When the Healthcare Plan Limits Hearing 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

  1. What are some reasons the MD might choose not to refer for further testing?
  2. 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?
  3. How might the HMO's plan limit the audiologist's actions in this case?
  4. What is the audiologist's obligation to the patient?

Related Readings

  1. Brett, A. S. Relationships between primary care physicians and consultants in managed care. Journal of Clinical Ethics 1997, 8(1): 60–65.
  2. Friedman, E. Managed care, rationing and quality: a tangled relationship. Health Affairs 1997, 16(3):174–182.
  3. Hillman, A. L., 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.
  4. 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.
  5. Morreim, E. H. To tell the truth: disclosing the incentives and limits of managed care. American Journal of Managed Care 1997, 3(2):35–43.

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