Healthcare Ethics: A Tale of Two Patients

by | Sep 21, 2024 | Nursing

 

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?

 

 

Sample Answer

Sample Answer

 

Discussion on Healthcare Ethics: A Tale of Two Patients

a. Would a bedside nurse know the difference between these two patients’ payer arrangements?

In many cases, a bedside nurse may have access to information regarding patients’ insurance details through electronic health records (EHR) or admission paperwork. However, the specificity of payer arrangements—such as whether a patient is in Fee-for-Service (FFS) or part of an Accountable Care Organization (ACO)—may not be immediately clear to nurses unless they are specifically trained or informed about the implications of different payer contracts. Nurses are often more focused on direct patient care rather than the intricacies of healthcare financing.

b. Should nursing be aware?

Yes, nursing should be aware of the differences in payer arrangements, as they can significantly influence the quality and type of care patients receive. Understanding these arrangements can help nurses better advocate for their patients, tailor education and support based on financial realities, and coordinate care effectively. Awareness of payment structures allows nurses to identify potential barriers to care, such as medication affordability, and promote resource utilization that aligns with the patients’ needs.

c. Should nursing continue to educate both patients on their disease?

Absolutely. Regardless of their payer arrangements, both RT and FS need education about their chronic obstructive pulmonary disease (COPD), its management, and lifestyle modifications such as smoking cessation. Education is essential for empowering patients to take control of their health and improve outcomes. Nurses play a crucial role in patient education, providing tailored information that addresses each patient’s unique circumstances and challenges.

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?

Yes, there would be a concern that RT and FS might receive different levels of support based on their healthcare arrangements. For instance, FS has access to additional resources such as home care services, respiratory therapy, and smoking cessation classes due to their participation in an ACO. In contrast, RT may lack similar support because of their FFS status and limited care coordination. This disparity could lead to inequities in care, further exacerbating RT’s health conditions compared to FS. Nurses must be vigilant to ensure that all patients receive appropriate support and interventions regardless of their payer arrangements.

e. Clinically, what is the better way to care for the patient? Does that match the payer payment?

Clinically, the better way to care for a patient with COPD involves a comprehensive approach that includes regular monitoring, education on self-management strategies, access to medications, smoking cessation programs, and coordinated follow-up care. For FS, the ACO model incentivizes this comprehensive approach by holding providers accountable for outcomes, which ultimately leads to better health management and reduced hospitalizations.

In contrast, RT’s FFS arrangement may lead to fragmented care without a focus on preventive measures or long-term health outcomes. Although both patients require similar clinical attention due to their COPD diagnosis, FS stands to benefit more from a system designed to promote coordinated and proactive healthcare management.

Overall, while the clinical best practices for managing COPD remain consistent, the alignment between effective care and payment models is crucial. A system that emphasizes value-based care—like that of FS—encourages better health outcomes and cost-effectiveness compared to traditional FFS models that may perpetuate reactive and fragmented care like that experienced by RT.

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