NU706 Unit 9 Program Ethics Analysis Example

A Safety Net With a Company's Name on It: A Unit 9 Ethical Analysis of a Hospital's Reliance on Insulin Assistance Programs

[Student Name]

Purdue University Global

NU706: Ethics, Policy, and Advocacy in Population Health

Unit 9 Program Ethics Analysis

[Instructor Name]

[Date]

The hospital, its program records and figures are composite and illustrative; the studies and frameworks cited are real.

The Program and Its Place in the Bundle

Drug manufacturers run patient assistance programs that supply brand-name medicines free or at low cost to eligible patients, usually those with low incomes and no insurance or inadequate coverage. The hospital's case managers treat these programs as the main route to insulin for uninsured patients leaving on new insulin. The process takes an application signed by the patient and the prescriber, proof of income, and shipping to the clinic or the patient's home, usually within two to four weeks.

Case management records for last year show 19 uninsured patients discharged on new insulin. Fourteen were enrolled. Three did not qualify, two because their incomes were slightly above the program's limit and one because he had been enrolled in a public program that made him ineligible. Two never completed the application. Of the 14 enrolled, 11 received their first shipment within 30 days of discharge, and the other 3 waited longer.

What the Programs Give

The benefits are real and should be stated first, because an ethics analysis that skips them misrepresents the program it judges. For 14 patients, insulin that would have cost hundreds of dollars a month was supplied free. Without the programs, many of those patients would have rationed or gone without. The programs cost the hospital little, and they use manufacturers' resources to help the patients least able to pay.

In the language of principlism, the programs serve beneficence directly: they help specific patients obtain a treatment they need (Beauchamp & Childress, 2019). They also serve a limited form of justice by directing help to people with the least.

An ethical analysis that starts by dismissing a program that fed fourteen patients insulin is not analyzing; it is posturing.

Gaps and Burdens

The concerns fall into four groups.

First, eligibility gaps. Each company writes its own rules. In a survey of these programs by Choudhry et al. (2009), structures and applications differed from one company to the next, half would not say what income limit they applied and only 4 percent disclosed how many patients they had directly helped. A hospital cannot plan around criteria it is not allowed to see. The three patients the hospital could not enroll fell through exactly these gaps. Their incomes were too high for the program and too low to pay cash for insulin.

Second, burden and delay. An application that requires two signatures and documents cannot be completed on a weekend, and shipment takes weeks. The bundle's own data show the cost of that delay: the Unit 6 case, a patient discharged on a Friday with no route to insulin, returned nine days later in crisis. A program that works in a month does not help a patient who needs insulin tomorrow.

Third, dependence. The programs exist at the discretion of the companies. Eligibility rules, covered products and the programs themselves can change, and the hospital has no say in those decisions. Building a core part of discharge safety on a private decision the hospital does not control is a vulnerability. The case managers already saw one program change its form in the middle of the year, which delayed two applications while staff learned the new version. A change in income limits, or the end of a program after a product leaves the market, would reach the hospital's patients without notice.

Fourth, substitution. The most serious ethical concern is that the programs make an unjust arrangement look acceptable. When charity fills part of a gap, the pressure to close the whole gap through policy can weaken. This is a concern about justice at the level of society rather than the individual patient.

Weighing the Considerations

The analysis does not conclude that the hospital should stop using assistance programs. Doing so would harm the 14 patients they help each year to make a point about policy, which would violate both beneficence and nonmaleficence. The considerations instead point to three conclusions.

The programs are ethically acceptable as one route among several, not as the safety net. The hospital's duty to the patient leaving on insulin does not end at an application.

The gaps are foreseeable, so the hospital is responsible for planning for them. A patient who does not qualify, or who needs insulin before a shipment arrives, is not an unforeseen exception but a predictable case. A bridge supply of 30 days, a lower-cost human insulin option and a scheduled follow-up are the obvious plans.

The hospital's reliance should be visible. If the hospital counts how many patients fall through each gap, it can use those numbers in advocacy for public solutions, such as the state safety net bill supported in the Unit 7 testimony. That is how the hospital can use the programs without letting them substitute for policy.

Recommendations

The analysis recommends four changes to the hospital's practice:

1. Start the assistance program application on the day insulin is started, not on the day of discharge, so that the paperwork is not left to the weekend.

2. Fund a 30-day bridge supply for any patient whose program shipment will not arrive before the current supply runs out, or who does not qualify. An academic hospital that delivered medicines to the bedside before discharge found that subsidizing them for uninsured and underinsured patients was the version that lowered readmissions most, and cost less per point of reduction than delivery alone (Stedge et al., 2023).

3. For patients who do not qualify, offer a lower-cost human insulin option with full teaching, as the Unit 5 reflection argued.

4. Report quarterly how many uninsured patients were enrolled, how many did not qualify and why, and how long shipments took, and share the report with nursing leadership and the hospital's government relations office.

Conclusion

Manufacturer assistance programs deliver real benefit to patients who could not otherwise afford insulin, and the hospital should keep using them. But their eligibility gaps, delays and dependence on private decisions mean they cannot ethically serve as the whole safety net. The hospital's obligation is to plan for the patients the programs miss, to make the bridge until shipments arrive and to count the gaps so that they become evidence for public solutions.

References

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

Choudhry, N. K., Lee, J. L., Agnew-Blais, J., Corcoran, C., & Shrank, W. H. (2009). Drug company-sponsored patient assistance programs: A viable safety net? Health Affairs, 28(3), 827-834. https://doi.org/10.1377/hlthaff.28.3.827

Stedge, B., Xu, J., Kubes, J. N., Han, E., Russie, C., Woods, L., & O'Donnell, C. (2023). Meds to beds at hospital discharge improves medication adherence and readmission rates in select populations. Southern Medical Journal, 116(3), 247-254. https://doi.org/10.14423/SMJ.0000000000001532