Health Care Cost and Quality - Essay Example

Health Care Cost and Quality Introduction Achieving the best health is always a priority among individuals, and most would do almost everything to reach this goal. In the recent events of rising health care cost, individuals tend to survive despite this expense, continuously hoping to attain the highest health care quality possible. More expensive health care cost may imply that better quality follows, a common assumption regarding their relationship. In this paper, the relationship between health care cost and quality will be ventured, citing endeavors of both public and private agencies to control such cost soaring without compromising the health care quality clients receive, and presenting the role of nurses in such issue. Health Care Cost and Quality In health care, “cost” may be defined in different ways, depending on the individual’s perception. Two of these definitions are (1) when consumers and financiers pertain to the “price” of health care; and (2) when it is seen in a national perspective, referring to how much a nation spends on health care services (Shi & Singh, 2008, p. 484). Health care quality is said to be judged subjectively, according to the standards of an individual or an organization. Donabedian (n.d.) identified three determinants of the overall quality of health care: (1) structure of care, referring to the qualifications of health care providers and characteristics of facilities; (2) process of care, or the manner health care is provided; and (3) outcome of care, or effectiveness of the care provided (as cited in Wiest, 1988, p. 54). It is contended that without the existence of these three, it is not possible to achieve a high quality of health care. Relationship between Cost and Quality In health care, cost and quality possess a certain relationship, where cost does not always equate to quality (Marquis & Huston, 2009, p. 210). Considerably, O’Kane (2006) presents that “what higher spending often buys is unnecessary care, which...exposes patients to risk and wastes time, resources, and money, all of which could be put to better use” (as cited in Marquis & Huston , 2009, p. 210). In this light comes the concept of cost-effectivity, where the term “cost-effective” connotes that the product or service gained is adequate to the resources used and the finances spent. For instance, the purchase of a needed drug previously not in stock increases cost of care, but is expected to increase care quality as well. However, in the event that a wrong drug is purchased and neglectfully given, the cost increases with a lowered quality of care. Further, being cost-effective also suggests that resources are not wasted by not spending without positively affecting quality. This may be exemplified in the case where a certain diagnostic test is required to a client without specifically pertaining to his or her medical condition. Because health agencies, public and private alike, have been trying to explore on measures to control health care cost without negatively affecting its quality, the following sections will specifically point out their roles and efforts in cost containment. Public and Private Agencies: Roles and Major Activities Health care delivery in the United States is provided by two sectors: the public and private. The public sector includes the government in its three levels with its funds and organizations, while private involves for-profit businesses and non-profit organizations (Maurer & Smith, 2005, p. 59). The government, specifically on the federal level, is responsible for coming up with health policies that will be followed in the country, as well as provision of funds in the delivery of health care to the general population. It allocates resources for health care delivery through financial and technical support, with its ability to tax and spend, and mandates standards on health rights the population should receive. Medicare and Medicaid are examples of health programs facilitated by the U.S. government, providing health needs of their clients. On the other hand, private sectors are responsible for delivering the health needs of their clients who also pass certain criteria to benefit from them. This is done through insurance systems, grants, donations, or other business arrangements adapted. They may also come up with researches to improve quality of care and use them as marketing strategies (in cases of for-profit organizations) to lure more clients to purchase their health programs. The Robert Wood Johnson Foundation is an example of a non-profit sector aiming to improve the health of Americans. Medicare and Medicaid Medicare is an insurance program designed by the federal government to cover for individuals 65 years and older, individuals under 65 with certain disabilities, and those with end-stage renal disease; while Medicaid is supported by both state and federal governments, helping those with limited income and financial resources. Both have quality measures to ensure that clients receive optimum care. Medicaid has a strategy called “Payment Aligned with Quality,” aiming to move towards payments that create much stronger financial support for the patient focused, high value care, and attempting to promote reimbursement for quality, access efficiency, and successful outcomes (Centers for Medicare & Medicaid Services [CMS], 2010). There was increase in the cost provided by Medicaid as the program expanded, thus also leading to shift to managed care to control these expenses. Robert Wood Johnson Foundation The Robert Wood Johnson Foundation (RWJF) is a large non-profit organization in the U.S. that is devoted to health and health care of Americans. The organization releases grants that concern their program areas, and also focus on promoting social change. Their program areas include “Quality/Equality,” where they define “quality care” as “care that works, is safe, and is tailored to patients” (RWJF, n.d.). In an effort to gain the quality health care Americans should receive according to how much they spend, RWJF funded the Prometheus Payment, which is a system that “explicitly base payment on adherence to clinical guidelines and patient outcomes, which by necessity will require tight coordination among an entire care team” (RWJF, 2008). Analysis of Initiatives As previously cited, both public and private sectors continuously endeavor to provide quality health care as it should be, according to the price paid. The U.S. government recently enacted the Affordable Care Act, which provides more improvements to their Medicare programs this 