Health Care Financing Essay
NURS 6050 Week 3 Discussion:
Financing of Health Care
Discussion: Financing of Health Care
With coinciding concerns about health care costs and the imperative to improve quality of care, health care providers and others face difficult decisions in the effort to achieve an appropriate balance. Such decisions often are addressed in the policy arena. How do policymakers evaluate which health care services should be financed through government programs? Health Care Financing Essay How do ethics-related questions and other considerations play into this evaluation process? Is it possible to contain costs and provide accessible, high-quality care to all, or is the tension between cost and care inherent in the U.S. health care delivery system? These questions are central to health care financing decisions in the United States.
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For this NURS 6050 Week 3 Discussion: Financing of Health Care, you will focus on the policy decision-making process that determines what types of care are covered by public and private insurers and the ethical aspects of such financial decisions.
To prepare:
Read the following case study, “Hard Economic and Finance Choices in US Healthcare” (Milstead):
Case Study 1: Hard Economic and Finance Choices in US Healthcare
Applied economics is all about managing scarce resources. Economics is an amoral field of study: it is neither moral nor immoral. Morality and values are determined by individuals at the personal level and by group consensus or majority opinion at the national level. State and federal governments determine the ‘will of the people’ about how to use scarce resources for the good of a nation. Health Care Financing Essay.
The U.S. health care system is an exemplar of scarcity: primary care physicians, substance abuse treatment centers, trauma centers, registered nurses, and the money to pay for goods and services. Finance is all about how to pay for goods and services. The Medicare Payment Advisory Commission (MedPAC) is appointed by the Executive branch of the federal government to make decisions about what the Medicare program will and will not pay for. Health Care Financing Essay In this role, MedPAC makes decisions about medications, procedures and treatments. Examples of MedPAC decisions include coverage for left ventricular assistive devices as a destination therapy, coverage for bariatric surgery, and in 2010, coverage of the drug Provenge™. By law, MedPAC is not allowed to use price or cost of any treatment in its decision-making processes.
Review the information in the Washington Post article “Review of Prostate Cancer Drugs Provenge Renews Medical Cost-Benefit Debate” in the Learning Resources.
Consider how policy decisions currently are made about what will and will not be paid for and what changes, if any, could improve the process Health Care Financing Essay.
Reflect on how the Washington Post example illustrates the tension between cost and care.
By Day 3
Post your analysis and assessment of the ethical and economic challenges related to policy decisions such as those presented in the Washington Post article. How does this type of situation contribute to the tension between cost and care? Substantiate your response with at least two outside resources.
By Day 6
Respond to at least two of your colleagues on two different days in one or more of the following ways:
Ask a probing question, substantiated with additional background information, evidence, or research using an in-text citation in APA format Health Care Financing Essay.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence Health Care Financing Essay.
Discussion: Financing of Health Care References:
National Health Expenditures 2010 Highlights, Centers for Medicare & Medicaid Services (n.d.). Retrieved from https://www.cms.gov/NationalHealthExpendData/downloads/highlights.pdf.
Milstead, J. A. (2013). Health policy and politics: A nurse’s guide (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers.
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US Healthcare Policy
A healthcare policy is a set of rules and regulations that are put into effect to assist in the operation and the shape of health delivery. A healthcare policy covers a range of issue including public health, chronic illness and disability, long-term care, the financing of health care, preventive health care and mental health. There are two models of a healthcare which consist of the single payer and the social insurance system. In the single payer model, taxes are paid to the government which then pays healthcare providers such as nurses, doctors, and dentists to provide health services to individuals. Health Care Financing Essay In a social insurance system, citizens must purchase health insurance from non-profit insurance companies who will then use this health insurance to pay for services provided by healthcare providers. Healthcare is financed through private insurance companies which individuals can access through their employers and for the many Americans that are uninsured, there are three programs in which they can go through called Medicare, Medicaid, and The State Children’s Health Insurance Program. Medicare mainly deals with Americans who are over the age of 65 or disabled. Medicaid deals with people who are of low income or maybe classified as being poor. The State Children’s Health Insurance Program deals with people who are uninsured or low income children. There are so many aspects that can make up healthcare policy and there will be many more that will have an impact on healthcare in the future.
Principles of US Health Policy
There are many principal features of the United States health policy, but to name a few critical ones are: government as subsidiary to the private sector; fragmented, incremental, and piecemeal reform; pluralistic politics; the decentralized role of the states; and the impact of presidential leadership. These key characteristics of health policy work together or separately to pressure the progress and growth of health policy to benefit the country.
The United Sates is one of the few countries in the world that does have a national health care system where their government pays the majority and is the leader in the health care organization. That is not the case in the US. The private sector is the leader and the government takes a back seat in the majority of the development of health policies. It is funny that Americans prefer to have as less involvement from the government as possible in relation to health care financing, delivery, and policy. Being a capital nation we are under the notion that the private sector can best organize and operate the production and consumption of goods and services in our country rather than the government. Health Care Financing Essay.
