Healthcare Finance
Assignment Instructions
Consider how compensation for healthcare services shape delivery of care, and reflects policy and policy changes and write a paper that addresses the bullets below. Be sure to completely address each bullet point. There should be four (4) sections in your healthcare finance paper; one for each bullet below. Separate each section in your paper with a clear brief heading that allows your professor to know which bullet you are addressing in that section of your paper. Include a “Conclusion” section that summarizes all topics. This assignment will be at least 1250 words.
This week you will reflect upon accountability in healthcare finance to address the following:
- Discuss the history of private health insurance and manage care and how it involved into a healthcare industry?
- Identify the key federal laws that protect individuals who are enrolled in private insurance.
- Briefly discuss consumer-driven healthcare and the empowerment of the healthcare consumer.
- Explore the opportunities which have emerged for nurses within the private insurance market.
Assignment Expectations
Length: 1250-1500 words in length
Structure: Include a title page and reference page in APA format. These do not count towards the minimal word amount for this assignment. Your essay must include an introduction and a conclusion.
References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of two (2) scholarly sources are required for this assignment.
Don’t let Pending Assignments Stress you. Get Expert help from Trusted Academic Professionals.
SAMPLE STUDENT ANSWER
Financing Healthcare
One of the important parts of care planning is considering the cost of care services. Access to healthcare services in the US is costly than in other developed countries, which strains the country’s economy. Most American citizens cannot sustain healthcare costs though care in the country is advanced technologically. In 2018, the cost of care in the US was about $3.8 trillion, or $11,582 per person, which is high than in other developed countries. (National Health Expenditure Accounts, 2020).
Other countries that provide expensive care services include Switzerland, France, Germany, Sweden, and Japan (Organization for Economic Cooperation and Development, 2021). In the US, care services are paid for by out-of-pocket funds, private insurance, or government programs, such as Medicaid and Medicare. The purpose of this assignment is to explore accountability in healthcare finance by discussing the history, development, and emerging trends in private healthcare insurance.
The History of Private Health Insurance and Managed Care and Its Involvement in the Healthcare Industry
Medical expenditure was low before the 1920s, and thus people did not see the need to have health insurance. People were more worried about them not going to work while sick, and thus they bought “sickness” insurance which is known as “disability” insurance, today to allow them to have income in the event they become sick (American Foundation, 1937). At the same time, commercial insurance companies were not willing to provide private health insurance due to a lack of data about the actual status of people’s health.
Between 1920-1930, the American Medical Association (AMA) brought changes that increased the cost of physician education and training, and thus the cost of care also increased. The increasing costs of care services gave rise to the introduction of private insurance. Blue Shield and Blue Cross were the first to venture into private health insurance because other commercial insurance companies were unwilling to provide the service.
Blue Shield and Blue Cross provided insurance for employed individuals. They focused on employed people because they are relatively healthy and young. After Blue Shield and Blue Cross succeeded in this endeavor, other commercial companies rapidly joined and provided private insurance. Managed healthcare developed during the increase of medical costs between 1970-1970. The delivery system was largely promoted by the passage of the Health Maintenance Organization Act of 1973. The law encouraged the growth of the first forms of managed care known as Health Maintenance Organizations (HMOs).
Managed-care plans were credited for reducing healthcare spending in the 1980s. The system is involved in healthcare by eliminating unnecessary hospitalizations, improving competitiveness and efficiency in the healthcare industry, and forcing physicians and providers to offer discount rates for their services. After enacting the HMO act, managed care has thrived and quickly became omnipresent in the US. Overall, private health insurance and managed care plans have improved the US health system by subsidizing the cost of care.
Federal Laws Protecting People Enrolled in Private Insurance
Many laws protect people enrolled in private plans to ensure that private insurance companies do not violate their customers’ rights. One of the laws is the Consolidated Omnibus Budget Reconciliation Act (COBRA). This law provides employees who have lost their health insurance and their families the right to continue with group health benefits offered by their group health plan for some time in circumstances such as job loss, job transition, death, divorce, and other events in life (Congressional Research Service, 2018). However, the law requires qualified individuals to pay their premiums.
The second law is 42 US Code § 300gg–4 – Prohibiting discrimination against individual participants and beneficiaries based on health status. The law prohibits private healthcare insurance companies providing individual or group insurance plans from developing policies for eligibility for enrollment under coverage terms based on health-related factors or status (CRS, 2018). The factors include claims experience, health status, medical problems, psychiatric and physical, medical history, receipt of healthcare, genetic data, disability, evidence of insurability, and any other factor determined by the Secretary of Health. In other words, the law protects people from facing discrimination under private health insurance.
