Ethics concerns grow for NPs and PAs

As out-of-pocket health-care expenses increase, patients are pressuring clinicians to bend the rules, according to an eye-opening new survey.

If you frequently find your clinical judgment thwarted by an insurance company’s unwillingness to pay, you’re not alone. Almost three out of four nurse practitioners and physician assistants polled in a recent survey reported third-party decisions within the past two years that “interfered with their ability to provide” necessary treatment. And more than half of that group (55.3%) said they ran up against such interference daily to weekly.

The goal of managed care is to keep down costs, and the goal of primary care is to maximize a patient’s well-being. When those goals clash, clinicians can find themselves grappling with ethical conflicts. A research team from NIH and several universities in Maryland and Pennsylvania recently explored those conflicts in detail. The results were published in Nursing Research (2006;55:391-401).

NPs and PAs “often feel caught between playing by the rules of the health plan or the system in which they work and advocating for their patients’ best interests,” the researchers stated. “The ethical issues cannot be avoided completely,” said lead author Connie M. Ulrich, PhD, RN, of the University of Pennsylvania School of Nursing in Philadelphia. “There are inherent ethical problems within the health-care system, such as concerns related to quality, cost, and beneficent care for patients. This creates challenges for providers in knowing how to best allocate care given the cost constraints.”

Ulrich’s team sent a questionnaire to a stratified random sample of 3,900 NPs and PAs nationwide. The 1,536 who responded had been in practice for an average of 10.5 years, and 19% had more than 20 years of experience. Most (73.5%) were generalists in family practice, internal medicine, pediatrics, or obstetrics/gynecology.

Annual health-care spending is expected to reach $3.3 trillion by 2013. As consumers pay more in health-care premiums and out-of-pocket expenses, they may be more likely to pressure providers to mislead third-party payers to gain coverage. Ulrich’s study cites a 2004 University of Pennsylvania survey of physicians and patients, which found that 26% of the general public supported deceiving insurers.

That pressure to deceive is being applied to NPs and PAs, especially as their role in primary care continues to expand.

Some willing to game the system Almost half the respondents in the new survey (47%) said at least one patient had asked them to mislead his insurance company to obtain coverage. About two out of three of the clinicians (63%) said they would “probably or definitely” refuse the request, but about one in four (27%) found it ethical to “game the system” (Figure 1). On the other hand, 73% said they would help patients fight for denied services, either through an appeals process or by helping patients appeal to insurers.

Among the survey’s other major findings:

• 58.2% of NPs and PAs believe managed-care values and clinical-practice values are at odds with each other.
• 52.7% said that it is sometimes necessary to bend the rules.
• 31% agreed it is sometimes necessary to report only partial truths to insurance companies.
• 39.9% agreed it’s sometimes necessary to exaggerate an illness.

Most respondents were concerned about the implications of choosing between clinical care and costs. For example, more than four out of five (85.5%) worried about “patient interests being overridden by business decisions,” and three out of four (75.4%) were troubled by the prospect of clinicians “evolving into an agent for the health plan instead of the patient” (Figure 2).


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The level of actual conflict reported over ethical issues was related to the importance clinicians attached to their role as patient advocates, the strength of their belief in playing within the system, and how often they encountered resistance from insurers. Adversarial patient relationships, patient demands for unnecessary treatment, and practicing in a for-profit setting were also associated with more intense feelings of conflict. Similarly, lower levels of conflict were reported among clinicians in group-model HMOs or large physician-group practices (>50 physicians), those who had the most autonomy, and those who had confidence in their decision-making.

“Clinicians need support in their clinical-practice organizations to bring forth ethical issues they encounter,” said Ulrich. “They need to work collaboratively with their colleagues and establish a safe and open dialogue surrounding ethical issues in practice.”

More ethics training needed

How should a clinician approach an ethical conflict? Although 44% of the sample said that adequate attention had been paid to ethical issues during their training, more than one in four reported a sense of isolation, and more than two out of three (68%) said that more ethics training is necessary.

“Both medical and nursing schools need to do better at educating clinicians regarding ethical issues in practice and the ethical frameworks they can use to identify the facts of each case, the relevant ethical issues, professional and legal positions on the issues, and methods for resolution,” Ulrich said.

All clinicians, especially those in primary care, can expect to face continuing ethical questions throughout their career. Other factors adding to the pressure, according to the study, include an aging population with chronic diseases, a growing number of uninsured patients, and disagreements about what constitutes medical necessity.

The researchers call for “greater inquiry to determine whether practitioners are responsible ultimately to the patient, the public, the health plan, or society.”

But the existence of a conflict of interest between providers and third-party payers does not eliminate an ethical resolution. “There’s a fine line, when rationing services due to cost constraints, between providing cost-effective care and bad care,” said Sherril Sego, MSN, FNP, a primary-care nurse practitioner at the Department of Veterans Affairs Medical Center in Kansas City, Mo., and a contributing editor to The Clinical Advisor. “Many acceptable options for drugs and services are less expensive, and it is the job of all providers to monitor these cost-saving efforts to assure we are maintaining quality in the pursuit of economy.”

Ms. Dembrow is a senior editor for The Clinical Advisor.

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