A Financial and Ethical Dilemma

Prompt:
You are the chief nursing executive for a small rural clinic that provides contraception services to low-income individuals. An insurer, providing care under the Affordable Care Act (ACA), has rejected paying the claims, stating that they are a not-for-profit religious organization and are not obliged to cover these services. You check your records and find that nonpayment for contraception places a significant financial burden on the clinic. These individuals do not have access to any other health care services in the region.
• What would you do to advocate for the patients of the clinic affected by the change?
• How do you justify your actions based on legal and ethical guidelines? Be sure to support your position with a scholarly source.

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Salganicoff & Sobel (2018): Abortion Coverage in the ACA Marketplace Plans: The Impact of Proposed Rules for Consumers, Insurers and RegulatorsLinks to an external site.
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ReplyReply to Module 5: Discussion – A Financial and Ethical Dilemma – Dr. Lehenbauer’s Section (#003)
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Collapse SubdiscussionApril Dollins
April Dollins
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Prompt:
You are the chief nursing executive for a small rural clinic that provides contraception services to low-income individuals. An insurer, providing care under the Affordable Care Act (ACA), has rejected paying the claims, stating that they are a not-for-profit religious organization and are not obliged to cover these services. You check your records and find that nonpayment for contraception places a significant financial burden on the clinic. These individuals do not have access to any other health care services in the region.

1. What would you do to advocate for the patients of the clinic affected by the change?
   According to the U.S. Department of Health and Human Services, (2022), “In all fifty states, the ACA guarantees coverage of women’s preventive services, including free birth control and contraceptive counseling, for individual and covered dependents” (para. 2). In June of 2022, the U.S. Department of Health and Human Services (HHS) sent a letter to health insurance issuers reminding them that they are obligated under the ACA to provide coverage at no cost for contraceptive services. In the letter, the HHS recognized that some plans were not appropriately providing this coverage and demanded prompt action to ensure women have access to the contraception they desire. In the above scenario, I would write a letter to the insurer outlining that they are in violation of the terms of the ACA if they failed to provide coverage for contraception. Per the HHS letter, failure to comply with the standards could lead to future enforcement actions. I would also appeal the non-payment for service. There are many instances in which a women may choose to use contraception for non-birth control reasons. For example, according to Lethaby et al. (2019) approximately 30% of referrals to gynaecologist are due to heavy menstrual bleeding. Lethaby et al. (2019), further explain that heavy menstrual bleeding (HMB) causes significant impact to a woman’s quality of life, can affect work attendance, and can lead to fatigue related to iron deficiency. Lethaby et al. (2019) continue pointing out the incredible costs related to HMB. The cost of treatment for HMB is estimated at 1 to 1.5 billion US dollars per year and the costs for loss of productivity are estimated to be at 12 to 36 billion dollars per year. Other health benefits or off-label uses of contraceptives include treating dysmenorrhea, treating acne, and for other hormone related affective symptoms such as mood stability (Taggart et al., 2018). Contraceptive use is also thought to provide some protection against ovarian, endometrial, and colorectal cancer. Taggart et al. (2018) explain that approximately 90% of women experience some affective symptoms associated with fluctuations in hormone levels. The appropriate documentation, such as irregular periods, HMB, dysmenorrhea, mood instability, etc should be included in the appeal to the health insurer. As an employee of a Catholic hospital, this question has been raised on numerous occasions. As I was always carried on my husband’s health insurance, my contraception was covered without any difficulty. As part of my practicum project, I have been spending time with a certified nurse midwife who practices within a practice that is owned by the hospital. She can prescribe any contraceptive except for Paraguard. The reasoning behind this is that the only use for Paraguard is contraception. The other options can be used to help regulate period, treat heavy menstrual bleeding, help regulate mood, and so on.
2. How do you justify your actions based on legal and ethical guidelines? Be sure to support your position with a scholarly source.
   Ethics has been defined by Haddad & Gieger (2022) as “moral principles that govern how the person or a group will behave or conduct themselves (para. 1). The Code of Ethics for Nurses encompasses several principles to guide the nurse in the care they provide. Among the principles included in the Code of Ethics are autonomy, justice, beneficence, nonmaleficence, fidelity, accountability, and veracity (Waxman & Knighten, 2023). Per the Code of Ethics, the primary commitment of the nurse is to the patient (Haddad & Gieger). This includes patient advocacy and promoting the rights and safety of the patient. One primary right of the patient is the right to autonomy. The patient has the right to make their own healthcare decisions based on their own values and beliefs. If a patient who has heavy menstrual bleeding wants medical treatment instead of surgical treatment in order to maintain their fertility, that decision belongs to the patient, not the insurance provider. As explained above, insurance providers participating in the ACA have a legal obligation to provide contraceptives at no cost to the patient. Additionally, as explained by Haddad & Gieger (2022), non-maleficence places a requirement of the nurse to avoid causing harm to the patient. Withholding hormonal treatment for a patient who is suffering from iron deficiency anemia due to HMB is not practicing non-maleficence.

Assistant Secretary for Public Affairs (ASPA). (2022, June 27). Secretaries Becerra, Walsh and Yellen underscore contraceptive coverage requirements for private insurance. US Department of Health and Human Services. https://www.hhs.gov/about/news/2022/06/27/secretaries-becerra-walsh-and-yellen-underscore-contraceptive-coverage-requirements-for-private-insurance.html Links to an external site.
Haddad, L. M., & Geiger, R. A. (2022). Nursing ethical considerations. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054/

Lethaby, A., Wise, M. R., Weterings, M. A. J., Bofill Rodriguez, M., & Brown, J. (2019). Combined hormonal contraceptives for heavy menstrual bleeding. The Cochrane Library, 2019(2). https://doi.org/10.1002/14651858.cd000154.pub3 Links to an external site.
Taggart, T. C., Eaton, N. R., Keyes, K. M., Hammett, J. F., & Ulloa, E. C. (2018). Oral contraceptive use is associated with greater mood stability and higher relationship satisfaction. Neurology, Psychiatry, and Brain Research, 30, 154–162. https://doi.org/10.1016/j.npbr.2018.10.004 Links to an external site.
Waxman, K. T., & Knighten, M. L. (Eds.). (2023). Financial and business management for the doctor of nursing practice (3rd ed.). Springer Publishing.