Health Care Delivery Systems and Legislature - Coursework Example

Health Care Delivery Systems and Legislature of Your Submitted This paper examinesthe concept of managed healthcare delivery and its implications for healthcare facilities and other stakeholders in the medical industry. The study evaluates and analyses important trends in the industry and how it plays out. The research discovers that efficiency and the reduction of cost by eliminating waste influences healthcare delivery systems in managed healthcare environments. This leads to corporate governance practices, outsourcing, cost cutting and the use of efficient methods and processes. The study also identifies that the current system leads to unethical practices, profit orientation to the neglect of relevant social issues and the possibility of presenting inefficient government policies. It is therefore recommended that healthcare facilities must integrate ethical and social metrics in their practice in order to promote efficiency and results. Contents Abstract 2 Introduction 4 Managed Health Care Quality 4 Contracting and Outsourcing 5 Cost Containment 6 Medical Insurance Systems 7 Future of Government Regulations in Managed Healthcare Systems 8 Government’s Role 9 Recommendations for the Improvement of Healthcare in USA 9 Conclusion 10 Bibliography 11 Introduction Health care delivery systems have a scope that spans across a wide array of situations and matters. These healthcare delivery system and healthcare legislation are all aimed at ensuring that the health sector of a given nation meets all its needs and objectives. The purpose of this paper is to investigate the quality standards, contractual scope, financial elements and stakeholder interactions in the Managed Health Care Delivery and Healthcare Reform Act. The paper will examine the legal instruments on these matters and also critique various peer reviewed journals to identify important trends and processes relevant to the thesis statement above. Managed Health Care Quality Managed health care is a concept that is used in the United States to encompass a system of providing high quality health care, utilization of techniques that optimizes resources and ensures effectiveness and efficiency in the provision of healthcare services (Feldstein, 2009; Kongstvedt, 2007). Some authorities argue that the main essence and fundamental motive of the managed health care delivery was to redesign the healthcare system and process in order to promote cost effectiveness and enhance the quality of health care delivery (Coleman, 2009). This includes the creation of an integrated framework in which quality standards are documented and evaluated to ensure that healthcare meets its objectives and improves the quality of life of patients. In practical terms, managed health care includes the integration of qualitative measures, technical/practical healthcare measures as well as other financial metrics that come together to ensure that patients get the best and optimal services when they visit healthcare facilities in the United States (Weiner, 2011). Therefore, this model implies that every healthcare organization is redesigned and positioned in a way and manner that it can operate as a managed care organization with the right metrics and standards in order to identify inefficient diagnostic systems and unnecessary costs and eliminate them (Kongstvedt, 2007). On the other hand, the managed health care system ensures that the service provided is one that effectively diagnoses and treats issues appropriately to ensure value for money. Contracting and Outsourcing The traditional post-World War II model of healthcare involved providing services in a blanket fashion where medical facilities hired the doctors who worked for specified hours in the day. Patients paid to the coffers of the healthcare facility and the healthcare professionals received monthly salaries irrespective of the quantum of labor they gave to the medical facility. However, under the managed health care quality model, there was a tilt towards outsourcing which meant that services were to be provided directly by entities outside the medical facility (Venditti, Falcone, Corrao, Licata, & Serra, 2009). Therefore, the new model involved breaking down the work structure in order to allow external entities to provide the services at the market value when there is a need for that service (Roberts, 2011). This avoids the inefficiency and waste of keeping a unit that might not be productive or necessary. It also promoted the proper sharing of costs between medical facilities. A textbook example is the case of radiography. Most large hospitals kept radiography facilities in-house which came with high overhead costs. On the other hand, after the implementation of managed health care quality model, most firms outsourced this function. Thus, radiographers set up specialized entities that were providing services that were paid for by medical facilities as and when they were needed. This also enabled private radiographers to provide their services to different facilities that valued and paid for the worth of services they received as per the fair value. Cost Containment The centralization of the medical service industry gave rise to the integration of corporate governance methods and systems whereby the facility was managed with a good and strong profit orientation (Kutscher & Meyer, 2013).This implied that the corporate governance system had a board of directors who were given the obligation to steer and run affairs in every significant medical facility. This culminated in the creation of metrics and standards that were applied to the provision of healthcare and the management of facilities