social responsibilities of hospitals

Question

2. What are social responsibilities of hospitals of health service organizations? Explain how each are addressed.
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Lesson:
Ethical Issues on the Horizon - Social Responsibility
Three dimensions of the social responsibility of health services organizations are examined in this lesson; generally, they are framed as contrasting service with financial performance. One dimension is protecting and enhancing organization assets while maximizing community benefit. A second is the moral obligation of health services organizations to provide services appropriate to a patient's needs, with no hint of decision making based on nonrelevant factors such as age, payment status, race, or sex. The third dimension of social responsibility considered is the organization's obligation to protect the commonweal—in terms of both private resources and public sources such as Medicare and Medicaid.

COMMUNITY BENEFIT

Controlling costs and improving efficiency should be of concern to administrative staff. They ultimately benefit the community and should be a focus for clinicians. Waste is an ethical issue. Obviously, the financial implications of even shared ownership make the physicians much more interested in improving efficiency at the center. Changing physicians' attitudes about the use of resources is a major challenge for managers and is reflected in efforts to tie physicians into the economic health of the organization through such arrangements as physician–hospital organizations. Macalin could attempt to force changes, but doing so would risk both physician antipathy and apathy. Applying expectations and patterns from the center to the hospital would be interpreted by physicians as interfering with professional judgment and decision making; after all, the patients are hospitalized when endoscopies are performed in Metropolitan. Education and working patiently with the physicians to gain their understanding of the applicability and transferability of efficiency from the center to the hospital are essential activities for Macalin as she exhibits the virtue of thrift. Improving efficiency (general duty of beneficence) benefits the community by reducing costs, thus making health services more affordable and accessible.

In addition to reducing waste, health services organizations have a moral obligation to collect debts owed to them. Not-for-profit organizations are expected to provide uncompensated care—services that provide community benefit—to retain their special tax status. Yet, they should, and arguably must, take reasonable steps to collect monies legally owed to them. Part of a health services organization's fiduciary obligation to its service area is to maintain its financial status. Aggressive debt collection raises ethical issues, however, even if the law allows the actions taken by the organization.

SIMILAR NEED, DISSIMILAR TREATMENT

It is likely fruitless to set a goal to provide the same services for all persons with the same medical need. The numbers and types of variables involved are staggering. For example, access is limited by geography, availability and capability of providers, individual desire to receive services, a subculture's attitudes about health, physicians' ability or willingness to treat or refer, insurance status, financial circumstances, mental state, and dozens of other attributes of individuals and the health services system. The problems of equity (fairness) are legion and probably unresolvable, regardless of how health services are organized, provided, or financed. Even systems with universal access have disparities in use or access because of system expenditures for services and technology, socioeconomic class, geography, and physicians' willingness to refer patients. Given the number of factors and the certainty that variability in service access and use are inevitable, it is nonetheless important that providers seek to identify these types of problems and make reasonable efforts to eliminate them or minimize their effects. Disparities begin far upstream.

Ageism appears to be present in parts of the health services system. For example, although older adults are at greater risk of dying from heart disorders, cancer, and influenza/pneumonia, there is evidence that they do not get the most aggressive forms of treatment and diagnostic and preventive care, which is standard for younger patients. The disparity may result from a notion that older adults cannot tolerate more aggressive treatment or do not want it, neither of which is necessarily true. Ample evidence exists that the process of dying is less than optimal. Too many dying patients suffer unnecessary physical symptoms such as pain, dyspnoea, nausea, and vomiting; too many suffer untreated depression, anxiety, and hopelessness; and too many feel they have lost their dignity. It is the perception that dying is a painful process filled with unnecessary suffering and indignity that fuels campaigns—and public support—for legalizing euthanasia and physician-assisted suicide.

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Big Bucks, Big Pharma: Marketing Disease and Pushing Drugs from Media Education Foundation. Closed captioned. Big Bucks, Big Pharma pulls back the curtain on the multi-billion dollar pharmaceutical industry to expose the insidious ways that illness is used, manipulated, and in some instances created, for capital gain. Focusing on the industry's marketing practices, media scholars and health professionals help viewers understand the ways in which direct-to-consumer (DTC) pharmaceutical advertising glamorizes and normalizes the use of prescription medication, and works in tandem with promotion to doctors. Combined, these industry practices shape how both patients and doctors understand and relate to disease and treatment. Ultimately, Big Bucks, Big Pharma challenges us to ask important questions about the consequences of relying on a for-profit industry for our health and well-being.
THE COMMONWEAL - Macroallocation

It is at the macro level that healthcare costs and their effect on the commonweal are most dramatic. Despite claims of a scientific basis, very little of what physicians do has been proved effective using the scientific gold standard of a random, double-blind study. Modern medical practice is based on tradition, pragmatism, inertia, logic, and long-held assumptions that remain scientifically unverified. The estimates of wasteful, ineffective treatments in the $2.5 trillion spent on U.S. healthcare in 2009 are as high as $650 billion, or approximately 25%. Other estimates are that 20% or more of all costs could be eliminated without harm to anyone, and that 40% of specialist visits and 25% of hospital stays are unnecessary. Areas in which healthcare costs might be reduced include excessive high-tech imaging, overuse of psychotropic drugs, unnecessary investigations of fainting spells, overtreating for back and neck pain, inappropriate use of cardiovascular stents and angioplasty, and overuse of knee arthroscopy in arthritis. Several factors contribute to the lack of interest in knowing the efficacy of generally accepted medical treatments: political cowardice, the many sectors in the system that benefit from overuse and waste, and the view of the public that good medicine requires numerous interventions, especially those that use high tech. There is some hope that the issues of waste, overuse, and inappropriate use of medical resources and technology will be addressed as financial constraints in the public and private sectors stimulate a greater search for savings.

