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Assignment: Restructuring Of The U.S. Health Care
Assignment: Restructuring Of The U.S. Health Care
As the country focuses on the restructuring of the U.S. health care delivery system, nurses will continue to play an important role. It is expected that more and more nursing jobs will become available out in the community, and fewer will be available in acute care hospitals.
- Write an informal presentation (500-700 words) to educate nurses about how the practice of nursing is expected to grow and change. Include the concepts of continuity or continuum of care, accountable care organizations (ACO), medical homes, and nurse-managed health clinics.
- Share your presentation with nurse colleagues on your unit or department and ask them to offer their impressions of the anticipated changes to health care delivery and the new role of nurses in hospital settings, communities, clinics, and medical homes.
- In 800-1,000 words summarize the feedback shared by three nurse colleagues and discuss whether their impressions are consistent with what you have researched about health reform.
- A minimum of three scholarly references are required for this assignment.
While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.
The health-care system in the United States has undergone significant economic changes during the last two decades, but no solution to the fundamental problem of cost containment has been found.
During most of this time, per-capita medical expenditures climbed at an inflation-adjusted pace of around 5% to 7% per year, with health-care costs occupying an ever-increasing share of the gross national product.
With the expansion of managed care programs in the 1990s, the rate of increase halted for a few years.
However, the rate is presently rising at a faster rate than ever before, and medical expense reduction has resurfaced as a key national priority.
Failure to address this issue has resulted in the majority of the health-care system’s other key flaws.
Half of all medical expenses are incurred in the private sector, where most (but by no means all) people under 65 have access to employer-based health insurance.
Until the mid-1980s, the majority of private insurance was indemnity, which meant that the insurer merely paid the usual hospital and physician fees.
Businesses may provide this coverage as a tax-free fringe benefit to employees (who might be forced to contribute 10 to 20% of the cost as a copayment), and employers could deduct it as a business expense.
Employers eventually abandoned indemnity insurance for most of their workers due to the financial load and unpredictability of ever-increasing rates.
Managed care plans, which contract with employers to deliver a set of health-care benefits at a negotiated and pre-arranged premium in a price-competitive market, have become increasingly popular.
Managed care has fallen short of its promise to keep prices from rising indefinitely.
One of the first initiatives of the Clinton administration, when it assumed office in 1993, was an ambitious proposal to bring federally regulated competition among managed care companies.
The goal was to keep premium pricing under control while guaranteeing that the public had access to universal health care, received high-quality care, and had the freedom to pick among providers.
It was hoped that all types of managed care plans, including older not-for-profit plans and more contemporary plans supplied by investor-owned corporations, would be drawn to the market and compete for patients on a level playing field set by government regulations.
However, this measure was shelved before it could be put to a vote in Congress.
The private insurance industry, which saw great profit prospects in an uncontrolled managed care market but not under the Clinton plan, was vocal in its opposition.
Furthermore, many people, including the leaders of the American Medical Association, were alarmed by the planned plan’s complexity and significant reliance on government regulation, leading them to believe it was “socialized medicine.”
Due to the failure of this attempt, private health insurance fell into the hands of a new and aggressive business, which generated huge profits by keeping premiums low while drastically cutting medical spending–and keeping the difference as net revenue.
This industry referred to its healthcare costs as “medical losses,” a term that encapsulates the fundamental tension between patients’ health and the financial goals of investor-owned corporations.
However, because traditional insurance services contained a lot of fat, these new managed care insurance companies could easily make money for their investors, executives, and owners by cutting off a lot of it.
They did so in a variety of ways, including denial of reimbursement for hospitalizations and physician services that the insurance judged non-medically necessary.
The plans also required hospitals and physicians to offer price concessions, as well as contracts that prevented primary care physicians from spending too much time with patients, ordering expensive tests, or referring patients to specialists.
In the private sector, these techniques were momentarily successful in reducing spending.
Managed care companies grew quickly as a result of their high earnings.
It then concentrated into a few large businesses that were well-liked on Wall Street, and it swiftly grew to wield significant power over the political economy of American health care.
