Opinion Article - (2021) Volume 18, Issue 7
Saad Bin Jamil*
Department of Internal Medicine, St Mary's Hospital, Waterbury, CT, USA
Received Date: July 10, 2021; Accepted Date: July 24, 2021; Published Date: July 31, 2021
The healthcare organizations in the United states (US) are either public or private entities. For-profit healthcare organizations constitute a large segment of healthcare infrastructure. Since the market based pattern of healthcare services can lead to significant profits, investment in the healthcare sector can be beneficial from an investor's standpoint. However, there can be a concern among the medical community and the public in general regarding amalgamation of business with health care. Furthermore the cost of healthcare expenditure is ever increasing in the US which may be driven with this model as well. The integration of business models with healthcare may lead to standardization algorithms with the expectation from healthcare providers to meet key metrics as well as targets which may result in compromised patient care. This has prompted the provision of value based care to patients instead of pay for service model. However, the balance between provision of optimal healthcare which is cost effective can be challenging from the hospital administration and healthcare provider’s perspective with ethical, moral, logical and practical aspects to keep in consideration. In this article we discuss a few factors which may raise ethical dilemmas for the hospital administration and physicians.
Healthcare systems; Ethics; Hospital; Medicine
Hospitals in the United States may be public or private. Investing in hospitals may be profitable as healthcare is a necessity. Investments in healthcare may have benefits for the health infrastructure as well; “various positive benefits of the investor-owned model are often cited: that it provides new impetus for innovation, more responsiveness to the needs and desires of patients and physicians, sounder approaches to management, and an important source of new capital for health services” [1].
Hospital medicine is “the field of internal medicine which concentrates on the practice of care for hospitalized patients by hospitalists” [2]. Since hospitalists are employees of an organization, there is certain expectation from them based on the employer’s goals while they ensure optimal patient care. Safe and affordable quality health care has been a challenge for the US health-care system [2].
There has been several reimbursement models that have been introduced at governmental level, which one can argue have made it increasingly difficult for hospitals to stay in profit. However, despite that, certain big organizations are acquiring more assets and obtaining profits. This may be due to evidence based medicine being practices with strong patient centered policies. Alternatively, there can be a concern of substandard provision of care. Private hospitals across the country have been following different business modules. Few changes in the organization of health care in the United States have stimulated more interest and alarm than the rise of a new form of entrepreneurism-investor-owned, for-profit organizations that provide health services as a business [1]. Hospital administration can be answerable to investors which it comes to profits. Where it is reasonable to expect profits, standards of heath care and ethical standards must not be compromised upon. Ethical investing is the practice of selecting investments based on ethical or moral principles [3]. However, there are certain realities of healthcare system; finances and healthcare recourses are not infinite. In this article we discuss a few factors which may raise ethical dilemmas for the hospital administration and physicians.
Length of stay (LOS) is the number of days a patient is admitted to the hospital. Insurance providers such as Medicare have allocated an expected duration of stay in hospital for all diseases based on which they reimburse hospitals. If a patient stays for longer that the designated LOS, the hospital bears the additional expenditure. Furthermore there is data to support that decrease LOS may result in better patient outcome. Hence, hospital administration’s goal is to treat and discharge patients soon. However, discharging every patient within their designated LOS may be not be practical as not all patients progress similarly. Therefore, hospitalists and staff may face pressure to ensure a patient is discharged within the allocated time while providing optimal care. Economic theory assumes that people act in their own interest, not that they act in the public interest [4].
Hospital management must ensure patient safety while ensuring optimal patient care. However, if viewed from an economic perspective, early discharge would result in higher profits for the hospital, although it may lead to certain unwanted outcomes. "Economics is a theory of choice and its unintended consequences” [4]. The consequence here unfortunately can be patient related adverse effects as with potential legal ramifications. Even if the economic theory is considered here from an investor’s perspective, it is in the interest of hospital administration and investors to ensure good medical practice is being practiced as there is always the concern for law suits when evidence based medicine is not done. Hence, hospital administrations must try to ensure optimal patient care is being provided, while profits are maintained.