American Hospital Association (AHA) data show that in 2009, hospitals provided $39.1 billion in uncompensated care. This was a large increase from the $22.3 billion provided in 2002, which, in turn, was a large increase from the $16 billion spent in 1995. The AHA defines uncompensated care as the sum of charity care and bad debt valued at the cost to the hospital of the services provided. It excludes other unfunded costs of care, such as underpayment from Medicaid and Medicare. Other health services organizations define uncompensated care to include costs in excess of payments received for Medicare and Medicaid services. In 2009, the 5,008 hospitals registered with the AHA had average uncompensated care costs of 6%. Major publicly owned teaching hospitals and urban government hospitals have an uncompensated care rate that is typically two to three times higher. The concern during the 1990s that hospitals would reduce uncompensated care to counter payment shortfalls from Medicare and Medicaid, as well as price discounts negotiated by managed care plans, did not materialize. Hospitals' commitment to treat those unable to pay continues largely unabated.

During the 1990s, a number of not-for-profit hospitals were converted to investor-owned (for-profit) status, a development that seems related to declining economic performance of the not-for-profits. From 1991 to 1997, there were 431 conversions. The uncompensated care provided by the converted entities decreased from 5.3% to 4.7%, approximately equal to a $400,000 reduction in per hospital spending. The decline was more substantial in public facilities that became investor-owned, which had reductions from 5.2% to 2.5% of total expenses, or about $800,000 less per hospital per year.

Noncompliant patients pose a special problem in microallocation decisions. Typically, they have chronic health problems that need continuing, periodic treatment, such as the dialysis that treats end-stage renal disease. These patients may be noncompliant in following a dietary and medication regimen, submitting to scheduled treatment, or they may behave such that staff cannot treat them. The organization is morally obligated to facilitate treatment for all patients needing its services. However, those with significant behavioral problems or who do not comply with their treatment regimen should be discharged from the program, with proper attention to legal requirements.

SUMMARY

This lesson examined some of the issues attendant to the social responsibility of health services organizations, primarily hospitals. Although organizations have an ethical obligation to husband resources, there are ethical limits, for instance, to how aggressively they should collect monies owed them. Also, sharp business practices should be avoided because they are inconsistent with various virtues and the principle of respect for persons. The virtues are fully consistent with the organization's efforts to protect and enhance its assets while maximizing patient and community benefit.

Through their managers, health services organizations are morally obliged to provide services that meet the patient's needs without considering nonrelevant factors such as age, payment status, race, or sex. Persistent variations in provisions of medical services appear to be more a function of how physicians practice medicine than deliberate expressions of bias. What is identified as ageism may be as much an expression of the culture's emphasis on youth as it is a bias against older adults. Ethically unacceptable, however, are implicit judgments about poor quality of life. Health services managers must identify and eliminate any hint of systemic or personal bias in medical decision making and delivery of services.

Protecting the commonweal—the sum of private and public resources—is a more ethereal responsibility. Much of what can or should be done is beyond the control of health services managers. Nonetheless, wasteful programs, regardless of funding source, and those of lesser clinical quality or that unnecessarily put the public at risk, must be eliminated. Husbanding resources is an ethical obligation for managers, because all resources, regardless of ownership, are part of the commonweal.

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Tackling the Root Causes of Health Disparities - LeNoir - NMA Pediatric Lecture. University of California Television (UCTV). Closed captioned.

There is strong evidence to suggest that where you live determines your life expectancy as well as your overall health. Anthony B. Iton, MD, JD, MPH is Senior Vice President at The California Endowment, discusses the root causes of health inequity, mostly living conditions as a result of poverty and economic opportunity, and how interventions at multiple points can change health outcomes.

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The Center for Health Equity and Social Justice at the Boston Public Health Commission provides funding and support to community-based organizations and coalitions to develop, implement and evaluate community-based strategies for eliminating racial and ethnic health inequities. This video provides an overview of the Center's granting model and features the stories of three of the Center's grantees.


References
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Fleck, L. (2002). Rationing: Don't give up. Hastings Center Report 32(2), p. 35–36.

Langreth, R. (2009, November 30). Useless medicine. Forbes 184(10), p. 64, 66, 68, 70, 72.

American Hospital Association. (2010). Uncompensated hospital care cost fact sheet (p. 1). Chicago. Author.

Costello, M. (2004). Nation's hospitals provided $22.3 billion in uncompensated care in 2002. AHA News Now, p. 1.

Burda, D. (1995). Hospitals' care for poor rises slowly. Modern Healthcare 25(19), p. 30.

Health First. (2003). What are not-for-profit/community-minded hospitals? What it means to your community. Retrieved March 26, 2011, from http://www.health-first.org/about_us/not_for_profit.cfm.

National Association of Public Hospitals and Health Systems. (2011). 2009 annual survey: Safety net hospitals and health systems fulfill mission in uncertain times. Retrieved March 26, 2011, from http://www.naph.org/Main-Menu-Category/Publications/Safety-Net-Financing/2009-Characteristics-Survey-Research-Brief.aspx?FT=.pdf.

Thorpe, K., Florence, C., & Seiber, E. (2000). Hospital conversion, margins and the provision of uncompensated care. Health Affairs 19(6), pp. 187–199.