In the absence of "ObamaCare" regulation, is ethics sufficient to guide American Allied Health practice?
Sarah L Latham B Physio (Hons)* |

*Medical Student, The Australian National University


he United States of America’s health care system is both complex and flawed with a convoluted history that has resulted in inflated health care costs without a paralleled ranking in performance or level of overall national health (1). President Barack Obama’s reforms however, have set in motion a significant regulatory overhaul of the US health care system primarily through the Patient Protection and Affordable Care Act (PPACA), informally referred to as “ObamaCare”, which was signed into legislation on March 23, 2010. The act, which makes it mandatory for all citizens to possess health insurance, aims to decrease the number of uninsured Americans and subsequently reduce the overall costs of primary basic healthcare.  Whilst previously America’s high health care costs have been primarily supported by private expenditure and minimal public spending (2), the PPACA sets out to ensure the lower socio-economic bracket, the unemployed and chronically ill, now have access to free or partially subsidised health insurance through the expanded government-funded Medicaid program or a novel compulsory “health-insurance exchange” program. Likewise, all other Americans require government-approved health insurance through either an individually-purchased package or an employer-funded scheme, with a penalty of 2.5% of one’s income imposed on those that fail to follow this legislation (3).

This reform has been received with mixed reactions (3). Both the average tax-payer as well as the socio-economically disadvantaged, chronically ill and unemployed undoubtedly benefit from the scheme as do the insurance companies. This is such, because although private insurers are now required to provide indiscriminate cover, even to those with chronic medical conditions, they have also experienced a significant influx of capital from young relatively healthy individuals who are cheap to insure, thereby boosting their profits. Subsequently, it is only the individuals who were fit and healthy and previously not engaged in a health insurance scheme that are now faced with a tough decision – to purchase insurance or pay a health-insurance levy with their tax? This new compulsory financial encumbrance has, for some, been an unwelcome spoonful of medicine, especially given that in spite of the changes being in the context of a socialist reform, compulsory insurance means these individuals are now financing the insurance company’s profits (3). However, in spite of this, the already-instituted provisions of this reform as well as those still to come have and will continue to have significant positive impacts on the accessibility and affordability of basic health care. The question is however, what is the impact on ancillary health care? Has allied health been affected? Not yet…

PPACA’s Impact on Allied Health

As a student, I had the chance to witness one facet of America’s health care system in action at an east coast physiotherapy practice. This was prior to the instigation of the PPACA, although practice has not yet changed significantly. The patients at this practice, holders of private health insurance, were recipients of what I perceived to be high quality care. However, it has been suggested that quality can be divided into five components, one being the separation of financial and clinical decisions (4). This was evidently not the case. In America, privately insured patients have their physiotherapy fees covered by the insurer, possibly with an additional personal co-payment.  The funding that is received from the insurer is dependent on what treatment techniques the therapist performs, with each treatment technique classified under a particular billing code and associated with a particular repayment sum. During my time at this practice, I was able to witness that the therapists would take advantage of this system by frequently providing the patients with long physiotherapy sessions in order to deliver multiple different techniques – manual therapy, exercise therapy and electrotherapy, for which they were then able to bill the insurer. It has been recognised by both myself and others (5), that this form of practice presents an ethical issue, in which there are both advantages and disadvantages affecting all parties (therapist, patient and insurer). At this stage the PPACA is yet to make an impact on this mode of practice in allied healthcare. Subsequently, in the absence of legislative regulation, Beauchamp and Childress’ relevant Ethical Principles - Beneficence, Non-Maleficence, Respect for Autonomy and Justice, should be examined in order to guide practice (6). Whilst there is little consensus in the literature as to the best process of ethical reasoning in physiotherapy (7), one comprehensive process, as described by Davis provides a satisfactory framework to apply Beauchamp’s principles and integrates ethical decision making into clinical practice:

  • Identification of ethical principles,
  • Clarification of professional duties,
  • Description of desired outcome, and
  • Decision upon a course action (7).

Identification of Ethical Principles

Beauchamp contends that the general ethical principles include beneficence, non-maleficence, respect for autonomy and justice (6). Beneficence, defined as the obligation to provide benefit and to balance the benefits against risks is particularly relevant to the case (6). It is the contention of both the American Physical Therapy Association (8) and Australian Physiotherapy Association (9) that physiotherapists are committed to delivering the best possible treatment outcomes, i.e. benefit, through evidence-based practice. In the case of my American experience, the patient is receiving valuable care through the comprehensive provision of multiple evidence-based therapies. This model of practice also has secondary economic gains for the therapist, whereby the provision of multiple therapies, allows the therapist to make numerous claims to the insurance company. However, in line with beneficence’s definition, these benefits must be weighed against potential risks. Whilst the patient, is not at risk of any physical harm, this does not fully satisfy “non-maleficence”.  Non-maleficence, meaning to do no harm, not only has physical dimensions, but also economic. This model of practice puts the patient at risk of economic harm if they are required to make substantial co-payments to the physiotherapist. There is also the potential for negative consequences related to the length of time required for all the therapies to be administered – e.g. missed work or reduced time for other commitments.  Not least, this practice also theoretically has an aspect of fiscal harm for the insurer who is funding all or much of the therapy. These different perspectives must be considered carefully and balanced against each other when it comes to making an ethical decision and conclusion about this practice.

