The Underlying Issue is Often the Same in Health Care – Ethics

So I opened my AIS Health Daily email and read two seemingly different stories that are actually related on an underlying level. The first discussed the 340B pharmacy pricing program that allows hospitals and other provider to buy drugs at a lower rate to when they  services to indigents and the uninsured.


340B Program Shirks Charitable Care, Undermines Formularies, Argue PBMs
Reprinted from Drug Benefit News

A new report from a coalition of stakeholders suggests that a considerable portion of the hospitals enrolled in the 340B Drug Pricing Program furnish a negligible amount of free or reduced-price care to indigent, uninsured patients …. Read Full Story

and the second pointed out the large amount of duplication of case management services found by ACOs , and that quote is here:

“The opportunity (for accountable care organizations) is so amazingly large when you get the systems to start talking to each other. One of the most amazing things to us is the duplication across systems — five [case] workers being assigned to one person was not unusual, and nobody knew anyone else was working with the individual.”

— Jennifer DeCubellis, Hennepin County (Minnesota) assistant county administrator for health, told AIS’s ACO Business News.

Click here to read the ACO BUSINESS NEWS article in which this quote appeared. (Free for ABN subscribers; $17 for non-subscribers).

Neither of these are a surprise to me nor probably to most professionals in health care and they relate to two fundamental problems with the system as structured today. Fee for Service as the payment mechanism of choice makes it too easy to set up shop and bill for services and, secondly, if there’s a way to make a buck or “stretch” the system someone will do it.

Obviously moving away from our current fee for service system will create the impetus to look at these issues, and maybe fix them (see the closing paragraph), but more importantly it get back to ethics.  In many if not most of the cases associated with the two instances above, these are non-profit organizations providing 340B drugs or case management services.

Lets look at the Case Management issue.

Case managers are supposed to be coordinating cases, yet don’t know that others are involved?

Come on, that’s their role.  More likely they know or have an inkling, but their organization recognize’s that in order to keep the funds flowing, they just don’t find out. When I worked with Medicaid programs around the country I saw this all the time; supposed case managers not truly coordinating services, closing the office too early, not knowing what was going on with their clients, tracking lots of contacts and other process measures, but having little to no tracking of outcomes. Other  providers servicing Medicaid had similar issues, home health aides providing little to no service, meals on wheels delivering inappropriate foods because they never knew the patient was a diabetic (in this case the patient had both a case manager and a 12 hour a day home health aide who accepted the meals), and the list goes on and on.

The health care system is a giant feeding mechanism for tens of thousands of companies and organizations. Its just too easy to ensure your own survival at a cost to the system because we have allowed it. As we change the payment method,  what do you think some of these organizations will do if they go full risk in a capitated model?  Might their current lack of ethics lead to under-serving their population to make sure they survive?


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