their underinsured patients. They may benefit from ancillary staff, often in social work, who can provide appropriate guidance and referral information. They should be certain that their patients with financial hardship are getting full benefit from the public and private resources that are available, such as public aid and pharmaceutical industry indigent drug programs.

• In considering whether to retain a patient or refer to a safety net provider, physicians must take into account the loss of continuity of care and uncertainties about the level of service available at alternative sites. They should also consider that services might be better elsewhere if the referral option is an academic institution or the patient is from an ethnic minority group with which the safety net provider is especially familiar. If a decision is made to refer, the physician should make direct contact with providers at the referral site to identify a contact liaison to optimize the referral process.

• If retaining a patient appears to be the preferable or only option, a physician may be forced to provide a nonstandard approach to care in order to best serve that individual. Documentation that a patient has declined a recommended study or therapy, including referral to a safety net provider, if available, and has been informed of the risks involved is critical. In such cases, close observation with frequent visits and basic laboratory studies can be an inexpensive alternative to ordering costly tests (which may have only a marginal benefit over careful observation). The relationship that develops in this setting can be a patient's lifeline when a strong physician advocate who knows the patient well is needed.

• Physicians should actively work to lower the cost of their services when they have clear evidence of financial hardship. For underinsured patients, they must do so in a manner that will not be interpreted as financially self-serving or in violation of the law. For uninsured patients, adjustments in fees are allowed. When the demand for free care threatens the financial viability of the provider institution, the physician can promote the adoption of charity policies that help direct subsidies to the most needy patients.

• To best serve their patients in the broadest terms, physicians must address issues of social justice outside of the office. Within their institution, they can lobby for a charity care policy, the use of means testing, and the application of sliding fee scales. In their community and through professional societies, they can lobby for support of safety net institutions, such as publicly funded hospitals and clinics. At a state and national level, they can participate in educating the public about the consequences of unaffordable health insurance for tens of millions of Americans. Finally, they can advocate for reforms that will broaden access to medical care and services, including medications and supplies.