The US health care system is fragmented so much that it is almost impossible to track. Employers provide a voluntary insurance program to their employees that are paid for through payments from employees and employers together. Then you have the elderly you are covered through Social Security tax, government subsidized voluntary insurance for physician, supplementary, and prescription drug coverage. The indigent obtain health care through Medicaid which is funded through federal, state, and local revenues. American Indians, Congress, members of the armed forces, Veterans, and the executive branch have health insurance that is financed through the federal government directly. Any type of reform in America is incremental and piecemeal especially health care. For example Medicaid has had many much needed changes since its beginning in 1965. First, Congress changed the policy to have more children become eligible and in 1984 pregnant women and children in two parent families were granted health care if income restrictions were met. Policy changes are met with an array of complex political roadblocks that make much needed reform difficult to accomplish. Often it takes a revolutionary presidential election to overcome such barriers.
As in any other policy debates in the US politics interest groups’ pluralism have an effect on the health policy. Powerful interest groups involved in health care politics adamantly resist any major change (Alford 1975). Each group deeply believes that their interests are the best and will fight very hard to protect their interest. For instance, American Association of Retired Persons (AARP) is a nonprofit, nonpartisan membership organization for American citizens over the age of 50. They are one of the most powerful lobbying groups in the United States with over 40 million members. Because they are such a well organized interest group they are very effective in influencing the decisions on policies that affect the seniors in this country. Health Care Financing Essay.
A decentralized role of the states has its pros and cons. The states provide financial support for the indigent and disabled through comprehensive health care programs. They also take on the additional responsibility of implementing the governments Medicaid and SCHIP programs for the elderly and children. On the flip side critics have suggested there is too much state control in regards to health policy changes. With each state having control over their own health policy decisions makes it extremely difficult to create a unified national health care policy.
New presidents have always been the stepping stone for policy changes in America. Every president from Johnson to Bush has made an attempt to reform health care in some shape or form. The most recent major historical change has come with the election of President Obama. He has done what no other President has done, Health Care Reform. He is putting the control of peoples’ health care needs in their own hands. President Obama’s presidential leadership impact will reform health care by making it more affordable, making insurance companies accountable for their actions, and provide coverage to all Americans.
Development of legislative health policy
“Health policy is a set course of action undertaken by governments or health care organizations to obtain a desired health outcome” (Cherry & Trotter Betts, 2005). The health care system, including the public and private segment, with the political forces influence how systems are shaped by the health care policy-making processes. Public health policies start from local, state, or federal legislation, regulations which manage the terms of health care services. There are also institutional or business policies related to health care in addition to public policies. Health Care Financing Essay In the private sector the policies are developed by hospitals, accrediting organizations, or managed care organizations. Nurses, the largest number of health care providers are the most familiar with institutional policies including those developed and implemented by the Joint Commission on Accreditation of Healthcare Organizations.
“The decision making in the public or the private sector, the scope of the issue, and the nature of the policy all have an impact on the characteristics of a policy” (Thurber,1996). A basic understanding of the policy process is the first step in having a strategy on how to encourage potential power and control important changes in the health care system. It is a process that uses multiple points of access in order to provide a vision that influences the decision makers involved at each stage. There are three stages of policy making: the formulation stage, the implementation and the evaluation stage. In the formulation stage, input of information, ideas, organizations, research from key people and interest groups are put together. The implementation stage involves disseminating the collected information and starting to put the policy into action. During this stage, “the proposed policy is transformed into a plan of action” (International Council of Nurses, 2005). Public policy endorsed by local, state, or federal governmental identities is usually put into practice through the normal process that interprets the policy into a written set of rules issued by the government agency that is responsible for overseeing the policy.
All concerned groups contribute in the development of health care policy by providing necessary information needed to decide on the implementation. Nurses are a very important part in the preparation and implementation of the policy. As the largest one group of health care providers, nurses can successfully sponsor health care policy project; they also have a distinctive point of view on health care policies and expertise to share with the responsible agents. Nurses are a strong voice and active advocated group that leads to positive change and build consensus on important issues.
“The policy process also includes an evaluation and modification phase when existing policies are revisited and may be amended or rewritten to adjust to changing circumstances” (Longest, 2006). Most major public policies are subject to modifications in this process. Smaller changes in already existing policies are usually easier to be implemented than major changes as less clarification and efforts are required to be implemented. A good example would be when the Medicare Program has undergone since its enactment in 1965. Another change is when the U.S. Congress in 1998 added nurse practitioners and clinical nurse specialists as providers that can bill for Part B services they provide to Medicare beneficiaries. Congress has changed Medicare program many times after that and put a number of preventive services to the Medicare program. The most recent change was done to Medicare Part D and added a prescription drug program available for Medicare beneficiaries. Health Care Financing Essay.
“Health care issue moves through the phases of the policy process, from a proposal to an actual program that can be enacted, implemented, and evaluated, the policy process is impacted by the preferences and influences of elected officials, other individuals, organizations, and special interest groups” (Longest, 2006). “Political interactions take place when people get involved in the process of making decisions, making compromises, and taking actions that determine who gets what in the health care system. Health Care Financing Essay. Special interest groups and individuals with a stake in the fate of a health care policy use all kinds of influencing, communication, negotiation, conflict management, critical thinking, and problem solving skills in the political arena to obtain their desired outcome” (Cherry & Trotter Betts, 2005; Kalisch & Kalisch, 1982) Health Care Financing Essay.
