Health Policy and Bioethics: Assuring Health Policy is based on Principles

Commentary

Recent headlines in national and local media and healthcare journals as well as some personal experience led me to share these thoughts today.

I’m writing to build on commentaries I’ve contributed to in the past few years that highlight some critical issues in our healthcare “system”. The degree to which politics and profit motives impact the policy and procedures related to how we try to access healthcare seemingly grows daily [1]. I’ll offer a few examples here, but the reader will have had experiences of their own that I’m sure resonate with my concern and frustration. These policies and procedures fall into different categories at multiple levels. The types include Federal Laws and Regulations, State Laws and Regulations, local laws and regulations, company policies (both among purchasers and insurers), and provider policies.

The last item was illustrated recently when I realized that one significant specialty provider group in my region has now eliminated the ability to speak with a human if you have a question, concern, or need clarification. Instead, they offer a call back within 24 hours (assuming you can maneuver the system to leave a message for the right person) and a warning to seek emergency care if you are having a health crisis. In writing this example seems even more ridiculous. When we could be using technology to enhance access to healthcare and health information, we instead are using it to limit and delay access [2].

In the past week I’ve seen two examples of cases where people were denied timely care through the use of “Required Prior Approval” systems. In each case their condition Commentary worsened so that the requested pharmaceutical would no longer be effective.

One patient also reported their providers office was happy to schedule a “Check-Up” or Annual Physical – in more than six months. You see the issue there. How can one be expected to have normal periodicity to contact with health providers with these time limitations?

It’s not all negative, some people are reporting useful access to providers through “Portals” where they can send private notes with a provider. I’ve used this myself with some important utility [3].

These examples and many others reflect some systemic issues with healthcare. There are well-known workforce shortages at every level. These aren’t new, and only limited solutions have been proposed and fewer implemented. This has led to a worsening of each issue that relates to the workforce in hospital care, ambulatory care, and home and institutional long-term care. In addition to workforce shortages there are workforce retention issues that have been exacerbated during the pandemic. Instead of enhancing the pipeline for healthcare workers (at all levels) many programs to recruit, train, and retain the workforce have been flat funded - or cut during this same period [4]. Many of these decisions have been subject to political influence, like the threats to shut down the Federal Government on October 1, 2023. This serves no one, and no government programs except the political needs of a few. I propose that this is never a filter we should use to develop programs designed to support and enhance our collective health. If we continue to agree on the goal of better health for all, adequate workforce is a precursor to any success [5].

The other filter that is sometimes ignored and set aside is the resource of science. Both the use of bench sciences and the use of information and policy science are essential for efficiency and better human outcomes from healthcare. This filter should be utilized at every level mentioned earlier when policy change or policy dilemmas are considered.

A concept when considering healthcare policy is first to identify the goal. If the goal relates to enhancing quality, increasing positive outcomes, supporting health education for health maintenance, and increasing healthy behaviors, limiting hospitalizations and emergency care through prevention and control of chronic conditions and injuries, and similar concepts - these are probably well worth consideration. Note that many of these may also result in cost savings and other efficiencies [6].

If the stated goal is rather delay, denial, limitation, or depersonalization, or worse politics or junk science. I recommend stopping immediately. In either case the proposal should always be run though the filters of established principles of bioethics [7]. These principles include:

• Autonomy: The respect for individuals exercising a right to informed decision making requires that those decisions be informed by facts.
• Beneficence: The principle calls on all who participate in the health system to do so with the intention to “do good”, to benefit all with their participation and knowledge. This goodness sometimes requires the investment of resources to evidenced-based interventions to achieve the good [8].
• Non-Maleficence: More commonly known as the principle to “do no harm,” calls on all of us to avoid harm whenever possible. When the policy itself can be a source of harm it is unethical at its core.
• Justice: What we often call the “Fairness Principle,” calling on us to focus on the “All” in “All are Created Equal”, and to assure that when we have knowledge and known effective programs.

Today I call on public officials, government officials and corporate leaders who both purchase and provide health insurance, leaders in healthcare workforce development, healthcare management, and clinical healthcare, and healthcare consumers to consider these principles and goals when considering and policy change at every level [9]. To avoid these essential concepts risks the quality of healthcare, healthcare outcomes for each of us, and the future of our collective health. I look forward to a time when being healthy is a common goal we share – because it’s good for us all.