Ethics Forum

Providing high-quality and ethical medical care to patients without insurance or the means to pay for their care is an increasingly common dilemma for rheumatologists.

How Much Is Enough?

This month we will explore the difficult yet increasingly important question of how to provide care to patients with chronic conditions who do not have health insurance or other means to pay for their care—and we want your help. Tell us how you would address this ethical dilemma by e-mailing [email protected].

The Case

This week I saw a 45-year-old woman who has had rheumatoid arthritis (RA) for three years. When she first became symptomatic, she was working and had health insurance. Her primary care doctor attributed her joint symptoms to stress, thus delaying the diagnosis. By the time she was referred to a rheumatologist, she had become virtually disabled and had lost her job and, as a consequence, her medical insurance. Finally, after many months of severe disease activity, she was referred to a nearby medical school clinic where patients with Medicaid were accepted. There was a six-month waiting list for new rheumatic disease patients at this facility. With this delay effectively blocking her access to medical attention again, she simply gave up and made no further attempts to get an appointment with a rheumatologist. Her friend has offered to pay for a visit to see me. Yet once I have evaluated her, what will be my obligation to help this patient?

Discussion

This unfortunate case highlights the problem of limited access to healthcare, especially for patients suffering with a chronic disease. In the rheumatic diseases, the ACR’s report on the future of healthcare in the United States highlight the impact and importance of the shortage of rheumatologists.¹ Further, the recent report of Schmajuk et al demonstrates how a shortage of appropriately trained physicians can adversely affect patient care.² Among more than 93,000 elderly RA patients insured in Medicare Managed Care plans, only 63% received appropriate therapy (disease-modifying antirheumatic drugs). Regional variation was noted, as were differences based on socioeconomic status and insurance coverage.

Our question, however, is this: How much should we do as individual practitioner? In terms of your obligation to the patient, what will an agreement to see her require of you subsequently? Does your obligation differ according to your professional relationship with the patient (i.e., consultant versus the patient’s primary physician)? What kinds of actions could you take, should you feel a responsibility to direct or coordinate her chronic care? Options include referring the patient to social service organizations that can help her obtain treatment and care; helping the patient obtain medication through plans available through the pharmaceutical companies; or even seeing the patient for a reduced (or no) fee.

Various organizations can be enlisted to help obtain affordable medical care for this patient, although they may only provide a partial solution to the problem or may only be able to help certain patients. Just how far you are willing to go is a matter of personal choice and belief. Nonetheless, given the inconsistent availability of care, the expense of current therapy, and the chronic nature of rheumatic disease, such problems are likely to remain part of the landscape in rheumatic disease care for the foreseeable future. In a previous issue we discussed that even treating a patient with methotrexate without the ability to monitor blood work is problematic (July 2010, p. 1). As is typical of many problems, the solutions are not obvious or easy.

What Would You Do?

We would like to hear your decision and analysis of this case. How would you provide medical care to this woman? How far would you go to see that she receives care for her chronic condition? What is the physician’s ethical obligation?

Send your comments to [email protected], and we will publish some of responses in a future “Ethics Forum.”

Dr. Meltzer is assistant professor of medicine at Thomas Jefferson University in Philadelphia. Dr. MacKenzie is associate professor of clinical medicine and public health at Weill Cornell Medical College, Hospital for Special Surgery in New York. Dr. Kitsis is director of bioethics education and a member of the rheumatology division at Albert Einstein College Medicine in the Bronx, N.Y.

References

1. American College of Rheumatology. The Future of Health Care in the United States. February 2009. Available at www.rheumatology.org/advocacy/acr_future_ of_health_care_usa.pdf. Accessed May 2, 2011.
2. Schmajuk G, Trivedi AN, Solomon DH, et al. Receipt of disease-modifying antirheumatic drugs among patients with rheumatoid arthritis in medicare managed care plans. JAMA. 2011;305:480-486.