2011. Some new benefits that would be enjoyed by Medicare clients are free annual wellness visit with a participating doctor, free critical preventive services, and 50 percent discounts for covered brand-name drugs for people with high prescription drug costs (Berwick, 2011). Previous statistics over the years have placed the U.S. as one of the countries that spend so much on healthcare but with the lowest life expectancy rates. Through this reform, may there be visible improvements on future figures. Seeing the burden of public sectors, private health agencies also do their part in reducing the county’s health cost and uplifting health quality. Methods to improve payment systems were piloted and the need to “achieve a national consensus on a single method to produce and release performance measurement information” to come up with high-quality, patient centered care (RWJF, 2009) were suggested, exemplified by the joint efforts of both sectors through the Quality Alliance Steering Committees’ (QASC) High-Value Health Care Project. However, these initiatives may be affecting the system both positively and negatively. For instance, the Affordable Care Act may be beneficial to those under Medicare, but may not hold true to those who are not under its coverage. There is also a need to review the accessibility of health care to uninsured individuals, and the development of a standardized system to be followed for health care delivery procedures. Implications for Nurses The relationship of health care cost and quality also has implications to staff and advanced-practice nurses (APNs). To illustrate, a document was released as an action plan for the state of Florida, where advanced-practice nurses may play key roles in improving access to health care and containing costs (Florida Coalition of Advanced Practice Nurses, 2008). These nurses have advanced education, adequate clinical training, possess certification, and provide care in different settings, proven to be as competent as other physicians with lesser professional fees. The document presents the extensive health crisis present in Florida, and how easily manageable cases are rushed to the emergency rooms of hospitals, which are responsible for expensive client bills. The organization, through its paper, asserts the competence of Florida’s APNs to handle certain cases, thereby giving an alternative solution to the state’s health crisis and helping clients to minimize cost without sacrificing quality. In hospital settings, staff nurses are said to play important roles in controlling health care costs, the responsibility not only given to nurse managers. Since staff nurses have the most frequent and direct patient contact, they develop cost awareness and have the ability to prevent unnecessary spending of supplies through resourcefulness and recycling. Tools for quality measures also oblige nurses to provide the highest quality of care, even in the practice of minimalized funds and resources. Wywialowski (2003) expresses that “as individuals are required to pay for more of the costs of their health care, ‘fairness of opportunity’ is becoming an accepted standard,” thereby it follows that nurses “need to become involved in organizational and clinical research” (pp. 131-132). There are several resources where nurses can gather recent updates on nursing practice, and apply them as evidenced-based practice in their institutions, with guidance from superiors and requests for training to implement such procedures. Through this, care provision will require less time, resources, and finances, with the assurance of producing quality care. Conclusion The issue of rising health care cost with a decline or without improvement in quality is debated in the United States. Cost is defined either by the price clients pay for health services or how much the country spends to provide health care to the population, and quality is determined by structure, process, and outcome of care. Although a common assumption may be an increase in cost equating to improve quality, it is not necessarily so. Instead, the concept of cost-effectivity comes in, where there is economic use of resources without compromising the quality of care patients receive. The United States health care delivery is provided by both public and private sectors, having different methods on how they contribute to the field. Medicare and Medicaid are examples of government health programs, while the Robert Wood Johnson Foundation is a non-profit organization dedicated to improve the health of Americans. Endeavors of lowering costs while increasing quality are evident in current health reforms and future plans, in the hope of improvements in the system. Nurses, despite the dominance of medicine, play important roles in cost containment and quality care, especially with the use of evidenced-based practice. Thus, it is essential for nurses to comprehend cost-quality relationships. References Berwick, D. (2011, January 20). A new year brings new improvements to Medicare in 2011. HealthCare Nortes. Retrieved from http://www.healthcare.gov/news/blog/2011medicarebenes.html Centers for Medicare & Medicaid Services (2010, December 07). Medicaid and CHIP quality practices. Retrieved from http://www.cms.gov/MedicaidCHIPQualPrac/ Florida Coalition of Advanced Practice Nurses. (2008). Advanced practice nurses: improving access to health care and containing costs. FL: Florida Coalition of Advanced Practice Nurses. Marquis, B. L., & Huston, C. J. (2009). Leadership roles and management functions in nursing: Theory and application (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Maurer, F. A., & Smith, C. M. (2005). Community/public health nursing practice: Health for families and populations (3rd ed.). St. Louis, MO: Elsevier Saunders. Robert Wood Johnson Foundation. (n.d.). The quality challenge. Retrieved from http://www.rwjf.org/qualityequality/challenge.jsp Robert Wood Johnson Foundation. (2008, May 21). Prometheus payment set to test new method of paying providers for high-quality health care. Retrieved from http://www.rwjf.org/pr/product.jsp?id=30231 Robert Wood Johnson Foundation. (2009, May). Charting the course to high-value health care. Retrieved from http://www.rwjf.org/files/research/hvhcissuebrief.pdf Shi, L., & Singh, D. A. (2008). Delivering health care in America (4th ed.). Sudbury, MA: Jones and Bartlett. Wiest, W. E. (Ed.). (1988). Health care and its costs: A challenge for the Church. Lanham, MD: University Press of America. Wywialowski, E.F. (2003). Managing client care (3rd ed.). St. Louis, MO: Elsevier Saunders. Read More