Health care system is continuously changing, nurses in many institutions are taking the advocacy role, working together to reflect nursing’s perception in health care policies and to be implemented. However, the legislative process needs to be well understood and policy advocates should be aware that they may run the risk of working with the wrong people or at the wrong time and therefore the policy may not be established. Well prepared professionals can always find ways to promote for a better health care system. Health Care Financing Essay For the more experienced professional there are many resources available to nurse policy advocates who want to learn more about how to make a difference in key health care issues using legislative and policy processes and working within the political arena Health Care Financing Essay.
The Future of Health Policy
The future of health policy is unknown and difficult to predict. The US has struggled with conquering the health care system as one comprehensive unit. Instead, there have been individual attempts at specific problems, resulting in fragmented solutions. The anti-socialist views of the US citizens have thus far prevented a nationalized health care system, but this has not and will not stop many influential leaders from trying. Regardless of health care being a universal or disjointed system, the future of health policy aims at containing costs, increasing access, and improving quality.
On March 2010, President Obama signed a health care reform bill. A preliminary estimate claims that the bill will reduce the deficit by $130 billion in the first ten years and by $1.2 trillion in the next ten years (Jackson & Nolen, 2010). State-based insurance exchanges will be implemented as a way to purchase insurance for those who do not have access through their employer. Health Care Financing Essay The Medicare prescription coverage “donut hole” will be closed by 2020 and seniors will receive a 50% discount on brand name medications. Medicaid will be expanded, will include childless adults, and illegal immigrants will not be eligible. Insurance companies will no longer be able to deny coverage based on preexisting conditions and children will be able to stay on their parents’ insurance plans until age 26. Beginning in 2014, there will be an individual mandate that everyone must have health insurance or have to pay a fine, with exceptions for low-income people. Health Care Financing Essay. Employers with greater than 50 employees will be required to offer health insurance. There is no telling what the ultimate success will be of this bill, as it is a continued hot debate between political parties, but it puts some definition on the future of health policy.
The role of state governments in health care has become more substantial. They hold the majority of the responsibility for regulating all aspects of the health care system. In addition, states contribute to financing Medicaid services, finance health coverage for state/public employees and retirees, and subsidize the costs of health care services for the uninsured. Health Care Financing Essay States also have the role of protecting the public’s health through controlling the spread of communicable diseases, protecting the environment, preventing injuries, promoting healthy behaviors, responding to disasters, providing health services to those without access, monitoring the population’s health status, and developing health care policies to benefit the community. The future of health policy shows that states will continue to perform these roles.
Conclusion
In closing, we feel that an issue such as healthcare must be thought through and have a decision made based on the need of the American peoples as well as the needs of the American economy. By this we mean that a decision should be developed based on a way to keep this great country from going bankrupt or prevent the American people from going broke when a plan goes into effect. In today’s world, the U.S health Care System of today is turning into a disaster because many people are getting to the point to where they are not able to afford healthcare services due to the fact that they are not able to afford it or have lost their jobs are may have partial health care benefits. We feel that all Americans must try to stand up for what they believe and fight for a healthcare policy that will enable everyone to be able to have healthcare coverage so that our government will see that there is a need for a change in the future. Health Care Financing Essay.
Resources
1. Shi, L. & Singh, D.A. (2008.) Delivering Health Care in America: A Systems Approach (4th ed.). Sudbury, MA: Jones and Bartlett Publishers
2. Jackson, J. & Nolen, J. (March 23, 2010). “Health Care Reform Bill Summary: A Look At What’s in the Bill.” cbsnews.com. Retrieved, April 20, 2010, from: http://www.cbsnews.com/8301-503544_162-20000846-503544.html.
3. Alford, R. R. 1975. Health Care Politics: Ideology and interest group barriers to reform. Chicago: University of Chicago Press.
4. S M Williams-Crowe and T V Aultman, State health agencies and the legislative policy process. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1403499/?page=1 Health Care Financing Essay
5. Pamela White, Tobie H. Olsan, Carolanne Bianchi, Theresa Glessner, Pamela Mapstone, Legislative: Searching for Health Policy Information on the Internet: An Essential Advocacy Skill. Retrieved from: http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN
NURS 6050 Week 9 Discussion:
Legal and Ethical Conduct
As emphasized in this week’s media presentation, all nurses need to be familiar with the laws and regulations that govern their practice: their state’s Nurse Practice Act, ANA’s Nursing: Scope and Standards of Practice, specialty group standards of practice, etc Health Care Financing Essay. In addition, basic ethical principles guide nurses’ decision-making process every day. ANA’s Code of Ethics and ANA’s Social Policy Statement are two important documents that outline nurses’ ethical responsibilities to their patients, themselves, and their profession. This said, there is a dilemma: The laws are not always compatible with the ethical positions nurses sometimes take. This week’s Discussion focuses on such a dilemma Health Care Financing Essay.
