Ethical implications of quality of health insurance service delivery: A case study of kidney transplantation

Much attention has been devoted to improving access to care as an ethical requisite to ensure quality care. However, there has been little discussion of ethical implications of the quality of patients' interactions with insurers, which are critical to gaining access to care. This paper describes how kidney recipients evaluated their experiences interacting with their insurers, and the kinds of difficulties they routinely encountered with insurance agencies. Kidney transplant recipients are an ideal patient population to consider because of their frequent interactions with insurers given their long-term reliance on insurance coverage for anti-rejection drugs. Anti-rejection medications are costly and must be taken for life of the kidney graft to ensure graft survival, yet most patients cannot afford them without insurance coverage. A consecutive cohort of kidney recipients (n=88) participated in a semi-structured interview. A third of patients (34%) reported a negative experience interacting with their insurer, and most (72%) reported a neutral or positive experience. Leading negative experiences pertained to problems with poor and rude communication, hassles involved in processing paperwork, and the time-consuming application process. Positive experiences related to having good coverage, simple application process, and having no problems or minimal interactions to date. Findings suggest that even when patients have insurance coverage, difficult interactions with insurers limit their ability to obtain necessary care and medications. These problems raise ethical concerns about preventing the waste of transplants, which are scarce societal resources. Patients' perspectives on the delivery of service by insurers should be included as a quality indicator.