Challenges to Provide Healthcare Services to the Newly Insured Population by Health Insurance Exchanges - Essay Example

Challenges in Providing Healthcare Services to the Newly Insured Population

Introduction

For more than 50 years, Americans had been struggling with a health care system that did not prioritize patients. The better part of the population was uninsured and had to pay even for merely visiting a doctor. The insured section of the population would lose their insurance at the time they needed they insurance cover the most. To many people, quality care including checkups and screenings was a luxury. Physicians focused on the quantity of care they offered rather than treating their patients effectively.

Today, the country is attaining a historic opportunity never achieved before. Some of the things that have contributed to the positive transformative changes include the Affordable Care Act, the public and private sectors working to align, initiatives towards precision medicine, and the ongoing efforts to empower the clients (Faguet, 2013).

Benefits and Limitations of Managed Health Care Organization

Benefits

A Managed Health Care Organization (MHO) employs the physicians who serve in the hospitals. They pay them on a salary basis and may accord them incentive payments and bonuses based on the productivity and performance. The MHOs employ doctors in all the common areas of specialization to cater for all the needs of their patients (Malkin, 2002). For health care services not frequently required, they enter into contracts with specialists in the society.

MHOs are such that the physicians are employees of the same organization. As such, they lock out all the community physicians who are not members. The staff in MHOs normally practice in some centralized ambulatory facilities. The facilities that are similar to outpatient clinics have ancillary support (such as radiology and laboratories) and office facilities to help them cater for the patients’ needs. They may enter into contracts with inpatient facilities and hospitals to offer non-physician services for their customers.

MHOs have a great extent of control over the physician’s activities. It becomes easier, therefore, for the organization to control and manage the use of health facilities. They provide a one-stop shopping convenience since they are a full service containing radiology, laboratory, alongside other departments.

There was a significant enrolment in the MHOs by 2015. Many people paid their premiums at the various integrated delivery systems (Preker & Carrin, 2016). There was a historic drop in the number of uninsured individuals in more than four decades after the passing of the Affordable Care Act in 2010. Over a five-year duration, more than 16.4 million people received insurance due to the integration of the healthcare systems.

The other benefit that accrued is the ability to continually fight the inequality in the health sector. There had been discrimination against African Americans, Latinos, and women in the society. More than 7.7 million uninsured women acquired cover between 2013 and 2015. As a result, slightly more than 55 million women are receiving preventive services, not from their pockets. Being a woman is no longer a barrier since there is no more discrimination based on gender.

Health care services are now affordable to a majority of Americans. As time goes, fewer Americans are still having difficulties in paying their medical debts and bills. Even fewer are now going without medication on the grounds of lack of financial capabilities. Also, due to the competition amongst the insurers, the consumers now have a wider field of choices from which to choose. In 2015 alone, there was a rise by more than 25% of the issuers. The consumers could now select from more than 40 distinct health plans. As the number of health plans rises, the more affordable the services become to the clients.

Finally, there has been a remarkable growth in the quality of healthcare services since the introduction of integrated healthcare systems. Between 2011 and 2015, patient harms such as traumas, falls, central line infections, pressure ulcers, and hospital-acquired conditions reduced by 17%. As a result, the system helped to save about 60,000 lives and more than $12 billion dollars.

Limitations

Developing and implementing MHOs is always a costly pursuit. The reason is that the employees’ salaries are extremely large. They also offer a confined field of choice from which the members should select (Freeman, 2007). Thirdly, many integrated health service delivery systems face productivity issues with their physicians. Such troubles have made them to raise the costs of providing health care. Fourthly, it is very expensive for MHOs to expand and extend their services into new regions. It becomes difficult to reach remote areas because there would be a need to come up with ambulatory health care facilities which are quite expensive.

The mechanism of sharing losses is also disadvantageous MHOs believe that not all profit-sharing members should share in losses. Particularly speaking, participants zealous to make profits may lack the capacity to partake of any possible losses. As such, losses become a burden to the few deemed financially fit to share in the losses. At times, an MHO may choose to opt to carry forward losses rather than imposing them on its members immediately, they happen. Whichever the case, the mechanism for absorbing the losses ought to be clear and undoubtable.

The physicians in an MHO are independent. This kind of independence makes them free to depart are compel for more money any time they feel like. Such circumstances make it costly to operate an MHO. Although an Integrated Delivery Systems (IDS) owns its staff (including the physicians), they also face financial challenges like MHOs. A huge diversity in IDS tends to complicate the entire management process.

Analyses of the Issues

Following the above-outlined challenges, there is a need to find lasting solutions. In the health profession, there has always been a tendency of competing factors to clash. For instance, there is a problem in the payment for autonomy and other services. The majority of health care facilities desire to offer their services at low costs no matter the quality. Most suppliers look at the volume and the protection of their intellectual property. Consumers, on their side, seek affordable and readily available services. A payer is always pursuing the right to incur low costs and reduced risks. Purchasers on their end desire high value of medication facilities at low prices.

The various stakeholders are in a zero-sum form of competition. The only means by which a payer can pay less is by negotiating with the service providers to incur a section of the cost (Tan & Payton, 2013). Alternatively, they have to force the consumers to receive a lower quality service. There is an addition of the administrative overhead since the employers work outside the direct care process. This form of external operation makes it difficult for them to improve the whole process.