To prepare:
Review this week’s Learning Resources, focusing on the information in the media presentation about the relationship between the law and ethics.
Consider the ethical responsibility of nurses in ensuring patient autonomy, beneficence, non-malfeasance, and justice.
Read the following scenario:
Lena is a community health care nurse who works exclusively with HIV-positive and AIDS patients. As a part of her job, she evaluates new cases and reviews confidential information about these patients. In the course of one of these reviews, Lena learns that her sister’s boyfriend has tested HIV positive. Lena would like to protect her sister from harm and begins to consider how her sister can find out about her boyfriend’s health status Health Care Financing Essay.
Consult at least two resources to help you establish Lena’s legal and ethical position. These resources might include your state’s Nurse Practice Act, the ANA’s Code of Ethics, ANA’s Nursing: Scope and Standards of Practice, and internal or external standards of care.
Consider what action you would take if you were Lena and why.
Determine whether the law and the ANA’s standards support or conflict with that action.
By Day 3
Post a description of the actions you would take in this situation, and why. Justify these actions by referencing appropriate laws, ethical standards, and professional guidelines Health Care Financing Essay.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days in one or more of the following ways:
Ask a probing question, substantiated with additional background information, evidence, or research using an in-text citation in APA format.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Health Care Financing Essay Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence..
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Constituent parts of healthcare finance
Healthcare has been an ongoing contentious issue in recent years. Health Care Financing Essay While Obamacare definitely made stridestoward the goal of universal healthcare, the current administration seeks to derail its efforts. Medicare is the United States’ national public health insurance plan and is divided into four parts, including:
Part A, or hospital insurance
Part B, or medical insurance
Part C, or Medicare Advantage plans
Part D, or prescription drug plans (Nau, 2011)
Medicare enrollees are guaranteed coverage in these areas, while consumers are given a choice between a traditional Medicare model to cover Parts A and B, or an Advantage plan, in which they are reimbursed for receiving private coverage (Nau, 2011). Mrs. Zwick is enrolled in the traditional Medicare model which includes Parts A, B and D. As Part A covers hospital inpatient stays, Mrs. Zwick’s stay is covered by Medicare (Nau, 2011). Health Care Financing Essay.
Part A
Part A covers hospital insurance, including skilled nursing facilities with adequate technology to meets the patient’s needs. That is, however, if the patient meets predetermined criteria. These criteria include:
A minimum of three nights at the facility
The condition must be diagnosed while the patient remains in the hospitals
The patient is receiving either rehabilitative care or another condition requiring supervision
The care requires treatment from a skilled professional (Nau, 2011)
Additionally, Part A fully covers up to 20 days in a skilled care facility, and 80 percent of all subsequent days up to 100 (Nau, 2011). Therefore, Mrs. Zwick would be required to pay for 20 percent of the remaining 20 days of her inpatient visit.
Part B
Health Care Financing Essay Medicare Part B covers medical insurance expenses and provides additional coverage for services not provided in Part A. These include:
Testing,
Vaccinations
Treatments for advanced illnesses (Nau, 2011)
Depending on Ms. Zwick’s employment and marital situation, her walker would likely be covered by Part B and potentially her extended stay at the facility. Medicare Part B is also responsible for costs associated with end-of-life care that are not covered by part A (Riley & Lubitz, 2010).
Part D
Medicare Part D covers prescription drugs. Mrs. Zwick’s antibiotics would be either fully or partially covered by Medicare Part D, depending on her premium, tax status and deductible (Nau, 2011). If Mrs. Zwick is enrolled in a prescription drug plan or advantage plan that contains drug coverage, her medications would be covered by Part D. Though Part D coverage is not standardized, nearly all insurance plans cover antibiotics (Nau, 2011) Health Care Financing Essay.
Failings of Medicare
Medicare policies
could potentially affect reimbursement for the additional care Mrs. Zwick needed when she developed a hospital-acquired infection in a variety of ways. Additionally, certain ethical implications exist regarding Mrs. Zwick’s incurring the costs related to her hospital-acquired condition. Unfortunately, no one understood that Mrs. Zwick’s infection did not exist prior to her hospital visit and she was given the financial burden. As mentioned above, Medicare policy for reimbursing patients for skilled nursing facility visits allows for 20 days of full coverage, and up to 80 more days requiring a co-payment.
Ethical concerns arising from healthcare workers
Based on the information provided in the current scenario, Mrs. Zwick would be required to pay for 20 additional days in the facility. Had the nurses known Mrs. Zwick acquired the urinary tract infection during her visit, the hospital would have been obligated to pay the additional fees (Riley & Lubitz, 2010). Medicare policy mandates that no additional payment is granted to hospitals due to infections acquired during the visit (Riley & Lubitz, 2010). The ethical implications of Mrs. Zwick being given the bill are considerable, as this is an obvious breach of Medicare’s policy and one of the more dangerous aspects of American health care. The responsibility, however, lies in the hands of the nursing staff that did not carefully evaluate Mrs. Zwick upon arrival Health Care Financing Essay.
COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 was a seminal piece of legislation passed mandating that employers maintain insurance programs that continue to insure employees following termination or retirement (Truffer et al., 2010). This act has had a profound effect on the U.S. healthcare system, and has been subject to numerous provisions in its history to best meet the insurance needs of employees to cover rising healthcare costs. Fortunately for Mr. Davis, COBRA covers employees for up to 18 months following termination of employment (Truffer et al., 2010). During this time, Mr. Davis is encouraged to find other employment or additional means of covering healthcare needs. As Mr. Davis’ illness classifies as a qualifying event for continuing coverage, and his former employer had well over 20 employees, Mr. Davis is likely covered by COBRA Health Care Financing Essay.
Challenges to care providers
State and local governments face challenges in providing care for patients like Mr. Davis, who have terminal illnesses but cannot afford care. First, the cost of treating terminally ill patients is substantially higher than healthy individuals (Truffer et al., 2010). Health Care Financing Essay The additional costs of medications, testing and laboratory work, and elaborate procedures places a significant financial burden on these governments (Truffer et al., 2010).
Raising premiums
An additional challenge is that these high costs force government-regulated health insurance companies to raise premiums, making healthcare unaffordable. This ultimately hurts the government, as a greater demand is placed on public healthcare (Nau, 2011).
One step these governments could take to alleviate these problems is to consider ways to increase competition among HMOs to lower customer prices
(Truffer et al., 2010).
This would force providers to adjust costs to meet buyers’ capabilities and maintain a degree of equitability in the healthcare system Health Care Financing Essay.
Universal healthcare and finance
Mr. Davis would be better off in a universal healthcare model, such as that of Switzerland or Germany. Such a healthcare model necessitates that citizens purchase a basic health insurance plan, while federal health insurance covers costs of medical treatment and hospital visits for all insured individuals (Riley & Lubitz, 2010). Great Britain maintains a similar policy, in which the majority of healthcare expenses are publicly funded, and patients have the option of purchasing additional private insurance Health Care Financing Essay. The National Health Service (NHS) covers more than 90 percent of hospital in-patient visits, and this system consistently receives among the highest patient satisfaction ratings in the world (Riley & Lubitz, 2010).
Conclusions
Federal health insurance covers all chronic and terminal illness conditions in a universal healthcare model (Riley & Lubitz, 2010). This includes access to coverage for:
Unemployed individuals
Medications
Pre-existing medical conditions
Costs would be significantly less in Japan, as well. In this system, the government covers 70 percent of all healthcare costs, while patients are responsible for the remaining portion (Riley & Lubtiz, 2010). Health Care Financing Essay The fact that employers can contribute to the patient’s portion, the freedom to choose physicians, and the government-set healthcare fees would contribute to a more ideal situation for Mr. Davis.
References
Nau, D. P. (2011). Intersection of quality metrics and Medicare policy.
The Annals of Pharmacotherapy
, 45(12), 1582-1584.
Riley, G. F., & Lubitz, J. D. (2010). Long-term trends in Medicare payments in the last year of life.
Health Services Research
, 45(2), 565-576.
Truffer, C. J., Keehan, S., Smith, S., Cylus, J., Sisko, A. Poisal, J. A., Lizonitz, J.(2010). Health spending projections through 2019: the recession’s impact continues.
Health Affairs
, 29, 1-10 Health Care Financing Essay.
HEALTH CARE IN THE DEVELOPED WORLD
Abstract:
Developed countries face similar problems for improving the performance of their health care system. The way the financing of a health care system is organised has effects on the funding levels, the rationing mechanisms, the provision of health services and the expenditure. The first part of this Health Care Financing Essay will discuss the various methods of funding – the Beveridge system, Bismarck system and the market-oriented system.
The second part of the essay will show that the differences in the above affect the levels of efficiency, quality, and/or access to health care systems. We will illustrate this using the United Kingdom (UK) which use the Beveridge system, Germany which use the Bismarck system and the United States of America (USA) which is market-oriented Health Care Financing Essay.
Introduction
There are various approaches to funding health care in the developed world. The methods are the Beveridge model which is funded by public insurance, the Bismarck model funded by social insurance, and the market-oriented system funded private insurance. These are augmented by an increasing reliance on out-of-pocket payments which are user charges, co-payments or cost-sharing depending on the health care system.
A health care system is a framework of users, payers, providers, and regulators. The health care systems are complex and even countries which use same method of funding have different ways of application which is usually based on historical, political contexts e.t.c.
The cost of providing high quality care has been on the rise in the developed world possibly due to the ageing population, increase in life expectancy, and the development of new technology which has led to the development of highly effective drugs which not only prolong life, but also create the need for more resources to be used for treating chronic conditions Health Care Financing Essay.
Also there is an increased demand by the public on the type of treatment they get and the need to able to exercise a greater choice about the health care needed.
This means that policy makers are faced with the problems of ensuring that the resources are used as efficiently as possible in achieving maximum benefits for the population while placing importance on the issue of equitable access to health care.
Upon analysis of the three systems, we concluded that the method of funding health care systems has a large effect of their overall performance. Health Care Financing Essay.
