Four Ethical Obligations Universal –Every member of society must have an adequate array of core...

Four Ethical ObligationsFour Ethical Obligations

• Universal– Every member of society must have an

adequate array of core health care benefits

• Fair– The contents and limits of health care benefits

must be established through an ethical process

• Sustainable– The health care system must be sustainable

• Accountable – The health care system must ensure that its

stakeholders have clear responsibilities for which they are accountable

Obligation 1 - UniversalityObligation 1 - Universality

• Universal access to a “core package”

– Not all services

– No particular means of providing coverage

• Reform will need to be comprehensive

– Interconnected effects of access, cost and quality

– Consider demands on all programs

• Should improve access to disadvantaged populations

– Incremental efforts are not unethical, but risky

– Reforms that improve access for the well off but not

the most vulnerable would be “blatantly unethical”

Obligation 2 - FairnessObligation 2 - Fairness

• “Set limits” rather than “ration”• Establish limits through an ethical process

– ‘Procedural’ versus ‘substantive’ fairness• Ethical expectations

– Transparent– Participatory– Equitable and Consistent– Sensitive to Value– Compassionate

“A consensus report on the ethical design

and administration of health care

benefit packages”

Fairness in Health Care Fairness in Health Care CoverageCoverage

Obligation 3 - SustainabilityObligation 3 - Sustainability

• Unethical to saddle our children with debt for the current care of ourselves and our parents

• No forced limit on individual spending– Limits must be applied to shared societal resources

• Need to set explicit spending goal– Consider long-term social benefit of health– Consider effects of (and on) other social programs

• Food, transportation, security, environment, etc.• Longitudinal measurement

– Revisable and responsive to changing circumstances• Unethical to trade universality for sustainability

– Improve affordability by changing benefit design, pricing or efficiency of delivery

Focus on prevention could avert >40 million cases of seven chronic diseases – cancers, diabetes, heart disease, hypertension, stroke, mental disorders and pulmonary conditions – in next 20 years. This would improve US productivity by $1.1 trillion/year.

"Most of the national policy discussion on healthcare is about financing mechanisms…[but] preventable illness as the country ages deserves equal focus…

Solving the problem is not going to be done the way we've done things in the past – dialing up co-pays and deductibles."

Kenneth Thorpe

Obligation 4 - AccountabilityObligation 4 - Accountability

• Reward quality, including efficiency: Unethical to waste resources

• Align accountability with responsibility & control

Risks of incentives not tied to control

• “Dr. Brook correctly states that the use of physician-specific outcome data would radically change how we practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere.”

– Stephen Clement, MD, Annals of Intern Med 1994

• “If my pay depended on A1c values, I have 10-15 patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to find new physicians.”

– Physician in a 2006 survey on pay for performance

Many ethical concerns with P4P

• Inequitable impact:– Large practices with HIT will win– Those already doing well will win– Non-adherent patients will be shunned– Minorities/elderly/immigrants will be shunned

• Inefficient use of resources– Documentation (rather than quality) improved– Inappropriate emphasis on what’s measured – Little more $ for lots more work – not enough to

offset costs of measurement• Focus on efficiency, not other facets of quality

– Patient-centered, equitable, safe, timely and effective

• Unreliable (therefore unfair) measures• Pay for performance could be deprofessionalizing



• Align accountability with responsibility & control

• Providers– Shared responsibility → shared

accountability – Promote teamwork and care coordination

• Patients– Reward healthy life-style & treatment

adherence– Recognize risks of more ‘skin in the game’

Patient responsibility

• Necessary to get to universal coverage– Absent a mandate, halving premiums would cut

number of uninsured by only 3%– RAND, HSR, July 2007

• Incentives work– Many wellness programs with incentives

• No pay – lose 2 lbs• $7 per 1% body fat – lost 3 lbs• $14 per 1% body fat – lost 5 lbs

RTI/UNC, J Occ and Env Med, Sept 2007

– ? Ethics of penalties, e.g., for smoking, failing to lose weight, etc…

• Some companies penalize for health risks. Lisa Cornwell, AP, Sept. 9, 2007

• ? Legality (ADA), cream skimming

Medicaid Plan Prods Patients Toward Health NY Times, Dec 1, 2006

“John Johnson has lost a leg to diabetes but eats “what I want” and continues smoking. He says he will not participate in the enhanced-benefit plan.”