Clarification of Professional Duties

Whilst consideration of beneficence and non-maleficience is important as decreed in the Hippocratic Oath (10), the physiotherapist must also consider the other ethical principles. Thus, respect for patient autonomy is perhaps the keystone to exploring this case. Autonomy is defined as the ability to act freely or independently (11). This is an important component of informed consent, which is the obligation of the physiotherapist to obtain, and appears to have been neglected here. In this case, the physiotherapist fails to explain the reasoning behind the treatment plan and discuss whether the patient can afford the time for the long consultations and/or the co-payments, but instead pushes for the multi-therapy treatment approach. It is not surprising that the physiotherapist advocates for this and chooses not to divulge that one reason for the lengthy consultations is to enhance their own reimbursement as it reveals a conflict of interest. However, whilst I find this conflict to be deplorable and such conduct is proscribed by the American College of Physicians (12), in reality it has been tolerated to-date in many areas of American healthcare.

Fortunately, whilst this is current practice, there is hope that the PPACA’s future provisions will force a change in this culture. With all Americans now requiring insurance, there is also a greater pool of potential patients requiring physiotherapy and rehabilitation. As a consequence, there will hopefully be a reduction in the risk of physiotherapists demanding lengthy consultations of relatively few patients, by instead distributing their care to a larger client base and providing consultations of a more appropriate length encompassing only the most necessary therapy techniques. This will hopefully also reduce any financial burden to the patient associated with excessive co-payments. However, until the effect of the larger patient pool takes effect, or further provisions are made under the PPACA, practice should be guided by our ethical principles.

The Desired Outcome

Recognition of the aforementioned principles, the associated individual perspectives and the physiotherapist’s professional duties provide the basis for the decision making process described by Davis (13). Ideation of the desired outcome is the third step in the process. The optimal outcome for the patient would ultimately involve receiving first-class physiotherapy within the framework of their personal time constraints and financial limits. For the therapist, it would involve complying with their professional obligations whilst still receiving modest reimbursement sums, and for the insurance companies it would involve only reasonable expenditure. Consequently we are faced with a decision regarding what course to take. This is the point where the fourth principle, justice, may be considered, i.e. the obligation of fairness in the distribution of benefits and risks (6). This idea is consistent with the utilitarian approach to ethical decision making, whereby the rights and wrongs of actions are assessed, and one practises in light of their consequences (10). One avenue in this situation would be for the physiotherapist, following the initial assessment, to discuss with the patient their ideal treatment plan – i.e. one inclusive of multiple evidence-based therapies but also ascertain the patient’s goals and limitations thereby ensuring that the patient is able to autonomously give free and informed consent. This approach reduces the risk of maleficence by allowing and respecting the patient’s autonomy in their treatment decisions. Furthermore it also benefits the patient through facilitating the provision of evidence based therapy, as well as there being the potential for the therapist to benefit financially if the circumstances permit. The only party which does not profit from this approach is the insurance companies. However, when looking at the larger picture of America’s healthcare system, even in the context of Obama’s new health care reforms, in reality this deficit is inconsequential, given the profitable nature of the insurance companies, and it would not be hard to judge that both benefits and risks have been fairly distributed in order to arrive at this outcome.

The Course of Action

In resolving ethical difficulties in the clinical context, one encounters many competing factors which must be evaluated in order to determine a moral course of action. This is complicated by the fact, that in any prospective contemplation, it is extraordinarily difficult to accurately predict all good and bad consequences (14). For this reason, it is essential that thorough ethical analysis is integrated into the clinical decision making process to ensure an ethical outcome. Davis’ process (7) utilised here, whilst not the only existing method, does provide a suitable guideline for ethical decision making (5). We will however continue to be faced with the challenge of appropriately integrating ethical reasoning into our clinical decisions, until there is a gold standard for this process. Until then, there will continue to be differences in method and choice of moral theory, influenced by the ethicist’s own personal moral values, with the potential for diverse conclusions for a single issue. Whilst this proposed course of action has benefits for both the patient and physiotherapist, it does not solve any of the fundamental inadequacies of allied health care in the context of the American health care system. This ethical approach however can hopefully operate constructively alongside Barack Obama’s health care reforms. Furthermore, as additional PPACA provisions are introduced, there will hopefully be further legislative contributions made which are able to guide not only basic primary health care practice but also allied health care for the American public (15).


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