Financing of Health Care Systems
There are three different types of methods for funding health care systems which are the Beveridge system, the Bismarck system and the market-oriented system.
1. The Beveridge System
The Beveridge system is named after Sir William Henry Beveridge who founded the British welfare state. In 1942 he presented a comprehensive report, known as the Beveridge report to the British Parliament on social policy. In the report was a proposal for the creation of a comprehensive social insurance which will include the integration of social insurance forms, creating a general health service to provide occupational accident insurance, family protection and ensure employment (Franke, 2004). Health Care Financing Essay The health system under the Beveridge model is provided and financed by the government through general taxation and many of the hospitals are publicly owned. Most doctors are employed by the government and there are also private doctors paid by the government. There is low cost per capita because the government controls the charges made by the doctors and since it is publicly owned it is more responsive to public priorities, as (Baggot, 20004) commented, since it is the government that acts as the provider and purchaser in a tax-funded system, this makes general taxation to act as a mechanism for cost containment as the providers are not able to increase revenue by raising prices or premiums as in the case of private or social insurance. The underpinning principle of this system is that all basic health care finance is covered by the general taxation so that individuals are able to have access to health care free at the point of delivery; hence (Cremer and Pestieau, 2003, p 182), concluded that the Beveridge system of social security is highly redistributive and achieves equal benefits for all Health Care Financing Essay. It can be seen that this system ensures cost control while at the same time providing equitable health for all its citizens.
Under this system individuals have access to health care not based on their income or health condition but according to need as (Donaldson and Gerard, 2005) argued, health system financed by taxation usually redistributes using two indicators of individual well being, health and income and can be more efficient than redistribution based solely on income. Unlike the market-oriented systems based solely on income and the social insurance system based on income and income. Health Care Financing Essay But this is not a guarantee because if taxation becomes less progressive, inefficiency will result. A main cause of inefficiency in this system is the issue of moral hazard which occur in any system that offer free service at the point of consumption and this has been controlled by the use of waiting lists, waiting times and general practitioner (GP) consultations as rationing mechanisms for controlling unnecessary demands. Amongst countries using tax-financed systems it is only Finland and Iceland that do not use gatekeepers. The use of gatekeepers is to control costs as (Gerdtham and Jonsson, 2000) argued, countries which use gatekeepers have a lower spending capita. Since they spend less it has been argued that the health system is under-funded which leads to rationing of care and that the quality of care is poor when compared to either social- or private-financed systems Health Care Financing Essay. The problems of the public systems are the difficulty of increasing funding to an appropriate level especially when the public sector is weak: ineffective application of rationing coupled with the difficulties in managing incentives to improve performance (McPake and Normand, 2008).
2. Bismarck System
The Bismarck system dates back to 1883 when the German Chancellor Otto von Bismarck introduced the statutory health insurance. He enacted a social legislation which was to protect workers against accidents, sickness, invalidity and old age because he had the vision that the only way to protect citizens from the catastrophic problems of ill health was if the whole community shared the risks. This gave rise to the comprehensive social insurance system with its underpinning principles based on solidarity. The health care system is funded through compulsory social insurance contributions but the taxes are specifically earmarked for health services and it is independent from the government. One distinct feature of the social insurance from the tax-based finance is that the revenue is earmarked for health and there is higher willingness to pay when use of funds are known (McPake and Normand, 2008). Therefore there could be higher spending owing to transparency, less interference and increased benefits from contributions when compared to Beveridge system. Health Care Financing Essay. This is actually the case as most countries operating this model are over-funded and there is over allocation of resource which can lead to inefficiency. The issue of moral hazard will also occur here as health care is delivered free and under this system price mechanism is used to ration care unlike the case of the public insurance which uses the GP gatekeepers e.t.c., the only country that use gatekeepers under the social health insurance is the Netherlands, though France and Germany has introduced soft GP rationing, it is not effective. Also compared with the tax-financed system, social insurance system use the contract model form where the there is separation of the purchaser and provider function where the insurers e.g. sickness funds purchase services from the providers. Under this arrangement the patients have a wider choice of providers compared to the Beveridge system, also coupled with the fact that there are rationing mechanisms like GP gatekeepers to prevent direct access to specialists’ services the quality of care are expected to be higher. Health Care Financing Essay. The quality of care will likely be the same with that in a market-oriented system. Patients usually have a wider choice of provider under the social insurance when compared with general taxation and the fact that this feature is a feature of the social insurance shows the extent to which the traditions of insurance have been retained (McPake and Normand, 2008).
A key feature of this system is that the insured makes regular contributions from their income, and the employer and employee make payments, but there are differences between countries. Individuals make contributions as a percentage of their income rather than specific health risks and are often shared by employers and employees (Blank and Burau, 2004). Since payment is not related to risks factors it can be seen that it provides redistribute policy like the Beveridge system ensuring universal coverage though it may be less � since eligibility is based on formal or informal employment it may limit the access of the unemployed. Though, the unemployed have the same entitlements as the working population and can have access to providers, thus there is solidarity which is the underpinning principle where the rich pay for the poor, the young for the elderly and employed for the unemployed. Hence there is equitable health for almost everyone v.