Ethical risks of ‘blunt’ patient incentives

• Unfair to hold someone accountable for something over which they have little control– Children missing appointments– Bus schedules, etc.

• Those with greatest need for enhanced services may be most likely to miss performance targets

• Ethical risk for physicians in “turning in” their patients who are non-compliant

© 2002 The New Yorker Collection from cartoonbank.com. All Rights Reserved.

Limitations of Consumerism in Health Care

THE

COMMONWEALTH FUND

More “Skin in the Game”Adults with High Deductibles More Likely to Avoid Needed Health Care

Because of Cost

168 11 12

2522

1217 19

3127

1926 24

44

0

25

50

75

Did not fill a

prescription

Did not see

specialist when

needed

Skipped

recommended

test, treatment,

or follow-up

Had medical

problem, did not

see doctor or

clinic

Any of the four

access

problems

<$500 $500–$999 $1,000+

Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

Percent of adults ages 19–64 insured all year with private insurance



• Align accountability with responsibility & control• Providers

– Shared responsibility → shared accountability – Promote teamwork and care coordination

• Patients– Reward healthy life-style & treatment

adherence– Recognize risks of more ‘skin in the game’

• Not disadvantage high-risk individuals or populations or the providers who care for them

SummarySummary

• Interdependence of cost, quality and access

• Limits must be set: need processes to set them fairly

• Balance health care spending with other worthy social programs

• Responsibility for all stakeholders– Link accountability to control

• Take the long view– All reform is incremental– Do something, STUDY it, revise it

For more informationFor more information

www.EthicalForce.org

http://www.ethicalforce.org/

THE

COMMONWEALTH FUND

Adults ages 19–64 with individual coverage or who thought about or tried to buyit in past three years who: Total

Health problem

No health

problem<200% poverty

200%+ poverty

Found it very difficult or impossible to find coverage they needed

34% 48% 24% 43% 29%

Found it very difficult or impossible to find affordable coverage

58 71 48 72 50

Were turned down or charged a higher price because of a pre-existing condition

21 33 12 26 18

Never bought a plan 89 92 86 93 86

Individual Market Is Not anAffordable Option for Many People


THE

COMMONWEALTH FUND

Percent of People Who SayThat Employers Do a Good Job Selecting

Quality Insurance Plans to Offer Their Workers

7468

7569 70

75 76

0

25

50

75

100

Total <200% 200%+ <20 20–99 100–499 500+

Percent of adults ages 19–64 insured all year with ESI

ESI = employer-sponsored insurance.

^ Based on respondents who are covered by their own employer’s insurance.


% FPL Number of employees in firm^


“You can’t legislate morality. Thank heaven”

Disparities and access to care

THE

COMMONWEALTH FUND

Adults with Higher DeductiblesAre More Likely to Spend $1,000 or More

on Personal Out-of-Pocket Expenses

27 2535 42

4 2

5

13

0

25

50

75

100

Total <$500 $500–$999 $1,000+

Annual out-of-poc ket c os ts $5,000 or more

Annual out-of-poc ket c os ts $1,000–$4,999


Annual deductible

31 27

40

55


THE

COMMONWEALTH FUND

Adults with Higher Deductibles Are More Likely to Spend a Greater Share of Household Income on Family Out-of-

Pocket Expenses and Premiums

4036

55

67

25 22

3643

0

25

50

75

100

Total <$500 $500–$999 $1,000+

Spent 5% or more of inc ome on out-of-poc ket c os ts

Spent 10% or more of inc ome on out-of-poc ket c os ts


Annual deductible


THE

COMMONWEALTH FUND

Figure 15. Adults with Higher Deductibles Are More Likely to Have Health Plans That Limit Total Dollar Amount Plans

Will Pay for Medical Care Each Year

3430

40

48

0

25

50

75

Total <$500 $500–$999 $1,000+


Annual deductible

Percent of adults ages 19–64 insured all year with private insurance who report plan limits

THE

COMMONWEALTH FUND

Adults with High DeductiblesHave Problems Paying Medical Bills

or Are Paying Off Medical Debt

148 6

172323

913

2735

20

5

17

31

41

0

25

50

75

Not able to pay

medical bills

Contacted by

collection

agency*

Had to change

way of life to

pay medical

bills

Medical bills/

debt being paid

off over time

Any medical bill

problem or

outstanding

debt

<$500 $500–$999 $1,000+

* Includes only those individuals who had a bill sent to a collection agency when they were unable to pay it.



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