Hospitals also have significant competition with good reviews and ratings bringing more business to a particular hospital. Competition is a process in which competitors engage [4]. Patient surveys play a significant role. However, achieving patient’s expectations and satisfactions may not necessarily mean good patient care. For instance, “use of patient satisfaction surveys may promote, at least among some clinicians and under certain circumstances, a culture of care that can be partially driven by satisfaction score rather than evidence based” [5]. Although is it a fact that hospitals have to compete, however patient safety and best medical practices must take preference. Excessive and unnecessary testing may lead to happy patients, but may also lead to overall decreased profit. This is where we can use the phenomenon of adjudication, “a process for deciding who has which rights” [4]. A sicker patient for instance must take precedence over healthy. Fortunately, in this circumstance due usual ethical codes of hospitals as well as strict US legislations and prior legal judgments in favor of patient, usually optimal patient care is maintained. While it is recognized that people cannot have an unlimited right to all the health care they could possibly want, health care is viewed as different from other goods and services, something to which one has some kind of moral right [6]. However, for non-life threatening medical problems hospitals improvise and so must patients. If people insist on obtaining absolutely everything to which they think they have a right, civilization will give way to warfare [4]. Competition in itself is not necessarily the negative aspect as competition may lead to hospitals striving for better care. However, it must not be at the cost of good and ethical medical practice.
Since the 1970s we have been attempting to reform our financing of health care and moving towards deregulation and a more marketbased health care system [7]. However “Business decisions are influenced by the presence (or absence) of economic profit [4]. With application of general rules of market there is a concern that healthcare may also be influenced by similar standards. The risk in normal business is that of a loss but in healthcare it can mean poor patient care. Hence, it is imperative to obtain profits as well provide excellent care. Incentives, positive feedback, encouragement are a few tools which can be utilized and often are. Furthermore, “there is evidence that medical institutions and physicians respond to economic incentives (as everyone else does), it seems realistic to view health care in these term” [2]. The goal however should be to maintain the intricate balance of profits and patient safety together.
As more and more for profit organizations are investing in healthcare, the dilemma for physicians is expected to rise. A physician can invest or try to obtain profits as long as no illegal method is applied. Some view physicians as a type of businessperson and see nothing wrong in making money from health care [1]. However, it is not as simple most of the times particularly when the physician is employed by an organization and there may be a difference in opinion when it comes to that of physician’s with regards to hospital management. A commonly held stereotype that expresses such differences is that physicians and other health care professionals are expected to act primarily or exclusively for the welfare of the patient, whereas it is perfectly acceptable for an ordinary business person to pursue self-interest even at the expense of the welfare of others [7]. An investor may expect certain results which the physician may not be able to obtain without compromising of his personal beliefs. Although once can argue it is acceptable for physician to also gain profits, however it must not be at the cost of compromised healthcare standards or under coercion to achieve results. A physician must try to obtain a balance between good medical practice regardless of his or her interest in business.
The relationship between business and professional health care has always been an ambivalent one [7]. Where there are many advantages to private health care organizations, “some observers see for-profit health care organizations as antithetical to the traditional mission and values of health care institutions, as a threat to the autonomy and ideals of the medical profession” [1]. There are several factors involved in policy making of a healthcare system when it is primarily driven as a business module for profit. Healthcare organizations may need to focus on potential conflicts between the patient's interest and the institution's or physician's interest [8]. Similarly, physician and hospital staff are trained to keep the patient’s best interest first. The potential for advancement in medicine with investment is huge and there are many positive outcomes that can occur from for-profit hospitals. However, “we can anticipate many points of ethical difficulty as for-profit health care enterprises evolve and force more direct interactions between the medical profession and its system of ethics and business with its system of ethics” [8].
The hospital administration and physicians must try to obtain the balance between a good business and module which is based on ethical as well moral medical practices. It is indeed a difficult balance to maintain; however, a balance which is necessary for investors, healthcare providers and most importantly, the patient.
