CASE SCENARIO
Healthcare Ethics: A Tale of Two Patients
RT is a 65-year-old who is a Medicare/Medicaid patient. This dual eligible status does not place them in a value-based contract. They are FFS for any hospital or provider who treats them. RT does not incur any out-of-pocket costs for medications. They have a primary care physician (PCP), but the PCP is private practice and is only loosely affiliated with several local hospitals. RT lives alone, is beginning to lose their sight, has no family close by, and has a case worker who runs their errands. RT has a history significant for chronic obstructive pulmonary disease (COPD) Gold Stage I, is on nebulizers at home as well as inhaled steroids, and goes on 3 L N/C of O2 at night. RT continues to smoke 1 pack per day and has for the last 50 years. No one pays any penalty if RTs outcome metrics are poor. But Medicare/Medicaid incurs the cost of care, testing, medications, oxygen, transportation to repeat ED visits, and multiple hospital admissions as RTs chronic conditions continue to deteriorate.
FS is a 67-year-old who has traditional Medicare. They have a PCP strongly affiliated with a local healthcare system. This healthcare system has contracted with Medicare to be in an ACO. This means that FSs PCP and the health system are accountable for FSs care and will only receive payment if FS stays out of the hospital and has good health outcomes. FSs history is also significant for COPD Stage 1. FS is on nebulizers at home, takes an inhaled steroid, and uses 3 L O2 PRN. They smoke 1 pack per day as well and are starting to have some significant deterioration of their COPD. If FS were to enter the hospital, the hospital will only receive a bundled payment, and if they re-enter the hospital in 90 days, the hospital will spend all the money they were given to care for FS just on this one episode. FS is also offered home care, respiratory therapy, and smoking cessation classes and coaching. FS says they cannot afford their inhaled steroid, so a pharmacist works with them to get the medications they need at a lower cost.
Discussion Question 1 (ALL STUDENTS MUST ANSWER THESE)
a. Would a bedside nurse know the difference between these two patients payor arrangements?
b. Should nursing be aware?
c. Should nursing continue to educate both patients on their disease?
d. What if these patients were in the same nursing unit? Would there be a concern that these patients were being offered different levels of support at home?
e. Clinically, what is the better way to care for the patient? Does that match the payor payment?
Healthcare Ethics: A Tale of Two Patients
Introduction
The healthcare landscape is increasingly complex, especially as it relates to the financial structures that dictate patient care. In the case of RT and FS, two patients with similar health conditions but vastly different payer arrangements, we see a stark contrast in the support and resources available to them. This essay aims to explore the implications of these differences on nursing practice and patient outcomes, ultimately arguing that healthcare professionals must be aware of these distinctions to provide equitable care.
Understanding Payer Arrangements
a. Would a bedside nurse know the difference between these two patients’ payer arrangements?
A bedside nurse may not inherently know the specifics of each patient's payer arrangement unless they are informed through chart notes or discussions with the healthcare team. However, nurses are trained to recognize that different insurance models exist and that these models can influence the resources available to patients. In practice, they may notice variations in care management strategies based on a patient's insurance type, but they may not have detailed knowledge about the contractual nuances of Medicare, Medicaid, or ACOs.
b. Should nursing be aware?
Yes, nursing professionals should be aware of the differences in payer arrangements. Understanding the implications of these arrangements is essential for providing holistic care. Awareness can lead to better advocacy for patients, enabling nurses to help navigate healthcare systems more effectively. For instance, knowing that FS has access to bundled payments and additional support services could prompt a nurse to encourage FS to utilize those resources actively.
c. Should nursing continue to educate both patients on their disease?
Absolutely. Regardless of payer arrangements, it is vital for nurses to educate all patients about their chronic conditions. Education empowers patients to take control of their health, regardless of their financial situation. Given that both patients suffer from COPD and smoke, ongoing education on disease management and smoking cessation should be prioritized. The disparity in resources should not deter nurses from providing comprehensive education tailored to each patient's circumstances.
Ethical Considerations in Care
d. What if these patients were in the same nursing unit? Would there be a concern that these patients were being offered different levels of support at home?
If RT and FS were placed in the same nursing unit, ethical concerns would arise regarding equity in care. While both have similar health conditions, the differences in their support systems may lead to discrepancies in care experiences and outcomes. Nurses must be vigilant about ensuring that both patients are receiving the necessary education and resources tailored to their unique situations. The potential for unequal care magnifies the ethical responsibility of healthcare providers to advocate for all patients, especially those like RT who may lack adequate support.
e. Clinically, what is the better way to care for the patient? Does that match the payer payment?
Clinically, a value-based care model, as seen with FS's ACO arrangement, generally offers better patient outcomes. The incentives aligned with this model encourage preventative care and proactive management of chronic diseases, reducing hospital readmissions and promoting overall health. In contrast, RT’s fee-for-service model lacks such incentives, potentially leading to fragmented care and higher costs for Medicare/Medicaid without improved patient outcomes.
However, while the clinical approach of value-based care may be superior, it does not always align with the realities of patient experience and access to care. Patients like RT may not receive adequate attention or resources simply due to their payer status, demonstrating a systemic flaw in how healthcare is funded and delivered.
Conclusion
The contrasting cases of RT and FS illuminate critical issues within healthcare ethics and nursing practice. Nurses must be aware of the implications of payer arrangements to advocate effectively for their patients and ensure equitable care regardless of financial constraints. Continuous education about chronic illnesses remains essential for all patients, as does an ethical commitment to provide equal support and resources. Ultimately, a shift toward value-based care models represents a more clinically effective approach that can improve patient outcomes while aligning financial incentives with quality care delivery.