ABSTRACT
BACKGROUND: Despite itsmany benefits, pulmonary rehabilitation (PR) is a severely underutilized service among marginalized populations because of low reimbursement rates. This is perpetuating systemic injustice and healthcare disparities. METHODS: The distribution of pulmonary rehabilitation was examined according to three frameworks in medical ethics for resource allocation: egalitarianism, utilitarianism, and distributive justice. RESULTS: Egalitarianism, the first bioethical framework for achieving justice, is based on the principle that all individuals are equal and therefore should have identical access to resources. PR is currently distributed in a manner that fails an egalitarian framework due to unequal access to PR among different population cohorts. A utilitarian approach to justice emphasizes maximizing overall benefits and “saving the most lives possible”. Poor access to PR means that outcomes are not currently maximized for patients with COPD and other respiratory conditions, thus failing the utilitarian model. A third approach, distributive justice, mandates that resources be allotted to those with the greatest need in a manner that does not infringe upon individual liberties. Allocation of PR in amanner consistent with distributive justice would provide PR to patients who have the most significant underlying disease and have been historically marginalized. Our current system fails the distributive justice framework as PR is more available to affluent populations. CONCLUSIONS: Utilization of and access to PR fails all three principles of justice. Additionally, inequities in PR access have worsened because of COVID-19 due to loss of employer-based insurance with rising unemployment and increased demand for PR. First, we recommend reforming and increasing PR reimbursement away from the bundled one-hour payment code, G0424. Second, we suggest that Medicaid coverage be extended for pulmonary telerehabilitation, and that this coverage apply to center-based, home-based, and web-based telerehabilitation. Finally, we advocate moving from fee-forservice to value-based payment systems. Our recommendations would not only lead to economic savings, but also to more equitable care for patients regardless of background, race, or socioeconomic status. PR represents an achievable means to provide affordable and high-quality care to more individuals, especially those from non-white and less affluent communities disproportionately affected by COPD, COVID-19, and other respiratory conditions. These proposals for payment reform would ensure the continued and increased adoption of PR and help transform the current system into one that achieves justice for historically marginalized patients. This is one small but important step in paving the future for equitable resource allocation in healthcare.