NRP/508 Week 7: Ethics, Equity and Cost in a Practice Decision, sample paper

Keep the Sliding Fee or Keep the Doors Open? An Ethical Analysis of a Rural Clinic Board's Proposal to End Discounts for Uninsured Patients

[Student Name]

University of Phoenix

NRP/508: Health Policy and Role of the Advanced Practice Nurse

Week 7 Assignment

[Instructor Name]

[Date]

The clinic, board and figures are composites written for a model paper.

Our rural clinic has a budget gap of about $85,000 for the coming year, driven by rising staff wages, a new electronic record contract and the fee for a prescriptive authority agreement. The board has proposed ending the sliding-fee discount that lets uninsured patients pay $25 to $60 per visit based on income and charging them a flat $120. About 15% of the clinic's visits are with uninsured patients, most of them farmworkers and self-employed ranch hands. As a nurse practitioner who will care for these patients, I have been asked for my view. This paper analyzes the proposal ethically and recommends a course.

The Facts

The sliding-fee program reduces revenue by an estimated $60,000 a year compared with full charges, although many uninsured patients would not pay full charges at all. Ending it would close most of the gap on paper. Staff estimate that many uninsured patients would stop coming, visiting only when very sick or going to the emergency department 70 miles away. The clinic is the only primary care in the county.

The Ethical Framework

Beauchamp and Childress (2019) set out four principles for clinical ethics. Autonomy asks that persons be respected as decision makers, nonmaleficence that harm be avoided, beneficence that good be done and justice that benefits and burdens be fairly distributed. Braveman and Gruskin (2003) define equity in health as the absence of systematic disparities in health between social groups with more and less advantage, emphasizing that equity concerns differences that are avoidable and unjust. The nursing code of ethics commits nurses (American Nurses Association, 2015) to promote the health of all people and to address social justice in health policy.

Applying the Principles

Justice weighs most heavily. Ending the sliding fee would shift costs onto the patients least able to pay, increasing a disparity that is avoidable and tied to social disadvantage, exactly what Braveman and Gruskin (2003) define as inequity. Beneficence supports continued access to preventive and chronic care, which uninsured patients would lose. Nonmaleficence warns against a policy likely to cause harm through delayed care, such as uncontrolled diabetes progressing to complications.

Yet beneficence also applies to the whole community. If the clinic closes, every patient, insured or not, loses primary care. A decision that protects the uninsured today but closes the clinic next year would fail them along with everyone else. Respect for autonomy matters as well: patients should decide about their own care with honest information about costs.

What the Clinic's Data Show

Before deciding, I asked the office manager for data. Over the past year, sliding-fee patients made about 1,900 visits. Nearly half were for chronic conditions such as diabetes and hypertension, and a quarter were for acute injuries and infections. Their no-show rate was similar to insured patients. Of the 312 uninsured patients, staff estimated that at least 90 might qualify for Medicaid or subsidized marketplace coverage but had never applied. These data change the analysis: part of the problem is not the discount itself but patients who could have coverage and do not.

Who Should Decide

The board has the authority to decide, but the patients affected are not represented on it. Respect for autonomy at the community level suggests that uninsured patients should have a voice. I propose a short survey of sliding-fee patients, in English and Spanish, about what they could pay and how they would respond to a change, and inviting two patients to speak at the board meeting.

The Options

Four options are available. First, adopt the proposal as written. Second, keep the sliding fee unchanged and accept a deficit, drawing on reserves. Third, keep the sliding fee but adjust it, for example raising the lowest tier from $25 to $35 and verifying income annually. Fourth, keep the sliding fee and close the gap in other ways.

Evaluating the Options

Option 1 closes the gap but conflicts with justice, nonmaleficence and the nursing code, and may not even produce the revenue expected if patients stop coming. Option 2 honors justice but risks the clinic's survival, which conflicts with beneficence to the whole community. Option 3 shares the burden modestly and preserves access. Option 4 seeks revenue and savings that do not fall on the poorest patients.

Other Ways to Close the Gap

Several measures could close much of the gap. Enrolling eligible uninsured patients in Medicaid or marketplace plans, with a staff member trained as a certified application counselor, would convert some uncompensated visits to paid ones. Improving coding accuracy, reviewed in Week 6, could recover revenue now lost to undercoding. Applying for rural health grants and state primary care funds could support the sliding-fee program directly. Renegotiating the electronic record contract, now in its first year, and sharing the prescriptive authority fee with a neighboring clinic could reduce costs. Evaluating the clinic for federally qualified health center look-alike status, which brings enhanced payment and requires a sliding-fee scale, is a longer-term option.

My Recommendation

I recommend option 4 combined with a modest version of option 3: keep the sliding-fee program, raise the lowest tier by $10, verify income annually and pursue enrollment assistance, coding review, grants and cost reductions. This protects access for the most disadvantaged patients while treating the clinic's finances as the ethical concern they are.

The Strongest Objection

A board member might argue that the recommendation depends on uncertain revenue, and that if grants are not awarded, the gap remains. This is fair. I propose a six-month review: if the measures have not closed at least two-thirds of the gap by then, the board should revisit the sliding-fee tiers with full data on who uses them and what they would pay.

Transparency

Whatever the board decides, patients should hear about changes well in advance, in plain language and in their own language, with information about enrollment help and other sources of care. A policy that changes quietly and surprises patients at the front desk would fail the principle of respect for persons even if the policy itself were defensible.

My Role as a Nurse Practitioner

My role is to bring the clinical and ethical perspective to the board with data, not only conviction. I will provide a summary of the clinical consequences of delayed care for uninsured patients, track visit patterns after any change and propose quality measures that show the program's value, such as diabetes control among sliding-fee patients.

Conclusion

Ending the sliding-fee discount would close the budget gap on paper but would shift costs onto the least advantaged patients, violating justice and risking harm. Keeping the program unchanged risks the clinic's survival, which also matters ethically. A middle course, a modest adjustment to the lowest tier combined with enrollment assistance, coding review, grants and cost reductions, with a six-month review, best balances equity and cost.

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Publishing.

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology and Community Health, 57(4), 254-258. https://doi.org/10.1136/jech.57.4.254