Explore BrainMass
Share

Health care cost

This content was STOLEN from BrainMass.com - View the original, and get the already-completed solution here!

1.Consider the costs associated with the American healthcare system, the contentions associated with managed care implementation, and the continued problems associated with macro and microallocation within this system. What ethics do you believe should guide continuing change in the American health care delivery system? (1 to 2 Paragraphs)
2.Why? (1 Paragraph)

© BrainMass Inc. brainmass.com October 24, 2018, 6:29 pm ad1c9bdddf
https://brainmass.com/health-sciences/health-care-ethics/health-care-cost-41819

Solution Preview

A health care delivery system is one that provides and administers health care services to individuals. There must be an agreement between the physician and the health care delivery system that allows the health care delivery system to bill and receive payment for services provided by the physician. There are three types of health care delivery systems: clinics, faculty practice plans, and managed care organizations.
While an emergency physician staffing company is not a faculty practice plan or a managed care organization, some staffing plans have tried to argue that they are "clinics." A clinic is a freestanding entity such as a physician group, outpatient dialysis facility, ambulatory surgical center, or imaging center that provides diagnostic and/or therapeutic health care services on an outpatient basis. ED staffing companies may not qualify as clinics in that they are not providers of outpatient services.
Why do people buy health insurance? Conventional theory holds that people purchase insurance because they prefer the certainty of paying a small premium to the risk of getting sick and paying a large medical bill. Conventional theory also holds that any additional health care that consumers purchase because they have insurance is not worth the cost of producing it. Therefore, economists have promoted policies-copayments and managed care-to reduce consumption of this additional, seemingly low-value care.
Regarding risk, the price discrimination relies on showing that consumers actually prefer the risk of a large loss to incurring a smaller loss with certainty. Therefore, if consumers purchase insurance, it is not because they desire to avoid risk. Instead, the price discrimination implies consumers simply pay a premium when healthy in exchange for a claim on additional income( effected when insurance pays for medical care) when they become ill
Ethical Issues
HCFA released an opinion on March 26, 1997, with regard to Coastal Physician Services, Inc. Coastal was a staffing company that provided physician personnel to hospital emergency departments in several states. Coastal did not employ any of the physicians. Coastal received Medicare billing numbers in several states and was able to bill and receive direct payment for services provided by its contractor physicians. HCFA concluded that Coastal could not receive direct payment for physician services based on its contractor relationship with physicians and hospitals. The opinion further stated that Coastal could not qualify for the "facility" exception,

Since 75% of U.S. physicians have signed managed care contracts, there is considerable interest in how successful this group will be. A previous attempt during the late 1980's by the Colorado Union of Physicians and Surgeons was not successful. The Sherman Antitrust Act prohibits self-employed business owners (private practitioners) from illegal price-fixing. One way or another, pressure is building for professionals to creatively explore options for unified action in the changing health care marketplace.
CCEMHC has been asked to respond to the recent contracted provider fee reductions by a large national managed care company. Federal and state laws prevent our organization from participating in contract disputes/negotiations or in any attempt to organize a boycott. Professional organizations are also prohibited from activities of this sort. It is important that you know your options and limitations in dealing with such contractual conflicts.
Under the California Knox-Keene Act, individual contractors cannot organize or appear to organize a boycott of an insurance company. Further, any attempt by contractors to form a group, association, or union in order to negotiate for a contract would be viewed as a violation of the federal McCarran-Ferguson Act and the Sherman Anti-Trust Act under price fixing violations. Anti-trust violations are subject to severe criminal and civil penalties.
Over twenty years ago, however, large employers in the U.S. became sufficiently troubled by cost escalation that some began to self-insure, bearing the risks of their employees, health expenditures themselves and contracting with insurers only to administer the premium collection and claims payment process (for a fee). They began t look for firms that could offer various forms of cost control services (managed care). Traditional insurers also moved into this market, initially with apparent success as suggested by American cost trends between 1992 and 2000. (These activites, however, generated significant additional administrative costs, both for cost controllers and for providers revisiting their control.) Since 2000 these private market initiatives seem totally to have lost their grip (in market contrast to the experience of other industrialized countries.) Employers are beginning to roll back coverage, passing more of the costs onto employees. What does this experience suggest what determines health care costs, and the long run scope for private health insurance even with subsidy and compulsion?
Managed care had influenced the ways in which healthcare providers make medical decision because shifting costs to consumers has replaced utilization management as the main tactic by which health plans and employers attempt to slow premium increases. But since the distribution of health care costs is heavily skewed-with a small minority of consumers accounting for a large majority of the spending-this tactic has limited potential to hold down costs. Amid rising financial pressures and consumer frustration with the growing health care burden, some communities are beginning to see the reintroduction of utilization management strategies associated with managed care that seemed destined for oblivion not long ago.Medical decisions are now changed because the managed system of health-care delivery that aims to control costs by assigning set fees for services, monitoring the need for procedures such as tests and surgical operations, and stressing preventive care. Managed health-care systems include health maintenance organizations; preferred provider organizations (PPOs), networks of doctors and hospitals that adhere to given guidelines and fees in return for receiving a certain number of patients; and point of service (POS) plans, which are similar to PPOs but allow patients to go outside the network for treatment, usually at a higher cost. The term is also used to describe more traditional health-insurance plans that require that more expensive procedures be reviewed and approved by a plan official before they are performed. In managed care, the doctor is often paid a set fee or is paid a set amount monthly for each patient, a scheme called capitation. Many physicians criticize managed care systems, saying that they take away their freedom to make treatment decisions, that they are motivated mainly by economics, and that they do not consider patients as individuals. Managed health-care systems also limit doctors' incomes and what many people consider to be the abuses of the older fee-for-service system that rewarded doctors financially for doing more procedures.
THE FOLLOWING UNETHICAL PRACTICES SHOULD BE AVOIDED

1. Disregarding personal and medical privacy.
Health care ethics call for the greatest respect for patient privacy and confidentiality. Privacy is especially important in mental health because patients talk about sensitive and personal topics like being ...

$2.19
See Also This Related BrainMass Solution

What impact do administrative issues have on the current health care environment?

View Full Posting Details