Sunday, July 20, 2008

The Ethics of Block Booking by Insurance Status

Recent cuts to Medicare bring up an interesting practice management problem. If a practice chooses to accept patients on social assistance medical insurance (such as Medicare) is it ethical to leave those patients waiting longer?


It would be easy enough to offer 1 or 2 appointments a day to publicly funded insurance plan patients and leave the rest for private pay (block booking based on insurance). The result would be longer health care wait times for public pay patients. The dilemma to providers, of course, is that publicly funded plans usually pay less. The alternative is either a cut in revenue for the clinic or complete denial of access to these patients.


The ethical dilemma stems from the fact that those with less access generally have poorer health. When a practitioner denies access completely the ethical dilemma is transferred to another because the patient seeks care elsewhere. Where a practitioner chooses to govern access through block booking they retain the moral quandary of different levels of care for patients under the same care provider. Once one chooses to accept a patient, is it ethical to allow two patients with the same disease to have different outcomes based on access to the clinic?

A Moral Choice

My opinion is that a clinic could morally limit appointments as long as the process was transparent to patients, made accommodations’ for emergency/urgent cases and did not violate any legal statutes that preclude differentiation based on insurance status. Ideally, wait times for publicly funded patients would still fall within regionally acceptable limits for wait times based on disease. I do not believe the latter is moral requirement so long as the prerequisite of transparency is met.

Practical Concerns

Another problem is that staff controlling schedules have not undergone the same ethical indoctrination as providers. That is not to say that they are any less moral, only that they may not share the same values with respect to patients’ needs which could lead to behavior and booking patterns contrary to the providers’ value system. To align provider choices with booking practices administrative staff require healthy clinic socialization in addition to formal professional education.

Public Policy Concerns

As countries the world over convert to a mix of private and public funding the issue of primary care access based on coverage are going to become more pronounced. If it is to be public policy that income should not correlate with access public policy will need to be set to bring public funds in the range of private expectations and legislation created to equal the playing field. Assuming that coverage remains an acceptable reason to deny access, practitioners who continue to run dual coverage practices will need to consider the ethical implications of offering the service and professional colleges the standards by which dual coverage access will be provided.

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