When the Healthcare Plan Limits
Care
Ethics Roundtable: Case Study
| Mrs. Morgan is 50 years old and directs a
local Meals-On-Wheels program. Mrs. Morgan is covered by
her husband's managed care plan. During a routine visit
with the family practice physician she raises concerns
about her hearing and some recent dizziness. The physician
approves a referral to an audiologist within the HMO.
The audiologic assessment reveals a mild hearing loss in
the right ear and a mild sloping to moderate-severe high
frequency loss in the left ear. Mrs. Morgan demonstrates
positive rollover of speech-discrimination scores in the
left ear, acoustic reflexes appear normal in the right ear
and elevated in the left, acoustic reflex decay is negative
in the right ear and positive in the left. Tympanograms are
within normal limits bilaterally. Mrs. Morgan is eager to
try hearing aids and her plan covers aids with a
physician's prescription.
The audiology practice provides behavioral testing
(i.e., air, bone, and speech), acoustic immittance
measurements, and hearing aid services. The practice does
not have equipment for auditory brainstem testing. The
practice relies on the managed care contract for a
significant portion of referrals and reimbursement.
The audiologist recommends follow-up testing to rule out
retrocochlear pathology (e.g., ABR, MRI) and requests
medical clearance for amplification and aural
rehabilitation. Two months later, Mrs. Morgan returns to
the audiologist with a prescription that states
"clearance for hearing aids, no further testing at
this time." The audiologist calls the physician's
office and a case manager for the HMO and is told that Mrs.
Morgan's test results do not justify further expensive
diagnostic tests. The audiologist remains concerned about
the possibility of further pathology and liability
issues.
Questions to consider
- What are some reasons the MD might choose not to
refer for further testing?
- What are some approaches the audiologist might
consider in further discussions with the physician or the
patient? Are there potential risks to bypassing the
physician's recommendations?
- How might the HMO's plan limit the
audiologist's actions in this case?
- What is the audiologist's obligation to the
patient?
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Ethics
Roundtable Home
Responses
Annotated Bibliography
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Related Readings
- Brett AS. Relationships between primary care physicians and
consultants in managed care. Journal of Clinical Ethics 1997;
8(1): 60-65.
- Friedman E. Managed care, rationing and quality: a tangled
relationship. Health Affairs 1997; 16(3):174-182.
- Hillman AL, Ripley K. Physician financial incentives in
managed care: their impact on healthcare for the elderly.
American Journal of Managed Care 1995; 1(2): 199-204.
- La Puma J. Anticipated changes in the doctor-patient
relationship in the managed care and managed competition of the
Health Security Act of 1993. Archives of Family Medicine 1994;
3:665-671.
- Morreim EH. To tell the truth: disclosing the incentives
and limits of managed care. American Journal of Managed Care
1997; 3(2):35-43.
To submit cases or to be added to the list of respondents
please contact: Helen Sharp Department of Speech Pathology and
Audiology, 307 WJSHC University of Iowa, Iowa City, IA 52242.
Phone: 319-335-6596, fax 319-335-8851, e-mail:
helen-sharp@uiowa.edu