Medical crowdfunding is touted for its potential to reach an unlimited number of people, the sum of whose individual donations can help achieve campaign goals for even the most daunting financial asks, such as $2.1 million to cover the cost of Zolgensma. For medical campaigns, that translates into all kinds of calls-to-action: Campaigns to pay bills for routine visits, afford costly treatments, offset income lost from chronic illness, and more. Increased reliance on medical crowdfunding has exacerbated ethical pitfalls in the healthcare arena while also leading to theoretical solutions for ways physicians can help. Physicians’ involvement, however, is a matter of whether medical crowdfunding falls within the bounds of their moral duty to patients.
An opinion from the American Medical Association Code of Medical Ethics notes physicians’ must not allow patients’ financial circumstances to affect access to appropriate and needed care. In other words, the system of ethical priorities ranks access to care above patients’ savings. The precept states physicians can offer forms of pro bono care or, when permissible, waive insurance copayments on a case-by-case basis. Under their contracts with payers, physicians are obligated to collect copays, coinsurance, and deductibles. They can on occasion make allowances for patients with demonstrated financial hardship. Given this, it doesn’t make sense why people are increasingly turning to medical crowdfunding to cover them. Put another way, reasoning might argue that physicians would assume the burden.
This appeared to be the case in one extraordinary example. Amid the COVID-19 pandemic, a physician was in the position to forgive his patients’ cumulative medical debt totaling $650,000. He made the lump sum decision upon closing his private practice. In general, however, active payer contracts with physicians stipulate they collect fees. Contracts also prohibit them from routinely forgiving patients’ copays and deductibles. The Office of the Inspector governs that routine waivers “results in (1) false claims, (2) violations of the anti-kickback statute, and (3) excessive utilization of items and services paid for by Medicare.” The clause discourages physicians from waiving out-of-pocket (OOP) expenses and happens to also conflict with an insight from a survey.
According to a NORC survey, 38% of participants want physicians to defray the cost of patients’ OOP burdens. The issue, again, goes back to the legal statute. In a hypothetical scenario, suppose a significant number of one physician’s patients can’t afford their medical expenses. Each patient proves financial hardship, so the physician waives each one’s OOP expenses in succession. The repeated instances can amount to routine practice, which, as was reported in Physicians Practice, can lead to insurers and the government suing the physician for fraud. Physicians, like the patients they treat, should not have to carry the burden, especially when federal laws constrain physicians’ abilities to waive patients’ OOP expenses.
If anything, physicians’ adherence to legal statutes forces them to compromise ethical obligations that can trap them into a form of moral injury. If statutes around OOP expenses interfere with physicians caring for patients, then, based on patient choice, physicians may find themselves needing to delay or forgo providing treatment. Alternatively, physicians may find themselves providing care but doing so quite possibly burdened with the awareness that their patients are assuming medical debt. Either way, the fine print imposes limitations on physicians that would want to alleviate patients’ OOP expenses, the very expenses that lead them or their beneficiaries to resort to medical crowdfunding.
In a study about the ethics of crowdfunding in pediatric neurology, researchers recommend physicians get involved in their patients’ medical crowdfunding campaigns. In one proposed example, based on nonmaleficence, physicians can discuss with patients the pros and cons of crowdfunding as they would the risks and benefits of treatment options. The analysis also proposes that physicians review their patients’ crowdfunding campaigns, specifically for proven treatments, for any infelicities. The researchers note that physicians would need to maintain patient consent and confidentiality in the process. By vetting patients’ medical crowdfunding campaigns, physicians would be reducing risk for medical misinformation, an ethical pitfall they can help mitigate. Though the level of involvement wouldn’t necessarily change patients’ medical burdens, it might fall within the scope of physicians’ moral responsibility without compromising the legalities of fee waivers.