The Legal and Ethical Impacts That Managed Care Practices Have on Quality and Access to Patient Care in USA - Research Paper Example

Outline 1. Abstract 2. Background 3. Definition of the problem 4. Literature review 5. Problem analysis 5.1. Cost-conscious healthcare. 5.2. Poor guidelines. 5.3. Detrimental financial incentives. 6. Possible solutions 7. Solution and implementation 8. Justification 9. Conclusion Evaluating the legal and ethical impacts that managed care practices have on quality and access to patient care in United States. 1. Abstract. This Research paper presents an evaluation of legal and ethical impacts on quality and access to patient care in managed care practices. Different scholars point at the rising cost of healthcare and cost controlled healthcare service as the problem. The problem leads to reduced access to health care and reduced quality in health care. Cost consciousness, poor guidelines and detrimental financial incentives cause the quality and access to health care to be compromised. The issues can be solved if a structure that facilitate quality healthcare and provide reasonable guidelines in managed care. The structure can be implemented with the assistance of healthcare providers who are involved in decision making. 2. Background. Managed care practices have caused legal and ethical effects that have made the quality of care and access to patient care a problem. Managed care institutions have to work within the limits of the available resources. Because the cost of health care is high, healthcare practitioners give limited health care to patients. Only the very sick and those who have great need for care are given priority. Physicians are trapped by monetary incentives that make them compromise decision making between patients’ needs and their own remuneration. There are poor guidelines that make needy patients lack access to procedures or appropriate medication for their specific medical needs. The cost of healthcare has become the motivation of the managed care practices as (Kongtvedt, 2001, p. 3) points out. 3. Definition of the problem. The problem with the managed care practices is the cost consciousness that is emphasized. The high cost in healthcare has led managed care practices to reduce the number of referrals to specialist. Less costly medication is prescribed to cut on cost. The physicians are restricted on the number of tests and procedures they can request. Cost consciousness could lead to misdiagnosis for lack of tests or inappropriate medication because of giving available less costly treatment. Cost consciousness causes the quality and access to quality care to be reduced (Patterson, 2001). This paper will answer this question: How can managed care practices improve the quality and access to patient care in managed care practices? 4. Literature review. The growth of managed care in the United States has caused various ethical concerns. The concerns emerge from the practices and policies that cause certain deficiencies. Many people lack insurance, others are partly insured while a small fraction of citizens have comprehensive insurance cover (Lynch, 1992, p. 9). The cost of health is constantly increasing and very few can be able to purchase a comprehensive insurance cover (Brett, 1999, p. 928). Cox (2010, p. 106) adds that, many citizens obtain health insurance through their employers, while others make individual arrangements with insurance firms to obtain medical insurance. The packages vary with the amount of premiums paid and the available services depending on the plans. The unemployed may end up without any insurance if they are unable to pay premiums. The heath care system has been commercialized with some healthcare practitioners encouraging consumer choice by advertising and creating competition. The poor who lack insurance or are partly insured are at risk of under treatment (Patterson, 2001). Güntert (2002) reveals that, budgetary allocation to the managed care institutions is very high, yet it cannot cover all the costs likely to be incurred. Since the funds are limited, the managed care institutions make efforts to control the costs so that they can attend to many people. Controlling the expenditure has resulted into reduced quality of care and reduced access to health care services. Managed care is a practice exercised by the healthcare system by making monetary and organizational arrangements to avail health care services. Medical practitioners and the managed care institutions obtain their payment from a third party. The plans include profit making and non- profit making institutions. The healthcare providers together with the patients ensure that there is equality in the distribution of resources. The healthcare providers are responsible for the larger part of the decision making. They modify the cost by dealing with individual cases of patients, make monetary incentives and review cases according to priority as Krumholz (2001, p. 1460) discusses. The high cost of health further causes issues of quality and access. The ethical challenge is that controlled expenditure causes the healthcare providers to limit their decision making to the available resources. The decision made may not be in line with the medical needs of the patient. Consequently, the patients trust towards the healthcare provider is compromised. The patient is not sure if the doctor will give the best treatment because of the financial control of the managed care institution. Patient’s choices may not be honored because of rationing the healthcare service. Controlled resources causes managed care practitioners to give limited priority to preventive measures. The large part of the budget is allocated to the terminally ill and the sick (Güntert, 2002). The legislative directives allow access to health care services for the majority of the citizens. The problem is that it dictates the expenditure and services that can be offered. Physicians are restricted on how much they can spend, yet the health care needs of patients cannot be predetermined. Managed care practice entails services for primary healthcare and prevention of illness development. Healthcare providers agree to get reimbursement that is low to enable many people afford medical services. The patients are only allowed to obtain specialist treatment with the approval of the primary healthcare provider. The plan limits relevant procedures that can be done and dictates specific medication that is deemed affordable for prescription. The plan tends to eliminate unnecessary costs. Consequently, the process has become deceptive and may cause harassment in the manner it is implemented. The managed care practice creates economies of scale and consciousness in decision making (Rebar, 1999, p. 923). Another impact on quality and access to patient care is the mistrust that has been created between patients and the healthcare providers. Patients believe that the fundamental duty of the healthcare providers is the wellbeing of the patient. They take an oath to protect the patient’s life. They trust that the healthcare providers will do their best to ensure that the life of the patient is no longer at risk. Managed care creates a conflict of interest; where limited finances conflict with the patient’s needs. The patient-doctor relationship and quality of care are compromised. A healthcare practitioner may withhold a certain procedure for diagnosis or a certain line of treatment which is his or her fundamental