ABSTRACT

Needed Health Care Services .......................................................................... 966 30.3.5 Intersecting Ethical Concepts and Con icts of Interest:

Opposing Social Forces Impacting Health Care Provider Clinical Decision Making ................................................................................................ 966

30.4 Historical Context and Key Stakeholders .................................................................... 967 30.4.1 Medicare, Medicaid, and Rehabilitation ........................................................ 968 30.4.2 Managed Care .................................................................................................... 970 30.4.3 Key Stakeholders ................................................................................................ 973

30.4.3.1 TBI Survivor and Family ................................................................. 973 30.4.3.2 Health Service Delivery Systems and Health Care Providers ... 974 30.4.3.3 Managed Care Organizations......................................................... 974 30.4.3.4 Private Sector Advocacy Organizations ........................................ 975 30.4.3.5 State Government ............................................................................. 975 30.4.3.6 Federal Government ......................................................................... 975

30.5 Organization and Legal Concepts ................................................................................. 975 30.6 Resolution ......................................................................................................................... 978

30.6.1 Alternative A: Maintain the Current Health Care System .......................... 978 30.6.1.1 Respect for Autonomy .....................................................................980 30.6.1.2 Bene cence ........................................................................................980 30.6.1.3 Nonmale cence .................................................................................980 30.6.1.4 Justice ..................................................................................................980 30.6.1.5 Duty to Care ...................................................................................... 981 30.6.1.6 Con ict of Interest ............................................................................ 981 30.6.1.7 Bene ts ............................................................................................... 981 30.6.1.8 Costs ................................................................................................... 981

Increasing health care costs in the United States during the past 35 years have proved dif- cult to control for both governmental and private health insurance entities. For approximately 47 million Americans (15% of the population), access to affordable health care is not available. In addition, during the past 40 years, health care spending has outstripped revenue by 2.5% annually, with increasing numbers of patient safety and quality problems.1,2 This harsh reality is ampli ed when attempting to provide treatment and care for those individuals who are catastrophically injured, requiring expensive trauma and acute care services, rehabilitation, and lifelong support services, as exempli ed by traumatic brain injury (TBI). The current sources of U.S. health care funding include (1) federal government programs that are, to a limited extent, universal in access, but population and mission speci c (Public Health, Medicare, Medicaid, Military Health System, and Veterans’ Administration Health System); (2) private health insurance policies available through employers or social organizations (e.g., American Association of Retired Persons) and for direct purchase that embrace contract law as the mechanism for determining allocation/ rationing of health services for premiums paid; and (3) indigent care offered, most often, through speci c health care providers (HCPs), with nancial losses offset, to a limited extent, by state budget contributions earmarked for indigent care.