Ethical Enigmas for Physical Medicine & Rehabilitation in the Post Acute Continuum of Care
Gans, M.D., B.M. (Wayne State University School of Medicine Detroit, Michigan USA)
The post acute continuum of care is rapidly emerging as a broader domain for the practice of Physical Medicine & Rehabilitation. Physiatrists and members of the multidisciplinary rehabilitation team are finding themselves actively involved in the care of patients within acute hospitals, rehabilitation facilities, rehabilitation and medical sub-acute programs, primary care programs, long-term hospitals, long-term care facilities, home care, and even in hospice and other end of life programs. Ethical issues abound in each of these settings and also are highly likely to emerge when patients are transitioning between settings. Ethical problems may include, but are not limited to, issues of patient placement, access to care based on funding availability, decisions to terminate care, and disagreements between the team, patient and family members. Resolution strategies for dealing with ethical enigmas include encouraging recognition of ethical dilemmas, permitting debate and the use of resolution mechanisms, making available ombudsman functions, and using ethics committees with ethical consultants whose span cross the continuum.
BIOMEDICAL ETHICS: REHABILITATION AND MANAGED HEALTH CARE
John L. Melvin, M.D. (MossRehab Hospital, Philadelphia, PA, USA)
The expansion of managed health care plans in the United States requires physicians to reexamine their ethical standards. These plans strive to align the interests of the physician with their own through financial incentives to control resource use and limit access to services. Many plans control the flow of' patients such that physicians truly find it necessary to choose between their own self interest and that of the patients.
Many plans require providers to agree to not communicate to enrollees anything that could undermine the confidence of enrollees in the plan or plan coverage. Some plans have interpreted this to exclude discussions with patients about treatment options not available through their plans. Others restrict referrals to specialists, programs or centers of excellence outside of the plan even if' physicians believe such referrals to be in the patients' best interest. Some plans do not permit physicians to disclose to patients that the physician under their plan has a financial incentive to limit services.
Physicians and rehabilitation facilities who have agreed to be providers of managed health care plans may continue to face ethical dilemmas. Plans may approve patients for so few days in the rehabilitation hospital that they are unsafe to discharge home. The question is whether such patients should be accepted at all by the facility, or whether the facility and physician should admit but provide uncompensated care until the patient is safe to discharge home. Other issues include whether deferral of some goals to be achieved after discharge is appropriate, how much of anticipated improvement justifies a program and what are the physician's responsibilities when a plan fails to authorize a hospitalization or procedure.