Comparative Ethics of Modern Payment Models

Photo by Marek Studzinski on Unsplash ABSTRACT Payment models directly impact the way patients experience care. Historically, payment model innovations have been examined mostly from economic, organizational, and public health lenses. Financial incentives exist in all healthcare systems, whether a socialized, private or insurance, single payer system. This article examines alignment of current predominant fee-for-service, capitation, value-based payments with patient care ethics. The volume-based incentive fee-for-service is misaligned care, while capitation relatively neutral highly modifiable model. Value-based offer unique benefit improving agency larger cost control. However, no adequately addresses disparities, consideration for justice needed designers when considering incentives. In related values, bioethics must expand discourse around ethics to cover interactions system market forces outside clinical context. INTRODUCTION Healthcare always controversial. Discussions about broadly include ethical, medical realms. “simple” act one party paying creates between payer, provider, patient. Payments are based an agreed-upon price provider. While most industries, at level retail delivery, direct customer pays item received, healthcare, more complex. Deciding what metrics base prices has become arduous. Whether organizations should charge nations where it considered human right subject debate. ethical debate over providing combined theoretical framework how pay healthcare. paper various approaches Outside controversial notion financing their existing involve some entity other than bulk – socialized system, insurance these implicit financial provide criteria arises.[1] Depending nature payment, may align with, be toward, misalign patient’s best interest goals These create capitalistic drive organizational behavior nationalized models.[2] We can see marketplace adaptations United States form shorter visits, unnecessary increased volume determination which provided coverage. Fee-for-service incentivized higher quality time patients, leading 10- 25-minute visits.[3] any metric implicitly moving provider action toward on, regardless intent conscious effort.[4] For example, body financially rewards hospitals inpatient stays, then average length stay will decrease.[5] numerous, widespread effects even they receive, creating economic issues. Oddly, strictly perspective, secondary consumers systems. With this, providers responsibility within bounds (specifically, body, such as company, assured that gets paid usually pre-agreed terms) duty-based As example interests, there clear deny prior authorization medication expensive yet otherwise appropriate alternative condition. could result equal treatment, perhaps generic version even, would not chosen otherwise. It being deprived choice. l. Patient Care Ethics Using four principles bioethics, tenets systems autonomy agency, conflict beneficence, non-maleficence, justice.[6]The tension navigating payers fulfilling causes dilemmas. Volume-based reimbursement schemes prioritize efficiency, major bioethical principles. To truly evaluate model, we need vaguely consider supposed moral intentions design pertains bioethics. I propose novel viewing framework. motivation use under lens summarized below. a. Payments, nature, active passive b. Incentives affect behavior, intent. c. Changed response impacts d. argument because foster competition and, therefore, cause disparities acknowledged.[7] against ignores reality especially States, progressive recommendations still retain agency. Therefore, focus this concerns models. models—including mixed models, —with difficult. argues appropriately aligned Rawlsian difference principle, distributive justice. ll. Models Alignment varied. currently stands, widely used globally companies physicians performed actions evaluations relative value units. Relative units physician work, practice expense, service rendered, professional liability.[8] Later like were enacted control costs. Simply put, purely capitated consist flat-term do change services rendered.[9] Within past decade, payments, value, defined outcomes divided costs, became popular.[10] There savings accounts primary (patients without insurance).[11] assuredly interesting areas study, mimic receive rendered discussed further article. lll. Fee-For-Service main worldwide.[12] played large role shaping structural particularly States.[13] Fee-for-service, although declining, pervasive US created indirectly geographic distribution obvious force.[14] Even advent remains mode compensation percentage US.[15] Fee-for-service’s number seen rendered. World Health Organization stated its 2010 System Financing report likely leads overprovision, inefficiency, upwardly spiraling costs.[16] misaligns goal. rudimentary attempts finance if good industry. But necessarily better bills, largely inefficient treatment schemes.[17] Tummalapalli, et al. found had lower visit frequency fewer interventional compared overprovision—in rendered—and costs violating beneficence population level. misalignment root problem. does mind, nor own goals, question here center patients. Instead, principle non-maleficence. Can say harm patients? US, negative social burdens minority populations, enhancing disparity.[18] arguably unjust, Disadvantaged groups bear disproportionally brunt deleterious fee-for-service.[19] wastefulness, failure injustice, becomes lV. Capitation Mixed Pure less common fee-for-service. maximum effectiveness generally achieved combination modifiers.[20] Both practice, capping term period inherently controls setting “cap.” From issue minimal pure cases, lead underprovision.[21] neglect problem: intended, visits models.[22] Some view under-provision disservice true rarely salary.[23] Adding balances issues maintaining discordant modifiers add reasons described following section. overall given moldable therefore regarding V. Value-Based Since inception, popular internationally.[24] revolves assumption adopting readily measured, challenge implementing aligning spurred adoption accurate accounting innovation patient-reported outcome measures. full details beyond scope paper, Robert Kaplan proponent using time-driven activity-based costing, essential component calculating empirically method forms payments.[25] accomplishment, ethically comes measuring outcomes. take two ways: objective measures ideally controllable disease factors, hospital admissions exacerbations living chronic obstructive pulmonary disease.[26] Such results, important aspect but absolute placeholder One largest critiques cannot simply measured empirical data account values.[27] solution critique (PROMs), factor values lifestyle into calculation.[28] A study Groeneveld showed PROMs useful evaluating progression stroke several different intervals.[29] Bernstein give insight sociodemographic factors experiencing, guide targeted interventions.[30] providers, sound innovative tools, resemble everyday scoring work consultations attempt formally incorporate items payment. incentivize innovation, values. valid critiques. potential those who healthy achieve favorable Adjustment worsen undermine model’s propensity patients.[31] Comparatively, force line contrasted advantage spurring competitive goal-like priorities accurate. standpoint, ideal (but comparatively less) worsening disparities. Safeguards protect realm. Another allowing desires play process. latter modicums Based comparative ethics, require safeguards. Vl. Limitations Addressing Disparities Distributive Justice aforementioned continually miss opportunities explicitly underserved at-risk populations. Studies shown groups. greatest chronically ill, poor, high determinants health.[32] touted route studies show socioeconomic status experienced modifier.[33] Other scholars pointed out both slower roll low-resource unintended consequence funding areas.[34] disparity lack access rather reflection capabilities. silver bullet address crucial medicine, equity. disadvantages payment-related spur innovation. end, place systemic approach maximize improvement least advantaged groups, discussing models.[35] procedural just equitable process once Yet, none them ensure low status. Future towards incentivizing many modify clearly tend leverage benefits help By leaving well-off society consideration, contribute All future improve designs them. Vll. How Should Ethically View Incentive Design? policy realize importance efficiency. well-being, autonomy, pertinent others depending discussion, patient's interaction scenarios. CONCLUSION remain powerful tool organizations. simple indirect impacting follow-up aimed neither intended remained neutral. Newer much stronger purpose positive patient-defined capitation. Yet fully tenet justice, employed lowest disadvantaged worse off before implementation new strive possible necessitating integrated factors. - [1] Porter M. What Value Healthcare? N Engl J Med. 2010;363(26):2477-2482. [2] Kontopantelis E, Reeves D, Valderas JM, Campbell S, Doran T. Recorded diabetes England after introduction scheme: longitudinal observational study. 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