Stratifying service levels raises an ethical question

Friday, April 30, 2004

Although Medicare does not require its Part B contractors to provide home delivery for beneficiaries, it has long been customary for them to do so at no charge.

But under the margin-erasing provisions put forth in the Medicare Prescription Drug Act that practice may come to a grinding halt. In fact, homecare consultant Kevin O’Donnell recommends providers get out of the transportation business altogether. Instead of shouldering the costs of fleet management, providers could instead arrange for third-party couriers to make deliveries - at the patient’s expense, he said.

“One absolute about healthcare is that reimbursement drives behavior,” said O’Donnell, president of Lewisville, Texas-based Healthcare Resources of America. “We’ve seen that in the hospital sector for 15 years and HME companies must now follow suit. They have to restructure their businesses according to payer policies and the fact is, there’s really no room for a fleet of trucks anymore.”

Whatever cushion existed for value-added services has now been flattened by the Prescription Drug Act, so providers could very well find themselves following O’Donnell’s advice. At the very least it may mean charging for delivery or establishing a service matrix that offers free delivery to some patients while requiring others to pick up their products.

At any rate, it’s a radical departure that leaves some wondering about the ethics of selective patient services. And misjudgment could make it a legal situation as well, said Jeff Baird, healthcare attorney with the Amarillo, Texas-based law firm of Brown and Fortunato.

Regardless of a provider’s delivery policy, the company is still obligated to provide maintenance support and that sometimes means getting service requests in the middle of the night. Here is where it gets thorny, Baird said.

“It’s a dilemma because although the company has to give a basic level of service, it’s human nature that they won’t be nearly as motivated to make those midnight runs for Medicare patients and will likely wait until morning if it’s not a life-threatening emergency,” he said. “Currently, there’s no case law on this situation, but that could change in the near future if a patient has a negative outcome due to a provider’s slow response. An ensuing lawsuit most likely will assert that the company had a duty to act in a swift and reasonable manner and consequently is negligent and liable.”

When it comes to the ethics of tailoring service levels to insurance coverage, opinions vary widely. Bioethicist Donald Light, Ph.D., is at the far end of the spectrum. Light, a bioethics fellow at the University of Pennsylvania, studies healthcare on a global scale and thinks the entire U.S. system is unethical.

“The ethics I believe in don’t exist here,” he said. “Other countries may discriminate by medical need, but the American system discriminates by money and that is unconscionable. Ours is the only system that allows multi-tiered care, which I find to be medically offensive.”

The Joint Commission on the Accreditation of Health Care Organizations, which considers itself to be the voice of conscience, takes a much more moderate stance. Stratified service levels aren’t seen as unethical, but providers must be consistent in how they classify their patients, said Maryanne Popovich, executive director of the Joint Commission’s Home Care Accreditation Program.

“It comes down to this - if you provide delivery for homebound patients, it must be provided for all homebound patients,” she said. “If you want to require ambulatory patients to pick up the equipment, that’s up to you. But the policy must apply to all ambulatory patients.”

When contemplating a new service methodology, providers also need to consider which products aren’t suitable for patient pick-up or generic courier, Popovich said.

“The goal should be that the patient has the appropriate equipment and knows how to use it,” she said. “If that goal is met, there isn’t an issue if the patient or caregiver has to come in and get it. But I don’t know anyone who would even conceive of having a patient pick up a ventilator and allow the family to set it up by themselves.”

Conversely, the Accreditation Commission for Health Care refrains from taking an ethical stance, preferring to let its constituents make their own judgments.

“Our motto has been ‘by providers, for providers,’” said Tom Cesar, president of the Raleigh, NC-based ACHC. “This means we are here to serve the consensus of the industry as defined by its principles, governing laws and best practices. The organizations that choose to go through our program are measured for compliance according to those standards.”