The ethics of charging patients an infection control fee in the context of COVID-19
Authors: Sonal Muzumdar, Jane M. Grant-Kels, Hao Feng
Journal: Journal of the American Academy of Dermatology (2020)

Dear Dr Dermatoethicist: Owing to the coronavirus disease 2019 (COVID-19) pandemic, my dermatology practice has had to increase sanitation practices and use significantly more personal protective equipment to protect patients and staff. The prices of personal protective equipment and disinfectants have risen significantly, with a recent report estimating a 1000% increase in personal protective equipment cost compared with pre–COVID-19 times.1Zimmet M. Silverberg J. Stawis A. Greenfield M. Society for Healthcare Organization Procurement Professionals.http://cdn.cnn.com/cnn/2020/images/04/16/shopp.covid.ppd.costs.analysis_.pdfDate: 2020Date accessed: May 24, 2020Google Scholar I am not reimbursed for this additional expenditure. Is it ethical to pass the higher cost of infection control on to my patients?—Dr Financially Strained Dear Dr Dermatoethicist: Owing to the coronavirus disease 2019 (COVID-19) pandemic, my dermatology practice has had to increase sanitation practices and use significantly more personal protective equipment to protect patients and staff. The prices of personal protective equipment and disinfectants have risen significantly, with a recent report estimating a 1000% increase in personal protective equipment cost compared with pre–COVID-19 times.1Zimmet M. Silverberg J. Stawis A. Greenfield M. Society for Healthcare Organization Procurement Professionals.http://cdn.cnn.com/cnn/2020/images/04/16/shopp.covid.ppd.costs.analysis_.pdfDate: 2020Date accessed: May 24, 2020Google Scholar I am not reimbursed for this additional expenditure. Is it ethical to pass the higher cost of infection control on to my patients? —Dr Financially Strained Dear Dr Financially Strained: Delivering dermatologic care in a "safe" environment is vital since the coronavirus disease 2019 (COVID-19) pandemic. Although practices are financially strained after mandated pandemic closure, the ethics of charging patients for the resulting higher financial costs of infection control are complicated. It is important to balance ethical care delivery and responsible business practice.2American Medical AssociationFees for Nonclinical & Administrative Services. Code of Medical Ethics Opinion 11.3.2.https://www.ama-assn.org/delivering-care/ethics/fees-nonclinical-administrative-servicesDate accessed: January 15, 2020Google Scholar Justice suggests that the benefits and burdens of medical treatment be distributed in an equitable manner. Current reimbursement models do not account for the additional cost of COVID-19 infection control that practices are now required to bear. In a time when practices have experienced unprecedented declines in revenue, the rising cost may further exacerbate the financial burden. This may force practices to close or implement staff layoffs, thereby potentially negatively impacting the quality of dermatologic care that they can offer to their patients and appropriate access to care, thus violating the principle of beneficence. Nonetheless, charging patients an infection control fee may result in maleficence because this increase in cost can make accessing care more difficult, especially for patients of a lower socioeconomic status. Additionally, it is likely illegal for providers to charge patients with in-network private insurance or Medicare, because infection control costs are already embedded within payments. Even in those cases where it is legal, charging uninsured or out-of-network patients may make medically necessary care less affordable and therefore would be an assault on distributive justice, causing an increase in cost and thereby reducing access to health care, especially for lower socioeconomic patients. Consequently, this extra charge is inadvisable. Furthermore, it is unethical to only bill the surcharge to uninsured patients or seek surcharge reimbursement only from those insured. Advocacy for higher insurance reimbursement or coverage, or both, of appropriate Healthcare Common Procedure Coding System (eg, 99070, A4928, A9286) to account for increased cost of infection control rather than charging patients an infection control fee may be a more ethical and feasible option. One may also consider increasing prices of cosmetic procedures, aesthetician services, and skin care products to help offset the practice financial strain. In cases where dermatologists can and decide to charge patients legally, they should charge only what is necessary to cover the added expense and provide an upfront, transparent written financial policy plus seek consent of additional costs before the visit to respect patient autonomy. Dermatologists must continue delivering high-quality care while practicing appropriate infection control to avoid preventable risk and harm, but more support is needed to ensure a more equitable distribution of the financial burden and minimize the harm to patients and clinical care. —Dr Dermatoethicist