The clash amongst the stakeholders brings forth several cultural hindrances to the quality of the entire heath care system. There is an improper alignment of the incentives aimed at catapulting and steering forward the delivery of the workers. The patients always pay more despite the fact that the providers tend to overuse resources yet they only end providing poor quality services. Whenever they provide the right quality of services, their payment always goes down since the quantity tends to reduce. The payment for coordinative and cognitive work is always much lower than that of the luxurious episodic and technical tasks. The CEOs in the health care have limited powers following the professional’s autonomy and the accruing competition for experienced physicians.

There is a terrible distrust amongst the stakeholders. Individuals tend to trust their individual physicians beyond those ones from the organization. They keep changing the health care plans as the government and the government and employers pursue means of controlling costs. In the US, the administrative overhead is approximately 40%. In the last few decades, the cost of technology accounted for more than a half of the entire rise in the cost. Lastly, the society seems to have compromised with the poor service delivery on a population basis. Whereas France spends about a half of the US expenditure on health care matters, the death rate amongst patients due to poor quality services is almost twice in the US.

To solve all these issues, there has to be the application of legislative changes. The existing health care culture faces discontinuous, disruptive alterations following the death of the original expert-based practices. Research reveals that a human being can handle between five and nine facts in one decision. There is a misuse of clinical care following its misuse, underuse, or overuse. In present-day medical description of phenotypes, the facts that support a decision go beyond the capacity leading to the underuse.

Low Quality and Increased Costs as the Critical Issues in IDS

Problem Definition and Introduction

For many years, the US healthcare system has been costly, fragmented, and complex, with considerable fluctuations. Many healthcare experts have been consistently for a reorganization of delivery systems and healthcare providers via a virtual integration. The integration of services seemed to be the best way to solve the quality and cost issues. However, the evidence backing the assertions is scattered and perhaps unreliable. There is an overwhelming evidence that IDSs do not provide the quality of service commensurate to the cost for their services. As such, there is a need to improve the quality will reducing the cost to include those from humble backgrounds.

Literature Review

In 2012, Academic Search Premier, Embasse Cochrane Reviews, and Medline served in performing research (Creswell, 2013). There were follow-up activities to investigate the impact of IDSs on the quality and cost. Other than IDS, the studies also investigated services such as vertical coordination, provider system integration, coordinated care, chains of care, and continuity of care. Although the literature search was not systematic, the process was similar to the peer-reviewed literature. The investigators used the internet as the search engine. They also used case studies alongside reports from different organizations. The publications cited documents and led to other studies for consideration. The search also included articles that dealt with quality and cost of integrated delivery systems. The researchers excluded all the theory-based articles, those published prior to 2000, and articles not particularly about the US health system.

The investigators found out that there were several publications on IDS. However, most of the materials focused addressed the principal requirements for successfully converting health systems to IDSs ((ASHRM), 2015). The review was interested in the papers and articles pertaining to the quality of services and the corresponding cost by IDSs. Previous reviews addressed the matters of defining and measuring the integrated healthcare service delivery.

The literature search 170 peer-reviewed articles covering the topic. The investigators excluded 80 of the articles on the grounds of the abstract and the review of the abstract. 22 articles addressed the quality issue while six of the remaining looked at the cost of the services and compared them to the quality. The last 6 publications covered the quality and cost of health services in a comprehensive manner.

On the topic of quality, the researchers established that coordination and continuity are the two critical elements of IDSs. According to most of the articles, integrated healthcare systems provide an improved quality of healthcare. Of the 22 reviews, 20 revealed improved quality over medication errors, lengths of stay, the number of patients visiting the office, and clinical effectiveness. The studies revealed that the treatment of chronic disorders is much better in IDS than in non-IDS setups.

However, the study found out that the rise in costs is not proportional to the rise in the quality of service delivery. Some studies had it that the rate of rise in the overall cost of services was almost five-fold the improvement in the quality of service delivered. This finding compelled another study to find out the way out on reducing the costs while not interfering with the quality of services delivered. The investigators weighed all the possibilities and agreed that it is through legislation that we can achieve the quality and cost goals.

Possible Solutions and Implementation Plan

The researchers proposed that the best approach to improve the quality and keep the prices low was via legislation. The civil society and any other concerned group can consider coming up with a bill that would inhibit the MHOs and IDSs from charging expensively. In so doing, the healthcare services would become readily available even for those from humble backgrounds. Secondly, both the central and county governments can help in subsidizing the cost of service delivery. The subsidized costs would imply that the IDSs do not strain to provide their services. As such, they would not have the excuse that they are unable to offer the best quality because of insufficiency of finances. Finally, the national government can also establish an IDS as a benchmark for others to follow. The IDS by the government should set high standards of quality to inspire others to do the same.

Conclusion

Managed healthcare refers to the various techniques aiming at improving the quality while reducing the cost of healthcare services in the United States. They aim at reducing the costs through approaches such as increased cost sharing, reviewing the necessity of some medical services, incentives to patients and physicians to choose cheaper services, controlling the rate of patient admission and subsequent length of the facility, and some cost-sharing incentives for surgeries. The principal issue in managed healthcare is that the rise in the quality is not commensurate to the corresponding rise in the cost. This study recommends that through legislation, the government can compel IDS to improve their services even further, while reducing the cost. Therefore, cost and quality remain to be the two principal challenges in providing healthcare services to the newly insured population.