were to work within the constraints defined by the board of directors. Thus, all departments of a healthcare facility had their budgetary allocation and they had to work within that budget over a given period of time. This led to a situation where the managers of these healthcare facilities had to optimize the resources they had in order to meet budgetary constraints and also maintain high qualitative requirements as and when they needed to do so. In reaction to this trend of rigid target setting and strong supervision, most firms tilted towards a model of utilizing project management techniques and tools (Smith, 2013). The consequence of this was that it allowed all units to get the best of their limited resources by defining their constraints and completing projects within strict schedules and targets. This kept firms efficient and operational in attaining the best results. This ensures that services meet financial targets through the restraining of targets and standards. Hence, specific targets were met and results were based on the actual activities that were supposed to be completed. Most firms in the healthcare facility therefore keep lean staff structures and only pay for specific projects without having to overspend beyond specified boundaries. However, this trend has led to a situation where most medical facilities are tilting towards financial targets, rather than social targets (Bentancourt, Green, Carrillo, & Park, 2010). This includes the marginalization of certain classes of people in healthcare facilities and the exclusion of social sensitivity to these peoples. This is problematic and ought to be addressed in the face of promoting the profit motive in the healthcare industry. Medical Insurance Systems Medical insurance systems place funds into healthcare systems and processes. Due to the culture and tradition of seeking to maximize benefits from resource usage through managed healthcare quality systems, medical insurance firms systematically moved towards reducing their costs and attaining profitability. This culminated in various arrangements including the institution of measures that were meant to prevent wastage and enhance resource usage. Medical insurance firms have therefore put in place internal methods of segregating customers in order to ensure they do not lose too much money. Thus certain classes of consumers are required to pay more whilst others are required to pay less as insurance premium (Nachega, et al., 2010). It is observed from most medical insurance entities that persons with some chronic diseases like HIV/AIDS are required to take their anti-retroviral drugs as a means of reducing healthcare costs. And in most cases, these persons were given a unique health insurance cover and they had to pay more for insurance. Another approach of health insurance services includes providing incentives for their customers to reduce their risks. This encompasses various activities like exercising and the promotion of free food supplements and other preventive care situations. This is meant to ensure that policy holders of these health insurance companies reduced their risks of getting sick and by extension, preventing them from reducing the stock of premiums held by the insurance company. Government insurance entities, Medicare and Medicaid which were poorly managed turned to use various forms of segregation to ensure that health insurance activities were sustainable (Swayne, Duncan, & Ginter, 2010). This is because the requirements imposed on firms and organizations to attain profitability forced these public sector healthcare systems to expand and find ways of remaining operational without requiring subventions to survive. Thus, gradually, these government insurance entities studied the ways of breaking even and making profits from their operations and activities. Future of Government Regulations in Managed Healthcare Systems The previous system of seeing the government as a free giver of services without care is gradually fading away. This is because most government policies are to ensure that the unit or the organization that is representing the government will have to work in a way and manner that it can pay for its bills and not have to go back to the government for more money and subventions. This is due to the fact that government institutions are also given targets and standards that they ought to meet in all situations and in all instances and as such, the different managers of these public healthcare institutions will have to ensure that they do not make a loss (Kotler, 2011). ERISA’s fundamental role is to ensure that employee healthcare insurance meet their obligations by requiring the authorities running these insurance activities to carry out their fiduciary duties and ensure that they meet their reporting requirements (Rodwin, 2010). This includes the integration of medical insurance practices that ought to be put in place to ensure that they are managed well and they operate in sync with the principles of managed healthcare (Peterson, 2001). This is likely to improve and extend in future in order to promote best practices of health insurance activities. Other complementing laws including the Health Insurance Profitability and Accountability Act (HIPAA) of 1996 provides administrative standards for health insurance coverage services for employees (Lund, 2005). These rules provide the framework for regulating the electronic and traditional transactions involving employees who are given insurance on the federal level and this comes with various decisions and choices that ensure the best interest of employees and other citizens (Silberman & James, 2000). They influence and are influenced by the managed