Access to care and allocating scare resources

The objective of this module is to provide information and generate discussion about ethical issues associated with allocation of health care resources and elderly patient populations.

Since there are limited resources available for health care, difficult decisions need to be made concerning how they are to be allocated. Due to a variety of factors, including the limited financial resources, an insufficient number of health care providers, and the expense and scarcity of medical products, it is clear that not every patient can be treated to the fullest extent possible and that not all of the country's health care desires or expectations can be fully met. Further, there are situations in which it is medically and ethically inappropriate to provide care.

Justice is a crucially important concept to consider when addressing the issues related to the allocation of health care. Roughly speaking, justice refers to the notion that resources should be fairly distributed within society. It usually entails that individuals should have the opportunity to obtain a share of the benefits that society provides. The specific details of what the concept of justice entails in health care contexts and how it should be applied to medical practice have been vigorously debated. One view is that the benefits received by an individual patient must be balanced against the medical needs of society in general.

Related to the concept of justice, the question arises concerning whether, and under what circumstances, it is morally appropriate to set priorities for health care. One view is that the sickest patients should receive treatment first. But this practice could take away valuable resources from patients who are more likely to survive and who may enjoy a better quality of life. Government agencies, health care teams, and insurance companies alike have struggled with determining what kind of strategy is appropriate for allocating care. In 1989, strategy for prioritizing health care was implemented by the State of Oregon. Oregon's program, which is part of the Oregon Health Plan, initially weighed "cost-effectiveness" as an important factor determining who would receive medical services.

Determining whether, and under what circumstances, resources should be used to provide end-of-life care raises important ethical issues. Health care communities have had ongoing debates, for example, concerning whether, and at what point, medical procedures can be halted when treating patients who suffer from dementia. One argument is that if the patient suffers from an incurable illness, then some treatments might be "futile"- i.e., they would provide no appreciable benefit to the patient.

Patient life-spans continue to extend as health care technology improves, and the demand for end-of-life care continues to escalate. As a result, health care costs have grown at an alarming rate. The development and use of new drugs, devices, and diagnostic techniques have significantly added to the rising cost of health care, which has placed a heavy burden on patients to seek affordable health insurance.

The transition from the traditional "fee-for-service" system to managed care, during the seventies and eighties, was primarily motivated by the desire to keep down or reduce health care costs. The philosophy of managed care involves applying business principles and practices, such as market competition, to the health care arena in order to ensure efficient and cost-effective care. Under managed care, the primary way that health care services are delivered is through Health Maintenance Organizations (HMOs). HMOs typically provide lists of approved health care providers for patients to choose from when receiving care.

Although managed care initially achieved some success at keeping health care costs down, the complaints lodged against it have been numerous. Even though a system of managed care is currently in place in the United States, the cost of health care continues to escalate at an exorbitant rate. Managed care is also criticized for causing the physician-patient relationship to deteriorate. Under HMO plans, physicians are typically encouraged to see a large number of patients per day, which can decrease the amount of time that they can spend with each individual patient. Critics of managed care suggest that this practice does not enable physicians to develop a good rapport with their patients. Critics have also argued that managed care interferes with the ability of patients to receive high quality care because HMOs typically place restrictions on when patients are allowed to be examined by specialists. Yet supporters of managed care respond that policies encouraging patients to see primary care physicians before being referred to specialists have helped eliminate unnecessary medical visits and costly procedures.

A significant number of elderly individuals in the United States have had difficulty getting access to quality health care because of factors such as poverty, homelessness, history of illness, and the lack of health insurance. Elderly patients are frequently unable to afford the high cost of hospital stays, medical procedures, and prescription drugs. Debates about how to keep the cost of prescription drugs down have been prolonged and intense. Yet there are no easy solutions available.

The desperation to find affordable prescription drugs has caused elderly patients to seek out companies outside of the United States to supply them with these drugs. The high cost of American prescription drugs, for example, has led some patients to drive to Mexico in their search for cheaper alternatives. Companies located in Canada have Internet sites frequented by American patients to purchase prescription drugs for lower prices than they could find in the United States. These examples indicate that measures are needed in order to assist patients, elderly or otherwise, with the cost of prescription drugs.

In 2003, Medicare Improvement and Modernization Act, Public Law 108-173 was signed into law. The Act's Prescription Drug Discount Program is scheduled to take effect in 2006. In addition, some health care companies offer specific types of plans to assist patients with the cost of prescription drugs. The practice of purchasing drugs on-line and abroad has caught the attention of our government and pharmaceutical companies because of safety concerns.

If an elderly patient cannot, or patient's insurance will not, pay for health care, this can place a heavy financial and moral burden on a health care institution. A significant number of elderly patients suffer from illnesses such as Alzheimer's disease that are currently incurable. This typically means that if "experimental" procedures become available for a patient's illness, the procedures will probably not be covered by the patient's insurance. The health care institution is then in the unenviable position of deciding whether to proceed with expensive medical procedures when it is unlikely that the institution will be reimbursed for its costs. In principle, economic factors should not interfere with good health care practices. However, if payment is not received for a patient's care, this can interfere with the ability of a health care institution to provide care for its other patients or for future patients.

QUESTIONS TO CONSIDER

1) What is ageism? Ageism is a form of discrimination that treats individuals differently based solely on their age.

2) Is ageism ever justifiable? There are circumstances where it is justifiable to treat people differently based on considerations of age. For example, forbidding an adult from playing on a child's sports team is a permissible form of age discrimination. With regard to health care decisions, there should be compelling scientific and/or ethical reasons for treating patients differently because of their age. For example, it is reasonable to refuse to perform heart transplant surgery on a 90-year-old patient suffering from dementia, because it unlikely that the patient will survive the surgery and the patient's chances of having a good quality of life are slim.

3) What does "triage" mean? "Triage" refers to a strategy applied when the number of demands on a system surpasses the resources available to respond to them. In health care contexts, there are situations when the number of health care providers available cannot accommodate the number of patients that simultaneously require medical attention. Thus, the health care providers might apply a "triage" strategy whereby treatment priorities are established based on the severity of the patients' respective illnesses and the expected efficacy of available treatments.

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