The Health Care Industry: Health Law and Ethics - Essay Example

? Health Law and Ethics of HEALTH LAW AND ETHICS Introduction The health care industry, like most industries is often faced with various situations that if not addressed adequately have the potential of crippling the delivery of services. Health care fraud and abuse is one of the current health care situations that are rampant in health care (Parver and Goren, 2011). The Health Insurance Portability and Accountability Act (HIPPA) defines health care fraud as the act of willfully and knowingly executing or attempt to execute a scheme with the intention of defrauding any health care benefit program or obtaining by means of fraudulent or false pretenses, promises, or representations any of the property or money owned by a particular health care benefit program (Levinson, 2010). HIPPA defines health care abuse as an intentional practice that indirectly or directly lead to an overpayment to the provider(s) of health care. Over the years, news have been emerging regarding the health care fraud and abuse in hospitals, hospices, home health agencies, durable medical equipment suppliers,, and clinical laboratories. It is estimated that health care fraud and abuse account for between 3 to 10 percent of the United States’ annual expenditures for health care. The National Health care Anti-fraud Association Report of March 2008 projects that this estimates are bound to rise to between 3 to 15 percent if this situation is not addressed adequately (Jacobson et al, 2011). This paper will discuss health care fraud and abuse as one of the current health care situations and examine and evaluate how organizational structure and governance, culture and focus on social responsibility affected or influenced health care fraud and abuse that happened in a hospital. It will also recommend what resources will be allocated to prevent this situation in the future and what ethical issues may be tied to this decision. Finally it will recommend how one can change the structure, governance, or focus on social responsibility to prevent this situation in the future. There is consensus among the health care industry players that health care fraud and abuse is costly not only to the industry but also to the entire society. Fraud and abuse in the industry results to losses estimated to be over one hundred and fifty billion annually, a figure that shows that fraud and abuse wastes about one-tenth of the health care resources in America every year (Parver and Goren, 2011). Various studies on the health care fraud and abuse have also revealed that the impact of this situation goes beyond cost, as it also compromises the quality of health care. In addition, this situation jeopardizes the wellbeing and health of patients because it sometimes exposes them to dangerous and unnecessary procedures and tests and treatment (Welch and Guerra, 2006). A lot of factors have conspired to bring about this situation. Mainly, this situation has been attributed to inherent vulnerabilities in the United States health care industry that attract groups or individuals who may want to fraud and/ or abuse the system. Also, the historical assumption of trust in health service providers has left the system exposed to their ethical dilemmas (Levinson, 2010). An example of how health care fraud and abuse happened is where Raritan Bay Medical Center agreed to pay $7.5 million to the government to settle allegations that it had defrauded the Medicare program, intentionally inflating charges for inpatient and outpatient care, and obtained outliers payments from Medicare artificially (Parver and Goren, 2011). Organizational structure and governance, culture and focus on social responsibility influenced what happened. Organizational structure influenced health care fraud and abuse involving Raritan Bay Medical Center. The organizational structure and governance of this medical center comprises of activities such as coordination, supervision, and task allocation which are aimed towards the attainment of organizational goals and objectives. While the organizational structure and governance of this medical center is designed in such a way that it seeks to achieve organizational aims, it has inherent vulnerabilities that influenced the fraud and abuse that happened. Within the organizational structure and governance of the hospital, its directors wield immense powers that allow them to make unilateral decisions that can greatly affect the activities of the hospital. In this case, the top management of the hospital made a decision to purposely inflate inpatient and outpatient care charges with a view of artificially obtaining payments from Medicare. This situation amounts to both health care fraud and abuse because the top management willfully and knowingly attempted to defraud a health care benefit program by obtaining money owned by the program through fraudulent or false representations (Parver and Goren, 2011). Organizational culture of the hospital also influenced what happened. In general terms, organizational culture is defined as the collective behavior that is part of the members of a particular organization and is reflected in the organizational symbols, systems, visions, working language, and values among other aspects of the organization (Welch and Guerra, 2006). Organizational culture significantly affect the way individuals or group of individuals within the organization interacts with stakeholders, partners, and with clients (Levinson, 2010). Considering the circumstances that surrounded the health care fraud and abuse committed by Raritan Bay Medical Center, it can be deduced that