Case study

In the following exercise you will be developing a short ethical analysis of the case that follows. In a short paper of not more than 750 words , using APA style you will answer the questions that follow the case study. Your short paper will be graded using the Short Assignment rubric.

You are a healthcare professional working on the quality management team for an insurance company. You received a call from one of your plan participants. Ms. Smith, about the safety and efficacy of using a surgical tool during the course of a laproscopic procedure. Smith, a medical professional, was recommended to undergo a fibroid operation after suffering persistent and worsening pain and experiencing sporadically abnormal pap smear results. The surgeon slated to perform the procedure utilizes a power morcellator during the surgery. The device cuts up fibroid tumors in a woman’s uterus, allowing for easier removal of the tissue pieces. Smith’s concern, which the surgeon did not allay, was that some of the fibroids may be malignant, essentially providing the opportunity for the cancer to spread during the fibroid demolition and removal.

In engaging in the preapproval process, Smith soon learned that this protocol seems to be standard industry practice; thus, it is covered in full by the insurance, whereas other surgical techniques are either not covered or employed by those practicing in her area. While the costs of the scheduled surgery with the morcellator are covered in full, Ms. Smith does not want to undergo this particular protocol because, based on her medical training and knowledge, she is concerned that the tool will spray potentially cancerous tissues throughout her abdomen and pelvis. However, knowing that the procedure is covered and standard, she also knows that pre-approval for a different, out-of-network surgeon who uses an alternate technique will be difficult, if not impossible, to procure. Accordingly, without pre-approval, Smith knows that she will personally be liable for the costs of the surgery, which is easily between $10,000 and $20,000, money which Smith does not have readily available. Smith has called you as the case manager, requesting an exception to the insurance company’s general rule, and seeking pre-approval to have her procedure, using an alternative surgical technique, reimbursed.

Smith is steadfast in her decision not to undergo surgery with the morcellator. In fact, if the decision rests between a free morcellator surgery, or paying out of pocket for a different procedure, she said she would forgo surgery altogether and take her chances — instead of being subjected to an increased risk of spreading cancer by shredding potentially malignant tissue and allowing it to migrate throughout her body.

Smith’s complaint seemed valid. Upon further research, you find that the FDA has not issued an opinion disparaging the surgical tool or deeming it unsafe for medical use. Accordingly, the procedure is, by all legal and regulatory standards, deemed safe. However, you feel that Smith is stating a legitimate concern. You feel torn because you aren’t sure if, just because something hasn’t been deemed illegal or unsafe, it is still the best procedure for patients to undergo.

You wonder if an exception should be made, allowing for Ms. Smith to receive reimbursement for the upwards of $20,000 bill for getting an alternate procedure from a doctor that does not use the morcellator. You also wonder if, perhaps, the insurance company should rethink its policy on only covering the morcellator procedure, instead expanding insurance coverage to alternate types of procedures for patients like Ms. Smith, who are uncomfortable with the morcellator.

You decide that it is best to outline the issues before approaching your supervisor utilizing one of the ethical decision analyses.

  • To prepare for the meeting with your supervisor, and keeping in mind the elements of the ethical decision making framework, briefly outline the ethical dilemma that Smith’s request presents.
  • Who are all of the stakeholders? Think of not only the persons but the institutions involved as well. Examine two potential solutions, including an ethical analysis supporting each conclusion, as well as any potential consequences which may arise to the insurance company by a judgment that this procedure is or is not the most medically appropriate way to remove fibroids.

Submit this brief case analysis in a short paper no more than 750 words in the assignment area.

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