QUESTION #1: Healthcare Ethics: A Tale of Two Patients

This case scenario presents a stark contrast in healthcare delivery and financing models, raising critical ethical and practical questions for bedside nursing.

a. Would a bedside nurse know the difference between these two patients’ payor arrangements?

In most typical clinical settings, a bedside nurse would not inherently know the granular details of these two patients’ exact payor arrangements, specifically the subtle nuances of “dual eligible FFS” versus “traditional Medicare with ACO/bundled payment contracts.”

Here’s why:

• Information Silos: Payor arrangements, contracts, and payment models (like ACOs or bundled payments) are primarily handled by financial, administrative, and case management departments. This information is often highly complex and not directly relevant to the immediate, task-oriented care the bedside nurse provides.
• Focus on Clinical Care: A bedside nurse’s primary focus is on the patient’s immediate clinical needs, vital signs, medication administration, wound care, and direct communication. Their electronic health record (EHR) view typically prioritizes medical history, current orders, and care plans. While basic insurance information (e.g., “Medicare,” “Medicaid”) is visible for billing purposes, the underlying contractual agreements are usually not.
• Confidentiality and “Need to Know”: Information about specific payment contracts might be considered proprietary business information and not part of the “need to know” for direct patient care, unless it directly impacts eligibility for a specific ordered service (e.g., if a certain medication wasn’t covered).

b. Should nursing be aware?

Yes, nursing should absolutely be aware, at a broader conceptual level, of the implications of different payor arrangements on patient care pathways and available resources, even if they don’t need to memorize every contract detail.

Here’s why:

• Patient Advocacy: Nurses are patient advocates. Understanding that a payor model like an ACO ties reimbursement to outcomes and prevention means nurses can better anticipate and advocate for preventive services, extended home care, or specialized programs that might not be automatically offered under a fee-for-service model. This awareness shifts nursing from a purely reactive role to a proactive one in securing optimal post-discharge support.
• Resource Utilization and Care Coordination: Knowledge of payment models, even generally, influences care coordination. Nurses who understand that a bundled payment incentivizes keeping patients out of the hospital for 90 days post-discharge will prioritize comprehensive discharge teaching, timely follow-up appointments, and connecting patients to resources like home health or smoking cessation programs. This knowledge helps nurses understand why certain services are offered or prioritized for some patients over others, guiding their resource allocation decisions.
• Ethical Implications: As seen with RT and FS, different payment models can lead to different levels of support or access to preventive resources. While the nurse’s direct care should never be discriminatory, understanding these systemic differences allows the nurse to identify potential disparities and advocate for more equitable access to services for all patients, especially those who might be disadvantaged by their payor model. It fosters a more holistic understanding of the patient’s journey beyond the hospital walls.
• Quality and Outcome Improvement: If nurses are aware that their organization is part of an ACO, they know that their clinical actions directly contribute to the organization’s financial viability through quality outcomes. This can motivate a stronger focus on evidence-based practices, patient education, and seamless transitions of care.

c. Should nursing continue to educate both patients on their disease?

Unquestionably, yes. Nursing’s fundamental ethical obligation is to provide comprehensive, evidence-based patient education regardless of payor status.

• Ethical Imperative (Beneficence and Non-Maleficence): The nurse’s duty is to act in the patient’s best interest (beneficence) and prevent harm (non-maleficence). Educating patients about their disease, self-management, and prevention strategies directly fulfills this duty. Withholding or providing lesser education based on insurance would be unethical and unprofessional.
• Patient Autonomy: Patients have a right to full information about their condition and care options to make informed decisions (autonomy). This includes understanding how to manage their chronic disease to improve their quality of life.
• Universal Standard of Care: Quality nursing care dictates a universal standard of education. While access to resources might differ, the provision of information should not. Both RT and FS have COPD and smoke; both need to understand the progression of their disease, the importance of adherence to nebulizers/steroids, and the critical need for smoking cessation.
• Long-Term Impact: Even if RT’s payor arrangement doesn’t incentivize positive outcomes for the hospital, educating RT on smoking cessation could improve RT’s health, reduce suffering, and potentially lower overall healthcare costs for Medicare/Medicaid in the long run. Nurses have a broader responsibility to public health, not just to their immediate employer’s financial incentives.

d. What if these patients were in the same nursing unit? Would there be a concern that these patients were being offered different levels of support at home?

Yes, there would absolutely be a significant ethical and clinical concern that these patients were being offered demonstrably different levels of support at home.

• Ethical Dilemma (Justice): This scenario presents a clear ethical dilemma related to justice (fairness and equitable distribution of resources). Two patients with the same clinical condition (COPD Stage 1, smoking history) are receiving vastly different post-discharge support due to their payor arrangements. FS is offered home care, respiratory therapy, and smoking cessation, with active pharmacist intervention for medication affordability. RT, conversely, relies on a loosely affiliated PCP, has no local family support, and likely receives less comprehensive follow-up due to the FFS model’s lack of incentive for proactive, preventive care.
• Clinical Inequity: Clinically, this is inequitable. Both patients have a deteriorating chronic condition. The evidence overwhelmingly supports that integrated, proactive support, including home care and smoking cessation programs, significantly improves outcomes for COPD patients and reduces readmissions (Pauwels et al., 2011; Rice et al., 2017). Offering this comprehensive support to one and not the other, based solely on payor, is a failure of equitable care delivery.
• Nurse’s Role in Advocacy: A bedside nurse, aware of these differences, would feel a professional and ethical obligation to advocate for RT. This might involve:
  • Raising the concern with the case manager or social worker to explore any available resources for RT, even if not directly incentivized by the FFS model.
  • Highlighting the disparity during interdisciplinary rounds.
  • Focusing heavily on comprehensive discharge teaching for RT, even if formal home care isn’t available, to maximize RT’s ability to self-manage.
  • Documenting the lack of access to specific services for RT, which could serve as data for future policy discussions.

e. Clinically, what is the better way to care for the patient? Does that match the payor payment?

Clinically, the better way to care for both patients is unequivocally the holistic, proactive, and coordinated approach exemplified by the care offered to FS. This includes:

• Comprehensive Discharge Planning: Ensuring a smooth transition from hospital to home.
• Home Care/Respiratory Therapy: Providing ongoing professional support and monitoring in the patient’s environment.
• Smoking Cessation Programs and Coaching: Addressing a primary modifiable risk factor directly and effectively.