The Problem of the Good Samaritan

Parables were told to alert the reader to profound truths.  This parable has been time tested as witnessed by our Good Samaritan laws and by its influence on medical ethics.  This parable (Good Samaritan Parable) was told in response to the question, “and who is my neighbor”.  In this story, the neighbor is never clearly defined, but only as someone who was robbed, beaten, and left half-dead.  His plight was deemed less important than the immediate agenda and safety of the first 2 highly respected persons who saw him from afar and passed on.  Shockingly, a despised foreigner saw the need, provided emergent care, and then paid for acute and post-hospital care.  

As health care providers, this parable challenges us individually and collectively as facility teams to have a high view of our calling to care for our “neighbors” who have fallen on hard times, even if we must sacrifice our agenda or take great risks or expense.  Providing this level of care is our moral calling, but the realities of how we are paid challenge this calling.  

At a recent hospital sponsored care transitions meeting, the lead hospital case manager commented on how difficult it was to place persons with dementia in SNFs.  A SNF administrator responded saying they provided excellent dementia care for their residents, but couldn’t afford to take care of many more persons with dementia because they were more expensive to care for than non-demented patients and funding for their care isn’t commensurate with the facilities incurred cost.  

In the age of QAPI, we are challenged to identify problems, adjust our care processes, confirm improvement, and sustain the gains.  The assumption is that good care is less costly, but what if that isn’t the case. This creates a moral conundrum, particularly since our payers are remote and unlikely to pay for better care that is more costly.  

At an individual level as a frontline physician provider, our joy comes from hearing the patient’s story and their concerns, while completing a comprehensive assessment (ICD 10 codes), and developing shared care plans that are then immediately available to the rest of our team.  This process is labor intensive with the added necessity for creating the EHR billing documents that simultaneously meet MIPS reporting criteria. If this process takes 1-2 hours, is the payment for these services adequate and sustainable? 

I know that we live in the real world with limited funding and that our mission is to deliver the best possible care while advocating for more funding when needed for the good of our patients, but this challenge can be overwhelming “morally” at a provider level.

At our recent CALTCM annual meeting, I attended the “in the trenches” session on burn out led by Dr. Ashkan Javaheri.   In his large Sacramento group of SNF providers, one of the best interventions they have found for burn out, is getting together socially on a monthly basis to informally talk about life and the care they are providing.  For most of my career, I have worked alone without that support, as have most of my colleagues. Maybe I need to change and arrange opportunities to share with other providers the psycho-social burden of caring for very complex patients in the age of declining funding and increasing accountability.    

The moral dilemma of the “Good Samaritan” appears to be worsening.  At CALTCM, we are aware of your pain and are open to hearing your success stories.

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