The third law is 42 US Code § 300gg–14 – Extension of dependent coverage. This law protects people in private health insurance by requiring insurance companies offering insurance plans that cover the contributor’s children to continue covering the children until the age of 26 (CRS, 2018). This law ensures that the children of contributors are well-covered. The fourth law is the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
This federal law prevents private health insurance companies offering mental health and substance abuse benefits from giving their clients less favorable benefits than surgical or medical benefits (CMS, n.d). This law protects people with mental and substance abuse problems from being exploited by private insurers. The last law is 42 US Code § 300gg–3 – Prohibition of preexisting condition exclusions or other discrimination based on health status. This law prevents health insurers from excluding people with preexisting conditions, such as diabetes and genetic diseases, from receiving health insurance (CRS, 2018).
Consumer-Driven Healthcare and Empowerment of Healthcare Consumer
A consumer-driven health plan is a type of health insurance plan that permits employees, employers, or both parties to save pretax funds to help cover the costs of qualified medical services not included in their insurance plan (Sandoval et al., 2021). Consumer-driven healthcare can be associated with integrated health reimbursement arrangements (HRAs) and health savings accounts (HSAs), allowing contributors to set aside money to cover co-pays. Participants in consumer-driven healthcare pay less for their cover but spend more out-of-pocket than traditional insurance plans.
Participants shoulder the out-of-pocket costs using pretax funds from their HRAs or HSAs. Consumer-driven plans reduce medical costs and help participants save on premium costs (Sandoval et al., 2021). The plan also increases employee satisfaction.
Morley and Floridi (2020) note that an empowered healthcare consumer is a person who makes care decisions based on the available data and not their instinct. Empowered healthcare consumers are vital in improving the quality and safety of care. These people make informed decisions about their care and ensure that physicians provide the quality and the best care.
Healthcare professionals and providers should ensure that healthcare consumers are empowered by providing them with the necessary data to help them make informed choices. Healthcare organizations and agencies can empower consumers by availing healthcare-related data on their websites and other online platforms.
Opportunities for Nurses within the Private Insurance Market
The emergence of the private insurance market increased the scope of responsibilities for nurses. Currently, nurses can perform many roles within the private insurance sector. For instance, nurses can work as educators in private insurance companies to provide education to their contributors. As nurse educators, nurses can empower contributors about the best health practices to make informed choices. Nurses can also work as health coach consultants in private insurance companies. As health coach consultants, the nurses will work with other team members to develop and implement a campaign for their respective organizations to improve their performance.
Nurses can also work as case managers in insurance companies. As case managers, the nurses can monitor the quality of care provided by hospitals and healthcare professionals they partner with and ensure that all the care agreements are met. They also ensure that patients get the right care at the right and place. Nurses can also play policy-making roles in insurance companies. They can use their medical expertise and help in providing advice about policies that guide insurance coverage.
Conclusion
Since the introduction of private insurance programs, the cost of care has reduced significantly. Private insurance companies emerged after the 1920s to help people pay for their healthcare services. Managed-care plans also helped subsidize care services. The federal government created laws that can help protect participants from being oppressed by private insurers.
For instance, Prohibition of preexisting condition exclusions or other discrimination based on health status prevented private insurers from discriminating people from registering for their premiums based on their genetic history or preexisting conditions. The laws also ensure that private insurers pay for the services when they are required. Consumer-driven care has improved healthcare financing by allowing participants to pay for quality services that traditional insurance companies offer.
References
American Foundation. (1937). American Medicine, Volume II. The American Foundation.
Anderson, Odin W. State Enabling Legislation for Non-Profit Hospital and Medical Plans, 1944. Ann Arbor: University of Michigan Press, 1944.
Centers for Medicaid and Medicare Services. (n.d). The Mental Health Parity and Addiction Equity Act (MHPAEA). https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet
Congressional Research Service (CRS). (2018). Federal requirements on private health insurance plans. https://www.everycrsreport.com/files/20180828_R45146_1446bb744f671a2510430c244d4c1e0e33fbd18c.pdf
Morley, J., & Floridi, L. (2020). The limits of empowerment: How to reframe the role of mHealth tools in the healthcare ecosystem. Science and Engineering Ethics, 26(3), 1159-1183. https://doi.org/10.1007/s11948-019-00115-1
National Health Expenditure Accounts (NHEA). (2020). Historical. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
Organization for Economic Cooperation and Development (OECD) (2021). Health expenditure and financing. https://stats.oecd.org/Index.aspx?DataSetCode=SHA
Sandoval, J. L., Petrovic, D., Guessous, I., & Stringhini, S. (2021). Health insurance deductibles and health care–seeking behaviors in a consumer-driven health care system with universal coverage. JAMA Network Open, 4(7), e2115722-e2115722. doi:10.1001/jamanetworkopen.2021.15722
Jermaine Byrant
Nicole Johnson
OVER
RATING
YEARS