duty, because of monetary control. Failure to conduct certain procedures may result in misdiagnosis (Stotland 1999, p. 698). Lee (2000, p. 1980) mentions that, the doctor’s decision to keep a patient under primary care because of limited resources and delay referring the patient to a specialist could result in complications. The American Medical Association requires organization with managed care practices to have a structure of the medical staff similar to that of other health institutions. The structure has a governing board of three representatives who should be practicing physicians. They review the restrictions of expenditure. Then there is the medical board made up of other physicians whose main duty is to review the quality and activities of the organization. Subscribers of the managed care can voice their concerns. This includes the desire to have specific treatment availed so that patients may benefit. Medical practitioners are allowed to disclose information available treatment, procedures and if there is alternative treatment. The information is given according to specific needs of the patient. The patient is told what is offered so that they can make decisions Brett (1999, p. 929) 5. Problem analysis. 5.1. Cost-conscious healthcare. The allocated funds to the managed care dictate the kind of healthcare that will be availed. Specialists are seen only on approval. Healthcare providers who send many patients to specialist or request for many tests may end up with reduced remunerations. The managed care practice gives services within a specified area (Patterson, 2001). 5.2. Poor guidelines. Guidelines on allocation of services, procedure or medications do not balance with the needs of the patient and available resources. The guidelines may be unfair to patients who cannot get a referral and are not financially able to obtain alternative treatment. The guidelines can be modified to suit the needs of different groups of patients and ensure that the physicians are compensated for their work. 5.3. Detrimental financial incentives. Financial incentives reduce the level of care that patients could have. Doctors may end up with low remuneration if they are not careful not to exceed the number of tests or procedures that are allowed by the managed care institution. The incentives may deny a needy patient important service or medication. In most instances, a patient would not know that a necessary procedure was omitted because of limited resources unless they are told. 6. Possible solutions. The legal and ethical impact in managed care practices can see beyond the controlled costs and capitalize on giving quality treatment to patient. Quality of life, integrity, responsibility to equality and the wellbeing of the patients can be prioritized. This can be achieved by increasing the emphasis on the preventive measures. Use of updated technology and the value for humanity can be considered. Preventing measures will result in reduced number of patients. Preventive care will reduce the number of terminally ill patients (Güntert 2002). Structural change of the management may be required to increase efficiency. The motive would be to create protection of the patient to obtain required medical care. Moreover, the managed care practices should uphold the integrity of the relationship between a patient and a healthcare provider. Therefore, the healthcare provider should not be limited to controlled finances but be enabled to validate their duty to restore health. Guidelines on allocation of resources can be developed. Patients in need of certain services should not be denied the opportunity. The guidelines should ensure that patients who qualify for the allocation of certain procedure or medication are enabled. The procedures should be safe and appropriate for the patient. Therefore, the healthcare providers should be involved in the development of the guidelines. When developing the guidelines, patient’s diversity should be deliberated, so that no patient will lack healthcare. This will ensure that all groups of patients will be considered. Patients have a right to treatment. Healthcare providers can consider putting the interest of the patient before their financial remunerations. Many healthcare providers have been able to defend their duty regardless of the financial and patient needs conflict. 7. Solution and implementation. The solution for the detrimental quality and access to healthcare is to adopt a structural change that will enable the managed care institutions as well as medical practitioners be able to maintain the integrity of healthcare and castoff cost consciousness. The Structure will require the healthcare providers to offer required medical intervention on individual patients. All healthcare providers should be involved in the development of guidelines that will enable the patients benefit according to their needs. The unnecessary test can be omitted while the mandatory ones should be carried on. The guidelines should be reviewed on a regular basis so that emerging issues are dealt with. Communication between the patients and the managed care practitioners should be encouraged. Patients should be given adequate information on available resources. The managed care practitioners can seek feedback so that they are able to improve on their services and enable patients to access healthcare (Kongtvedt, 2001, p. 3). 8. Justification. Managed care practice has the responsibility of ensuring that it offers quality and accessible healthcare to patients. To be able to achieve the goal, it is necessary to come up with a structure that is capable of delivering quality healthcare. Communication and development of guidelines will enable quality work to be delivered. The physicians should be involved because they are responsible for making decisions on the line of treatment that a patient requires. 9. Conclusion. The cost of healthcare has increased and many American citizens cannot access quality healthcare because of cost consciousness, poor guidelines and financial incentives given to physicians. The law and ethics can be exercised if a good structure with considerate guidelines will be implemented. Quality of life and the wellbeing of the patients are of uttermost important. References Brett, A. S. (1999).Managed Care: Perspective from Academia. New England Journal of Medicine.25, 340, 928- 936. Cox, T. (2010). Legal and ethical implications of health care provider insurance risk assumption. Healthcare Law, Ethics and Regulation. 12, 4, 106-116. Güntert, B. (2002). Managed care: evaluation and performance measurement of integrated care systems, International Journal of Integrated Care 2,2, 1568. Kongtvedt, P. R. (2001). The Managed Health Care Handbook, Fourth Edition, United States: Aspen Publishers. Krumholz, H. M. (2001). Angiography Use in managed Care vs. Fee for service. New England Journal of Medicine.16, 343, 1460-1466. Lee, T. H. (2000). Are Managed Care patients steered to Higher-Risk Hospital for Cardiac Surgery? Journal of American Medical Association, 283, 1976-1982. Lynch, M. E. (1992) Health Insurance Terminology, Health Insurance Association of America. Patterson, D. J. (2001). Indexing Managed Care, United States: McGraw-Hill. Rebar, R. W. (1999). Managed Care Delays Surgery for Benign Gynecological Disease, Obstetrician Gynecologist 93, 922-927. Stotland, N. L. (1999) Depressed Patients Stick with managed Care plans They dislike. American Journal of Psychiatry. 156, 697-701. Read More