healthcare system and this promotes the best practices and best activities of health insurance entities. Government’s Role The government role in a nation like the United States is to maintain the laissez-faire system and avoid interfering excessively. The government will just allow the healthcare providers to use their efficiency-oriented systems and approaches to provide services (Lund, 2005). Government will have to continue promoting its approaches and systems in order to ensure that the current system is maintained and improved where necessary. The current trend towards a universal healthcare system is one that will extend healthcare to all and sundry. However, it is apparent that there must be some kind of care to ensure that this process and system must not tilt to become a welfare oriented system that fails to meet its standards and expectations. The universal health care system needs to be self sufficient and it must pay for itself and retain its usefulness in order to avoid becoming a burden on the state. Recommendations for the Improvement of Healthcare in USA The current system of financial focus in the managed healthcare system implies that most healthcare facilities are focusing on financial metrics and profitability. This provides the ability to meet quality and economic standards but there are many social elements that are neglected. There is the need for the current managed healthcare system to promote social sensitivity and prevent marginalization. Poorer sections of the society must be protected through various arrangements that will enable them to attain results. Profitability taking the center stage implies that most healthcare facilities will easily tilt into unethical practices. This has culminated in various challenges and difficulties. However, there is the need to integrate ethical targets in the affairs of healthcare facilities and medical insurance entities in order to ensure that they do not veer of their legal and ethical obligations in their quest to safeguard profitability. Finally, the universal healthcare act will also need to be carried out with important financial metrics in order to ensure that it does not become a drain on the economy. Efforts must be made to ensure that all necessary economic and other targets are met in order to ensure it fits into the system of managed healthcare delivery in America and not become a drain on these facilities. Conclusion Quality standards have become a practical yardstick for the delivery of high quality and efficient health care services to patients and stakeholders in America. For most healthcare facilities and related entities the profit motive leads to outsourcing and contracting. This is due to the corporate governance structures which set rigid health and financial targets for units who in turn use more efficient systems and processes like project management and cost management to ensure that the best results are attained. The government has enacted acts and reforms that ensure healthcare institutions meet high standard and expectations. However, these approaches lead to major neglects of some social classes and unethical practice. Also, the proposed universal healthcare system might end up becoming a welfare-based system that might be problematic. It is recommended that social and ethical metrics must be integrated into managed healthcare systems. Also, there must be strict management systems that will be integrated into the universal healthcare system at hand now. Bibliography Bentancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2010). Cultural Competence And Health Care Disparities: Key Perspectives And Trends. Health Affairs, 499-505. Coleman, K. (2009). Evidence On The Chronic Care Model In The New Millennium. Health Affairs, 75-85. Feldstein, P. (2009). Healthcare Economics. Mason, OH: Cengage. Kongstvedt, P. R. (2007). Essentials of managed health care. New York: Jones & Bartlett Publishers. Kotler, P. (2011). Reinventing Marketing to Manage the Environmental Imperative. . Journal of Marketing, 132-135. Kutscher, B., & Meyer, H. (2013). Rumble over jailhouse healthcare. As states broaden outsourcing to private vendors, critics question quality of care and cost savings. Modern Healthcare, 6-17. Lund, J. (2005). ERISA enforcement of the HIPAA privacy rules. . University of Chicago Law Review, 72(4), , 1413-1443. . Nachega, J. B., Leisegang, R., Bishai, D., Nguyen, H., Hislop, M., Cleary, S., . . . Maartens, G. (2010). Association of Antiretroviral Therapy Adherence and Health Care Costs. Annals of International Medicine, 18-25. Peterson, C. (2001). The evolving effect of ERISA on managed care liability. . Hospital Topics, 79(1), 5. Roberts, V. (2011). Managing strategic outsourcing in the healthcare industry. Journal Of Healthcare Management, 238-249. Rodwin, M. A. (2010). The Metamorphosis of Managed Care: Implications for Health Reform Internationally. The Journal of Law and Medical Ethics, 352-364. Silberman, P., & James, K. (2000). Managed care regulations: Impact on Quality? . Quality Management in Health Care, 8(2), 21. , 321-342. Smith, M. (2013). Extensive IT outsourcing: advice from providers. Healthcare Quarterly, 127-139. Swayne, L. E., Duncan, J., & Ginter, P. M. (2010). Strategic Management of Health Care Organizations. Hoboken, NJ: John Wiley and Sons. Venditti, M., Falcone, M., Corrao, S., Licata, G., & Serra, P. (2009). Outcomes of Patients Hospitalized With Community-Acquired, Health Care–Associated, and Hospital-Acquired Pneumonia. Annual International Medicine, 19-26. Weiner, D. E. (2011). Causes and Consequences of Chronic Kidney Disease: Implications for Managed Health Care. Journal of Managed Care Pharmacy, 121-130. Read More