Antiretroviral therapy and Primary Care Chris Boyle, MD 9/8/2011.
Barriers to Health Care & Access to Care Philip Boyle, Ph.D. Vice President, Ethics
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Transcript of Barriers to Health Care & Access to Care Philip Boyle, Ph.D. Vice President, Ethics
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Barriers to Health Care&
Access to Care
Philip Boyle, Ph.D.Vice President, Ethics
www.CHE.ORG/ETHICS
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Goal of Today’s conversation• Is there a moral right to health care?
– If so, how much do you get?• Whose is obligated to provide?• What process & criteria are there to
fairly allocate it?
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History• How we got here?
– The Social Transformation of American Medicine, Paul Starr
– The rise of social insurance in Europe– WWII & offering benefits
• Where are we going?– Consumer-driven health plans & high
deductible savings account• Largely perceived outside our control
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Case• Joe 31-yr-old sentenced felon 14 yrs
– $1 mil heart transplant– Viral infection
• Frank 41-yr-old CHF– Raised $150,000
• 83,00 on waiting list– 5000 die waiting– 17,000 get one annually– 8,800 donors
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So what is (are) the moral problem(s)?
1. Identification of moral problem2. Identification of interests3. Need facts4. Values at issue5. Priority of values6. Alternatives evaluated in light priorities
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poll• Is healthcare more valuable than other
values?• Why is healthcare valuable?
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Why is healthcare a primary value?
• Purposes of healthcare– Relieves pain and suffering– Restores functioning– Prevents death– Improves opportunity for life plan– Provides valuable information
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poll• If health care is a primary good, is there
any obligations in the way we distribute it?
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HC needs to be distributed equitably?
• Well being• Opportunity• Information• Interpersonal significance
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Equitable means?• Equality• According to benefit or need• Adequate level
– Excessive burdens– Acceptable burdens
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Poll• Is it a social obligation?
– Why?• Is a social obligation the same thing as
a right?
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A social obligation?• Requires skills and efforts of many• Few can plan for it or secure it• Illness is largely undeserved & unevenly
distributed
• Rights – Liberty rights—free of restrictions– Entitlement rights—claim on another
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poll• If it is a social obligation, can people
forfeit the claim?
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Does personal responsibility limit access?
• Difficult to identify– Voluntariness difficult to ascribe
• Institutionalization leads to discrimination
• Fair share of burden
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Who is responsible to assure ?• Market?
– People can’t plan to afford– No all places have markets– Lack of information
• Charity?• Government?
– Subsidiarity• Local, state, federal
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Home health: What’s fair?Mr. Brown LSW• Client 1-- 4 hours 3X-a-week, niece cares• Client 2-- Home worth $10,000-15,000• Client 3– 85-yr-old cost sharing at 94%
– $15,000 in savings– Income $2155 monthly
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What is adequate? • Professional judgment• Average current use• List of services• Overall evaluation
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Social distribution• When there are inadequate resources
are there reasons to prefer some patients over other patients?– Severe & persistently mentally ill v. those
persons with mental illness for which we can do something
– Oregon experiment
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Ethics of Process• Organizations are powerful moral
agents– Transparency
• Is it clear how the decision is made?• Who makes the decision? • The criteria that are used
– Participation • Whose interests are considered?
– Applied evenly and consistently – Appeals– Checks and balances
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Ethics of ProcessDue process – Notice: what alternatives exist– Means of meaningful appeal– Consistency in judgment and action– Transparency to those affected
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Criteria • What technology is being assessed &
allocated?– New & old?– All ox being gored?
• What is the goal of managing the resource?– Whose goals?– Does it meet the goal?
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Criteria • What measurements are used to
assess & allocate?– Unit of care?– Evidence-based
• Safer• Higher quality• More efficient• It works• Effectiveness? Effective for what?• Cost-effective
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Criteria • What measurements are used to
assess & allocate?– What costs are relevant?
• ROI analysis– Over what period of time?– For a system or society?
• Non-financial costs
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Criteria • What measurements are used to
assess & allocate?– Social Measures?
• Holistic care: high tech, low touch• Preference for those who are poor• Quality of life• Cost that could reduce access• Supports population health• Preventive care
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• How does the mechanism work?
– Was there a previous informal mechanism?– Who devised & when is it used?
• Is there clarity in definitions & consistency in application?
• Unintended consequences of process?
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Conclusions• Establishing why it is a right• Rights are inviolable• Allocation is a mix of fair process &
criteria