3. Voluntary Insurance-based health care Systems
Under the voluntary health insurance (VHI) there is no health cover provided by the State and the patients pays for all health services they receive. Reliance on private insurance place considerable emphasis on individuality and this is never complete and therefore private funding co-exists with some public funding particularly for the poor and elderly (Blank and Burau, 2004). Health Care Financing Essay. This clearly indicates that this system is complex and also inequitable as most individuals will not have access to health care because it is based on income as McPake and Normand (2000) argued, private insurance has an important role because in countries where it is applied it always co-existed with some form of compulsory arrangement for those excluded. This system operates a market based health acre whereby private insurance sell to the public at a price of the population average so that can make profits while guarding against adverse selection which common in the insurance market. “The process, whereby the best risks are selected out of the insured group, is called ‘adverse selection’” (Donaldson and Gerard, 2005), and coupled with the fact that access to health care becomes free at the point of delivery for those who have insurance leads to moral hazard and hence market failures which can lead to inefficiency. Since it is based on income and risks the health care spending is very high and there is provision of high quality care for those who can afford it. There is no gatekeeper which means that the patients also have wider range of provider when compared to the Beveridge system but this is based on income. Under this system co-payments and cost-sharing are used to control moral hazards, but noted by (McPake and Normand, 2005) insurance agencies still ration not by price but based on disease and service exclusion lists such as cosmetic surgery Health Care Financing Essay. But with these controlling costs even with public intervention is difficult. This is the case with the USA.
The funding and provision of the health care system is the same as that funded through taxation, but the contracts are not subjected to public regulation directly and therefore there is principle for providing care for everyone based on their needs. Therefore there is limited coverage always as access to basic health care needs.
A Comparison of the Three Systems
Cost containment and maximisation of health outcomes in terms of quality of care, ease and equity of access to health care have been the principal objectives of health care systems worldwide. The extent to which these objectives are achieved will determine the overall performance of a health care system. Health Care Financing Essay.
Apart from the USA which is unique and dichotomous and characterised by mixed sources of funding, which public contributes 45% and private 55%, the UK and Germany are funded through taxes though in Germany these are earmarked for health services only, while in the UK revenue from tax compete with other expenditures.
1. Efficiency
In economic terms, performance is a measure of efficiency: a health system is considered efficient if it is able to use the scarce resources at its disposal to achieve much, while it is considered inefficient when there is a waste of resources in achieving high levels of health, responsiveness and fairness (World Report, 2000). Health Care Financing Essay The USA health system is the most expensive in the world and health care expenditure as a percentage of the gross domestic product (GDP) was 16% in 2007(OECD, 2009), and funding is income-based and risk related and is said to be regressive according to the Kakwani index. The German health system is funded through SHI spends about 10.4% as a percentage of GDP (OECD, 2009) but national figures indicated a higher value at 11%, the Kakwani index is negative, therefore financing is also regressive. While according to OECD data the UK spends 8.4% as a percentage of its GDP in 2007 and funding is by general taxation which is proportionally to income, therefore the Kakwani index is positive.
However, the higher expenditure levels for the USA and Germany do not imply that there health system is more efficient than the UK, but that there is greater allocation of resources to their systems which is likely to lead in improvements to services: the earmarking funds to the health care sector only in the Germany system created a greater acceptance to any increase in premiums due to the transparent nature, while in case of the USA , it is market-based and consumers must pay to get access. In contrast, increasing taxes will tend to cause uproar as this can be done via increasing income tax rate or reducing funding to other public sectors which is politically sensitive. This is one of the reasons why user charges were introduced in the UK. This user charges also address the issue of moral hazard which is a persistent problem in publicly financed systems. To correct the problems of unnecessary use the UK system makes use of gatekeeping. This issue of moral hazard is also common to the German and USA systems and co-payments and cost-sharing have been used to deter over-use of the systems Health Care Financing Essay. The use of gatekeeping has been shown to reduce inefficient use of health resources.
The funding in the USA is based on income and risk related this leads to adverse selection which is prevalent in the UK but to a lesser extent, but apparently non-existent in Germany. Adverse selection arise as a result of asymmetric information in the insurance market, as (Donaldson and Gerard, 2005) commented, it is the process of selecting those with the best risks out of the insured group. Health Care Financing Essay. This means that a lot of individuals will be left without health insurance and cannot access health as in the case of the USA where about 46 million persons are not insured and this will introduce market inefficiencies. The first cause of this inefficiency is that the insurer sets a price that do not reflect the consumer’s marginal cost, hence the consumer feels that the amount they are prepared to pay is more than the premium set by the insurer, who cannot set prices on individual basis because of lack of signaling. Donaldson and Gerard (1993, p31) comments, “thus the market fails to transmit efficient price signals to consumers”. This will lead to a situation where the risk pool may include those with high risks and thereby causing premiums to increase and more people will drop out and finally insurance companies will then design their plan which will deter the sick and attract the healthy.
