Reid Lynette
Department of Bioethics, Dalhousie University, PO Box 15000, Halifax, NS, B3H 4R2, Canada.
Health Care Anal. 2017 Jun;25(2):151-167. doi: 10.1007/s10728-016-0324-4.
In bioethics and health policy, we often discuss the appropriate boundaries of public funding; how the interface of public and private purchasers and providers should be organized and regulated receives less attention. In this paper, I discuss ethical and regulatory issues raised at this interface by three medical practice models (concierge care, executive wellness clinics, and block fee charges) in which physicians provide insured services (whether publicly insured, privately insured, or privately insured by public mandate) while requiring or requesting that patients pay for services or for the non-insured services of the physicians themselves or their associates. This choice for such practice models is different from the decision to design an insurance plan to include or exclude user fees, co-payments and deductibles. I analyze the issues raised with regards to familiar health care values of equity and efficiency, while highlighting additional concerns about fair terms of access, provider integrity, and fair competition. I then analyze the common Canadian regulatory response to block fee models, considering their extension to wellness clinics, with regards to fiduciary standards governing the physician-patient relationship and the role of informed consent. I close by highlighting briefly issues that are of common concern across different fundamental normative frameworks for health policy.
在生物伦理学和卫生政策领域，我们经常讨论公共资金的合理界限；而公共和私人购买者与提供者之间的界面应如何组织和监管则较少受到关注。在本文中，我将探讨三种医疗实践模式（礼宾医疗、高管健康诊所和包干收费）在这个界面引发的伦理和监管问题，在这些模式中，医生提供有保险的服务（无论是公共保险、私人保险还是根据公共指令的私人保险），同时要求或请求患者为服务付费，或者为医生本人或其同事的非保险服务付费。选择这些实践模式与设计保险计划以纳入或排除用户费用、共付额和免赔额的决定不同。我分析了与公平和效率等常见医疗保健价值观相关的问题，同时强调了对公平获取条件、提供者诚信和公平竞争的其他担忧。然后，我分析了加拿大对包干收费模式的常见监管回应，考虑到其扩展到健康诊所，涉及管理医患关系的信托标准和知情同意的作用。最后，我简要强调了不同的健康政策基本规范框架中共同关注的问题。
