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Ch 9 allocation of resources

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  • 1. Ethics in the Life Sciences Chapter 9 Allocation of Resources 1
  • 2. Learning Objectives • Identify issues of macro allocation in apportioning resources • Articulate the ethical theories underpinning allocation decisions • Describe the issues of micro allocation that nurses may face • Describe the genesis and evolution of the U.S. healthcare delivery system • Discuss the pros and cons of the managed care movement 2
  • 3. Justice in Healthcare Distributive Justice • The fair allocation of the benefits and burdens of society. • Who gets healthcare, how much do they get, and at what cost are all questions of justice. Questions in the U.S. healthcare system • Is healthcare a basic right? • What level of healthcare should be available? • Is it a privilege? • If so, how does one acquire the privilege? 3
  • 4. The U.S. Health Care System • The U.S. health care system is very complex. • Health care is subject to extensive regulation and oversight. • Health care coverage continues to expand for more people today than in any time in the past. • Health care cost are rising and more of that financial burden and responsibility is being shifted to patients. • Has operated primarily on the fee for service structure for many years. 4
  • 5. The U.S. Health Care System Health Maintenance Organizations (HMO) • Started in the 1930s with Kaiser Permanente in California. • An attempt to contain and control cost by instituting a level for approving by another party other than the primary care physician. • The HMO is tied to the federal benefits law, Employee Retirement Income Security Act of 1974, permitting HMO’s to avoid all state law liability. 5
  • 6. The U.S. Health Care System Preferred Provider Organizations (PPO) • A hybrid of the fee for service and HMO models. • Companies negotiate with hospitals, physicians and other providers to provide a discount to the companies employees. • Employees have a list of providers and hospitals to choose from. • If the employee goes outside of the PPO they are responsible for a larger portion of the healthcare cost. 6
  • 7. The U.S. Health Care System Medicare/Medicaid • Both government programs • Medicare- for persons > 65 years old, on hemodialysis, blind or otherwise disabled. • Medicaid- operated by the states and was intended for women and children or those with chronic medical conditions or disabilities. • Income and qualifying requirements exist for both programs. 7
  • 8. Access to Care • Financial implications is one factor that limits the availability of healthcare resources for people. • Health care disparities also occur based on race, ethnicity, and age. • Some groups are more vulnerable than others. • Some illnesses have less coverage, such as mental health, when compared to the coverage available for other illness. 8
  • 9. Managed Care Health Promotion/Maintenance Programs • Managed care organization (MCO) programs focus on health promotion • Health promotion programs help to control cost for the MCO • Some examples include: • Smoking cessation • Weight reduction • Stress management • Seat Belt use • Helmet use • Domestic violence screening • Car seat uses • Mammography • immunizations 9
  • 10. Managed Care Use of Clinical Pathways by Managed Care Organizations • More common in MCO’s. • A fixed amount is paid for a patients diagnosis based on the ICD-9 code or federal program of diagnostic related groups (DRG’s) . • The theory is the patient should have an expected course of treatments and outcomes for the specific diagnosis assigned. • The assigned pathway helps to ensure that the patient is treated according the diagnosis and unnecessary expenditures are mitigated. 10
  • 11. Managed Care Prescribing in a Managed Care Organization • Prescribing limitations in MCO’s can pose problems for physicians. • Patients may be forced to choose generic medications that may not provide the desired effect • The goal of the MCO is to find an equivalent medication that can be provided at a lower cost. 11
  • 12. Managed Care Financial Incentives/ Disincentives • Some MCO’s provide a bonus to physicians who use less resources than expected. • Physicians are then placed in a position of conflict of interest, deciding whether to put their own financial interest over the interest of patient treatments. • Financial disincentives may be implemented when physicians use more resource than expected. 12
  • 13. What to do? Possible Solutions at the Government Level • Health Care Reform- meant to ensure more coverage for more people. • As health care reform is phased in more people in the U.S. will have access to care that in the past they have not been able to have due to financial constraints. 13
  • 14. What to do? Possible Solutions at the Personal Level • Complementary and Alternative Medicine (CAM) • Occurs at the patients cost • More affordable • Evidence exist for CAM therapies • Informal Caregiving • Caregiving by other than healthcare professionals. • Caring by family members has increased with shortened hospital stays and the cost associated with home healthcare. 14
  • 15. Nurses’ Role in Macro Allocation Political Action • Involvement in professional associations • Becoming informed and informing decision makers 15
  • 16. Nurses’ Role in Micro Allocation Staffing • Nursing shortages contribute to staffing issues that challenge units and healthcare organizations. • Education and promotion of nursing can help fill the gaps during times of shortage. 16
  • 17. Nurses’ Role in Micro Allocation • Determining the Appropriate Level of Care for patients • Three levels of care to accommodate patients • Tertiary care which is the most technologically complex and sophisticated • Secondary care which may be technologic complex but focuses on reducing morbidity and restoring health in those with a chronic condition or disability. • Primary care which focuses on prevention and health promotion. 17
  • 18. Summary • Nurses should be aware of ethical underpinnings of resource allocation decisions • Ethical distress can occur when the nurses values are not the same as the organizations values • Nurses should strive for responsible stewardship of health care resources while advocating for services that meet patient care needs • Nurses should continue to educate themselves on healthcare reform so that they can be ready to anticipate changes and continue to advocate for their patient in the changing healthcare environment. 18