Comments on July’s Ethics Forum
Let me preface this by first applauding all of you for the creation of the ethics column and the selection of the first case, as it so adequately reflects the current socioeconomic climate within which we practice.
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In regards to the case in which the patient stated that she could not afford the visit nor the labs required for her methotrexate to be refilled, I encounter this problem almost biweekly in our small Reno rheumatology practice. I first tell the patient why I can’t just prescribe the medicine. (Remember, most patients they think this simply entails the writing of a prescription without any liability or actual concern for patient safety.) After telling the patient what I can’t do, I then utilize a common strategy in customer service, which is to tell the patient what I can and am willing to do for him or her. I do ask that the patient be seen to discuss the matter further. If there is no insurance, a practice can offer a discount for not needing to bill the patient. This is not incongruent with commercial insurance or governmental program contracts, because your “discount” is not for the medical service, but rather for not having to bill the patient, provided they pay the discounted amount at the time of service. Of course, you must be willing to offer a similar discount to other patients in the same situation to avoid being accused of “unfair business practices.” This is not the same as discounting the fee for a patient with insurance, who has a large deductible or copayment, which would likely be a violation of the provider’s agreement with the insurer. Of course, each provider would have to verify individual state laws.
When I see the patient, I advise him or her of why I can’t simply provide the prescription. I am held to certain guidelines. These guidelines have been established to provide adequate patient safety. Good care is good care, regardless of ability to pay. However, there is a difference between “good” care and “ideal” care, and I am willing to provide “good” care if the patient is also willing to settle for this. I am not willing to provide “unsafe” care. If the patient suffers a complication, in this case due to methotrexate toxicity, I am not held to a lower standard of care because of the patient’s inability to pay. Of course, the patient will insist that he or she would never sue me, but I remind them that their loved ones or the state can sue me on their behalf, and I will have to live with the effects of my decision. My failure to follow minimum standards is not only malpractice, but unethical. It is one thing when a patient decides, after informed consent, to decline treatment because of the inability to afford such treatment, and the patient suffers a preventable complication as a result of omission of such treatment; it is another matter when the patient suffers a preventable complication as a result of a treatment which I helped by my provision of treatment.