The Challenges and Ethics of Charitable Care

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By Caryn Earl, CPO/L

Why do we do what we do? Before we knew of the challenges ahead, before we considered the cost of a foot, the hours of labor required to provide quality O&P care to a patient and family, or the tenuous bottom line of an office, a department, or a healthcare system, we embarked on an O&P career with hopes of helping people find their way to rehabilitating from a physical trauma.

We are now faced with increasing numbers of uninsured, under-insured, and undocumented patients requiring our services to continue to be viable contributors in their lives and the lives of their families. Simultaneously, we are being asked to provide these services with reduced internal resources and a focus on finances and budgeting. Can we do this and stay in the black? Will saying no damage our reputation in the community and negatively influence our relationships with referral sources? Will it reduce the resources for our other patients? If we decide to help at no cost, how far should we go?

These questions are on my mind every day, and everyone in O&P recognizes that pressure. I work at an institution with a mission of serving the underserved; we are obligated to care for uninsured patients. Our challenges lie in the cost of a lifetime of free services against the constant budget constriction and the difficulty in setting a hard line on who qualifies for services (i.e., Can someone come to the city for free care? How long does he or she need to reside here? What if he or she received a prosthesis prior to coming here?).

In many countries, people needing mobility assistance use crutches or wheelchairs as their primary means of mobility. When budgets and finances collide with the reality of possible alternatives, should we consider wheelchairs and crutches as an acceptable option in the United States? If this practice is justified for charitable care, does it jeopardize the provision
of O&P services to the insured? The unintended consequence of a decision could be detrimental to our services a whole.

There are organizations that offer grants for medical expenses, and they often require some contribution fromthe patient, sponsor, or both, and rely on the parties involved to put in the effort to receive the care.

Creative ideas to reduce negative financial impacts of charitable care include:

  • Using discounted items for provision of services (i.e., a free foot with purchase of a knee)
  • Billing institutionally to the budget of the referring department instead of the O&P department
  • Getting permission/legal clearance from the organization to use donated components
  • Creating "wish lists" of items to be crowdsourced for patient needs

Then the reality hits harder. What are the ethics of a practice that provides free O&P services for some, but holds others with a large deductible responsible for thousands of dollars? It certainly does not feel right to turn away a single working parent who cannot afford the $5,000 copayment for a prosthesis that will allow them to return to work, yet provide free services to others that do not have insurance coverage at all.

We all got into this to help people, and things have gotten so much more complicated since then. Where will we go from here?


Caryn Earl, CPO/L, is the manager of the University of Washington Medicine Prosthetics & Orthotics Clinic.