Ethical Debate

Case Study 1 NURS362

By: Sean, Marie, Rose, & Hillary

Case Study 1

A 27 year old nursing student has just graduated and developed a rare and life threatening illness, a progressive muscular degenerative disorder which causes significant pain. A new procedure or therapy has been found to improve life expectancy. The physician feels this may be the best hope for his patient and refers patient for treatment. The patient is low income and has government assisted health insurance. The medical insurance denies coverage for this procedure as it is new, experimental, and not covered under the stated policy. It is expensive and although the company who has this "cure" has discounted the cost, it is still unaffordable for this patient. The patient states, "I can't believe I am going to die from this because I'm poor." The hospitalist stabilizes his condition and writes for patient to be discharged. The family is seeking legal advice to sue the medical insurance, hospital, and physician.

This poses a couple questions

1.

Did the doctor even consider the young patients insurance policy? Or simply, did the doctor just think of the procedure and whats best? 2.Is it ethical or morally right, for a hospital to discharge a patient who is stable, yet dying? 3.What about hospice, or palliative care? 4.Can the patient appeal the insurance company, and demand coverage?

Joke or Real life?

HMSA Coverage in Hawaii

All

care you receive must meet all of the following Payment Determination the purpose of treating a medical condition. most appropriate delivery or level of service, considering potential and harms to the patient. is determined first by scientific evidence; to be effective in improving health outcomes; provided that:

Criteria: For The

benefits Known

-Effectiveness If

no scientific evidence exists, then by professional standards of care; If no professional standards of care or if they exist but are or contradictory, then by expert opinion; and for the medical condition being treated compared to

And

exists

outdated

Cost-effective

alternative
this

health interventions, including no intervention. For purposes of

paragraph, cost-effective shall not necessarily mean the lowest price. that are not known to be effective in improving health outcomes but are not limited to, services that are experimental or investigational

Services include,

HMSA continued

Experimental or Investigational Services Under the HMSA Medical Plans: A medical treatment, procedure, drug, device, or care is experimental or investigative if: The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished. The drug, device, medical treatment, or procedure, or the patient informed consent document utilized with the drug, device, treatment, or procedure was reviewed and approved by the treating facility's Institutional Review Board or other body serving a similar function, or if federal law requires such review and approval. Reliable evidence shows that the drug, device, medical treatment, or procedure is the subject of ongoing Phase I or Phase II clinical trials; is for the research, experimental study, or investigational arm of ongoing Phase III clinical trials; or is otherwise under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy compared with a standard means of treatment or diagnosis. Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, toxicity, safety, efficacy, or its efficacy compared with a standard means of treatment or diagnosis. For the purposes of this provision, "Reliable Evidence" shall mean only: Published reports and articles in authoritative medical and scientific literature. The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, medical treatment or procedure. The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, medical treatment, or procedure.

http://www.hmsa.com/health-plans/individuals-families/metallic-plans/

How Research Can Be Approved

The

Nuremberg Code - Set of provisions for research that must be followed for the federal government to approve research. http://www.hhs.gov/ohrp/archive/nurcode.html

Who is covered?

Options for patient

Ask about alternatives - Covered by insurance, just as effective Investigate clinical trials - If you're a candidate for a clinical trial, its sponsors probably will cover the cost of many tests, procedures, prescriptions and doctor visits. Get a second opinion - Another physician may suggest alternate treatments, or he or she may confirm the advice of your primary doctor. Suggest a payment plan - If the treatment is essential and not covered by insurance, ask your doctor's office to work with you to pay the bill over a period of time. Appeal to insurance coverage http://www.hhs.gov/healthcare/rights/appeal/appealinghealth-plan-decisions.html

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