The other half of medical expenses is paid for by the government, and this sector has been unable to keep costs under control even temporarily.
The first move taken by the government was to implement a mechanism of reimbursing hospitals based on diagnostic groups (DRGs).
Rather than paying per-day or per-procedure expenses, the government would pay a fixed amount for treating a patient with a specific condition.
As a result, hospitals were given significant incentives to shorten stays and save money on inpatient care resources.
Simultaneously, they encouraged physicians to perform various diagnostic and therapeutic treatments in ambulatory facilities that were not subject to DRG-based reimbursement limits.
Meanwhile, the temporary success of private managed care insurance in lowering premiums–along with its much-touted (but never proven) claims of higher quality care–led many politicians to believe that the government could solve its health-care cost problems by handing over a large portion of the public system to private enterprise.
As a result, governments began contracting out a large portion of the Medicaid services supplied to low-income people to commercial managed care programs.
For political reasons, the federal government could not so casually outsource Medicare care, but it did begin to urge persons over 65 to enroll in government-subsidized commercial plans instead of receiving Medicare benefits.
Up to 15% of Medicare seniors chose to do so at one point, primarily because the plans provided coverage for outpatient prescription medicines, which Medicare did not.
What about efforts to keep physician bills from skyrocketing for the vast majority of Medicare enrollees who prefer the traditional fee-for-service system?
The government proposed compensating doctors using a DRG-style system similar to that used for hospitals, but this plan was never adopted, and the previous “usual and customary” payments were replaced in 1990 by a uniform price schedule.
Physicians, on the other hand, discovered a means to keep their earnings by disaggregating (and so multiplying) billable services and increasing the number of visits, while Medicare’s reimbursements for medical services continued to climb.
Physicians’ professional role as champions of their patients’ interests has been eroded as a result of cost-cutting measures by for-profit managed care organizations and the government.
Physicians have become more entrepreneurial, entering into a variety of business relationships with hospitals and outpatient facilities in an effort to maintain not just their income but also their professional autonomy.
A growing number of imaging centers, kidney dialysis units, and ambulatory surgery clinics are owned and operated by doctors.
Physicians have monetary stakes in the medical products and services they use and recommend.
They’ve invested in expensive new equipment for their offices, which has resulted in increased billing and revenue.
Furthermore, a recent trend has seen groups of physicians invest in hospitals that specialize in cardiac, orthopedic, or other types of specialist care, putting community-based general hospitals in competition for the most profitable patients.
Of course, physicians justify all of these self-serving responses to insurers’ cost-cutting measures as a strategy to defend the quality of medical care.
Nonetheless, they raise health-care costs and raise major problems regarding the impact of financial incentives on professional decisions.
Managed care has failed to deliver on its promise of preventing long-term cost increases in the private sector.
After squeezing out all of the excess, the only way to make more cuts was to reduce fundamentals.
Meanwhile, new and more expensive technology continues to emerge, driving up medical costs inexorably.
Employers are once again confronted with catastrophic cost inflation that they simply cannot and will not tolerate, so they are reducing insured benefits and pushing more costs to employees.
Furthermore, there has been widespread public opposition to managed care’s limits, prompting several state legislatures to pass legislation prohibiting private insurers from restricting patients’ health care choices and physicians’ medical decisions.
Complaints that managed care programs are usurping physicians’ prerogatives and injuring patients have begun to gain traction in the courts.
In the public sector, a considerable percentage of Medicare patients who switched to managed care are now back on traditional coverage, either because they were dissatisfied and left their plans or because the plans’ government contracts were canceled due to a lack of profit.
The government is cutting back on benefits to patients and payments to physicians and hospitals as a result of the unrestrained growth in Medicaid and Medicare spending.
Increased unemployment has reduced the number of persons covered by job-related insurance, resulting in an increase in the number of uninsured people, who today number more than 41 million.
Because of the lower payouts, several doctors have refused to accept Medicaid patients.
Some doctors are debating whether or not to continue accepting new senior patients who do not have private Medigap insurance to supplement their Medicare coverage into their offices.
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