the organizational culture of the hospital was not founded on the values of honesty and integrity. Organizational culture ought to be founded on values that do not compromise the relationship between the organization and its clients, partners, and other stakeholders. The decision by the Raritan Bay Medical Center to deliberately inflate inpatient and outpatient care charges is a reflection of its organizational culture which can be said to lack in honesty and integrity. In addition, lack of focus on the social responsibility on the part of the hospital influenced what happened. Hospitals, like many organizations are expected to fulfill their obligation of acting in ways that benefit the entire society. Raritan Bay Medical Center had a duty to perform act in ways that benefited it as well as everyone who are impacted on by its actions. It was also expected to avoid any acts that are socially harmful to the society. By purposefully inflating inpatient and outpatient care charges, the hospital lost focus of social responsibility as this act presented a potentially harmful effects to its partners and the society at large (Welch and Guerra, 2006). As a result of its acts, the government incurred losses and the quality of health care services was compromised. It is no doubt that health care fraud and abuse has devastating consequences to the entire society and to the specific clients, partners, and stakeholders. It is against this background that there have been concerted efforts by the government agencies, private health care companies and concerned individuals to address this situation to reduce and possibly eliminate losses and improve the quality of health care services (Jacobson et al, 2011). Adequate resources should be allocated to prevent this situation from occurring in the future. The resources to be allocated are those that are designed to better detect fraud and abuse in the health care sector with a view of deterring future fraud and abuse (Levinson, 2010). These resources should be allocated in the areas of training and education that is aimed at improving practitioners’ knowledge on fraud and abuse, as well as enhancing their capacity to detect and deter future fraud and abuse. Besides, resources should be allocated to the implementation of computer-aided coding (CAC) which has proved to be extremely effective in detecting fraud and abuse. Also, resources should be allocated to the increased monitoring of fraud and abuse by the federal enforcement (Welch and Guerra, 2006). Since the challenge of health care fraud and abuse is national, it is critical that the federal enforcement agencies be allocated more resources for monitoring of fraud and abuse in the health care sector. Along with that there is need for reinforcement of federal penalties in order to enhance the fight against fraud and abuse. Moreover, resources should be allocated to the use of data modeling and data mining since it has been established that fraud and abuse in the health care involves multiple actors who commit subtle acts over a relatively long duration (Jacobson et al, 2011). Since it has been established that honesty and integrity were the main ethical issues that led to the happening of this situation, they should be tied to this decision. Honesty and integrity should be tied in the decision of allocation of resources to prevent this situation from happening in the future. Similarly, these two issues should be tied in the organizational culture of the hospital. Furthermore, it has been noted that organizational structure, governance, and focus on social responsibility influenced what happened. There I would recommend some changes to these aspects of the organization to prevent this situation in the future. The organizational structure should be in such a way that it involves decision making of all employees and not simply the top management, particularly on issues of policy (Parver and Goren, 2011). The organizational culture should also be changed to reflect values of honesty and integrity. More importantly, the focus on social responsibility should be changed and focus concentrated on acts that benefit the society at large and in avoiding acts that are harmful to the society (Levinson, 2010). Conclusion It is evidently clear from the discussion that the situation of health care fraud and abuse is critical to the health care sector and the society at large. Often, this situation is influenced or affected by organizational structure and governance, culture and lack of focus on social responsibility. In order to prevent this situation in the future, it has been recommended the following resources be allocated: training and education; computer-assisted coding; fraud and abuse monitoring; and data modeling and mining. In order to make the recommendations more effective honesty and integrity should be tied to this decision. Lastly, the recommended changes to organizational structure and governance, culture and focus on social responsibility should be prevented to prevent this situation ion the future. References Jacobson, P. et al. (2011). Regulating the U.S. Health Care System: Failure in Motion. Journal of Health Politics, Policy & Law, 36(3), 583-589. Levinson, D. (2010). Health Care Fraud and Abuse Control Program: Annual Report for Fiscal Year 2009. Diane Publishing. Parver, C., & Goren, A. (2011). Significant Details from the 2010 Health Care Fraud and Abuse Control Program Report. Journal of Health Care Compliance, 13(3), 9-22. Welch, J. M., & Guerra, K. (2006). The Health Care Fraud and Abuse Control Program: 7 Billion Reasons It Works. Journal of Health Care Compliance, 8(1), 67-81. Read More