In terms of efficiency the German and the USA health systems are considered to be inefficient when compared to the UK NHS, for example in both systems there is a lot of wastage where some investigations are carried out without medical justification. Health Care Financing Essay. The NHS is under-funded so more emphasis is placed on more productive allocation and the efficient use of scarce resources. There is over-provision of funding in the German and the USA systems which results in fewer incentives to use these resources in a productive manner.
In terms of overall performance, the UK was ranked 18th, followed by Germany ranked 25th and the USA was ranked 37th in WHO ranking in 1997.
2. Quality of Care
From their expenditure the USA is expected to have high quality health care, but quality of care is difficult to measure as it involves value judgements, as Blank and Burau (2004, p 90) argued, “the main difficulty with defining quality is that we lack an objective means of measuring what quality medicine is”. Health Care Financing Essay The USA Institute defined described quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Docteur and Berenson, 2009). The USA , the quality of care is high because the patients are selected by insurers health, therefore the consumers have a wide range of providers to choose from and also access to latest advances in medical technology. They have better facilities and waiting lists are short. This definition refers to quality in terms of technical and /or clinical quality but McClellan and Kessler (1999) disagrees and argued that defining quality in terms of the number of machines, the number of specialists and the intensive medical interventions performed can be misleading. The quality of care is also better in Germany that the UK since they also have access to a wide range of providers and no waiting times, though the NHS has also moved towards the trend where patient have choice of providers but the problems of under-funding with rationing of services will lead to poor quality care
3. Access to Health Care
Access to health care can be either financial or geographical. Most countries in the developed world have restructured their health care funding to provide universal coverage for its citizens. Germany and UK whose health systems are funded by public funds guarantees universal coverage for almost everyone as Blank and Burau (2004) commented, that public funding by use of taxation or SHI contributions creates universal or near universal access to health care. The USA has an unfair system of financing which has led to majority of the population not having access to health care because they are uninsured. Except for the USA which does not have a national health system, all other countries were successful in achieving universal access despite using various means (Blank and Burau, 2004) Health Care Financing Essay.
Conclusion
In conclusion in can be seen that the method of financing health systems affects the performance of the health care system. In terms of controlling costs and affordability the Beveridge system appear to be more successful than the Bismarck and Voluntary Insurance-based systems, while these are better in terms of access to health care Health Care Financing Essay. Though comparing health system is very controversial because selecting indicators to use for comparisons. In comparing these countries we used health outcomes, health care expenditures and quality of care � where these indicators covers the most relevant aspects of health system comparison is open to future debate.
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Discussion: Financing of Health Care
With coinciding concerns about health care costs and the imperative to improve quality of care, health care providers and others face difficult decisions in the effort to achieve an appropriate balance. Such decisions often are addressed in the policy arena. How do policymakers evaluate which health care services should be financed through government programs? How do ethics-related questions and other considerations play into this evaluation process? Is it possible to contain costs and provide accessible, high-quality care to all, or is the tension between cost and care inherent in the U.S. health care delivery system? Health Care Financing Essay. These questions are central to health care financing decisions in the United States.
For this NURS 6050 Week 3 Discussion: Financing of Health Care, you will focus on the policy decision-making process that determines what types of care are covered by public and private insurers and the ethical aspects of such financial decisions.
To prepare:
Read the following case study, “Hard Economic and Finance Choices in US Healthcare” (Milstead):
Case Study 1: Hard Economic and Finance Choices in US Healthcare
Applied economics is all about managing scarce resources. Economics is an amoral field of study: it is neither moral nor immoral. Morality and values are determined by individuals at the personal level and by group consensus or majority opinion at the national level. State and federal governments determine the ‘will of the people’ about how to use scarce resources for the good of a nation Health Care Financing Essay..
The U.S. health care system is an exemplar of scarcity: primary care physicians, substance abuse treatment centers, trauma centers, registered nurses, and the money to pay for goods and services. Finance is all about how to pay for goods and services. Health Care Financing Essay. The Medicare Payment Advisory Commission (MedPAC) is appointed by the Executive branch of the federal government to make decisions about what the Medicare program will and will not pay for. In this role, MedPAC makes decisions about medications, procedures and treatments. Examples of MedPAC decisions include coverage for left ventricular assistive devices as a destination therapy, coverage for bariatric surgery, and in 2010, coverage of the drug Provenge™. By law, MedPAC is not allowed to use price or cost of any treatment in its decision-making processes.
Review the information in the Washington Post article “Review of Prostate Cancer Drugs Provenge Renews Medical Cost-Benefit Debate” in the Learning Resources.
Consider how policy decisions currently are made about what will and will not be paid for and what changes, if any, could improve the process.
Reflect on how the Washington Post example illustrates the tension between cost and care Health Care Financing Essay.
By Day 3
Post your analysis and assessment of the ethical and economic challenges related to policy decisions such as those presented in the Washington Post article. How does this type of situation contribute to the tension between cost and care? Substantiate your response with at least two outside resources.
By Day 6
Respond to at least two of your colleagues on two different days in one or more of the following ways:
Ask a probing question, substantiated with additional background information, evidence, or research using an in-text citation in APA format.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives. Health Care Financing Essay.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence Health Care Financing Essay.