Improving Health Care Access for the Uninsured and Underinsured, Essay Example

Please respond to each of the questions below.  The answers should be in your own words, however, if you quote or paraphrase others, please cite this in the body of your responses.  The exam accounts for 25 points of the possible 100 points in the course.  Grading of the test will be based on 5 points for each question.  Be sure to answer each part of each question.

Understanding the hospital/physician relationship is key to understanding how healthcare “works” in the US.  What are the factors that are driving change in the hospital/physician relationship and how is their relationship changing? 

The factors driving change are managed care, payment rates, reimbursements, supply and demand. There have been changes over the last ten years when it comes to healthcare facilities (Wakefield, 2010). It has been said that over the past ten years, nursing practices have changed from being more inclined with paper work, to now being more patient-centered. Nurses today need more education, and it is now common for a nurse to have a bachelor’s degree, a master’s degree or even a doctorate degree. The need for more qualified individuals for this position has risen along with the changes in the healthcare system (Wakefield, 2010). Other than the developments in nursing, technology within healthcare facilities have also drastically changed. The availability of point-of-care-testing is more and more available for patients. This allows patients to monitor their illnesses from home and reduce costs (Wakefield, 2010).

What is the problem with variation in care and quality in the US? What is, and can be, done to resolve the problem(s)? 

According to the Agency of Healthcare Research and Quality  website problems come about by under,  over, misuse,   or excess errors. Differences in aAccess to supplies, beds  and medical specialist  accounted for variatons by regions. The problem could be resolved by filling in the gaps of missing access. (Kovner., 421).

There is a need seen in the United States today concerning the health of the overall population. A great number of hard-working Americans are seen not well cared for by health care facilities. This is because of the growing number of the uninsured population. These people are uninsured because they can either not afford insurance, or their employers cannot afford it. Fortunately, there are new reforms in the United States in regards to health care which is aimed to help those who struggle with health care and abuses which the insurance industry brings upon them; this new reform is under the Affordable Care Act and will give Americans the benefits which they once could not afford, these rights and benefits aim to give the population more health coverage as well as access to better care, without putting a burden on them in terms of finances. The Affordable Health Care act is something which would greatly benefit America.

A certain population’s health is not only based on the strength of its health care professionals and diagnostic capabilities – to a great extent, the health of a population is shaped by factors that exist outside of its health care system, this includes the health and well-being of the underinsured (Wakefield, 2010).  Community health and its development require strong support networks and supportive social environments, education and a literate population, good working conditions, a stable physical environment and a strong culture, amongst other things.  Together, these “Social Determinants of Health” are what shape the health of a population, and people should not be segregated in categories depending on their insurance (Mahar, 2010).

According to Newport and Mendez (2009) about 17.3% of the American population does not have health insurance. The uninsured are seen in families that work. Studies show that 51% of the families have a working household head that are employed full-time and worked for a full year. These uninsured groups work in firms where insurance coverage is not available, dependant coverage is not available, insurance coverage is not available or employees coverage may be paid yet dependant coverage is too expensive (Newport & Mendes, 2009). Or, the case could be that these uninsured work in a firm which has very little employees. Small firms, which have around 3-9 employees, are seen to least likely offer insurance coverage. There are many issues when it comes to purchasing insurance for small firms. Small firm employers cannot afford comprehensive health coverage for their employees (Newport & Mendes, 2009). For those who do provide health coverage, they can only manage to pay for their employees and not their dependents. If this were the case, employees would be seen paying higher out-of-the-pocket costs for coverage and co-payments. There are no alternatives which are low-cost for dependent coverage. Most of the uninsured in the United States are those from low-income families. Surveys show that 26% of these families live below the poverty guidelines; 41% of these families earn between 100% to 250% of the Federal Poverty Level (FPL) Guidelines. All ethnic groups from the United States suffer from being uninsured. The highest rate of uninsured under an ethnic category is the Hispanic community (Newport & Mendes, 2009). In a study which observed the uninsured from adults which are aged 18 years and older, 41.5% of these uninsured people were Hispanics. 28.6% of the overall group earned less than $36,000/year.

The US , under health reform, is implementing a number of strategies related to reimbursement structures. 

The uninsured are eligible to apply for programs provided by the government to help families with healthcare costs (“The state of health insurance”, 2001). There is a program called Medi-Cal which covers low-income families; these families are the ones who generally fall under 100% of the Federal Income Guidelines. However, it is very difficult to obtain benefits as there is a lot of paperwork to be done. The good side is that there are multiple programs in which uninsured families can take part in. 14% and 40% of the uninsured adults and children are eligible for Medi-Cal yet are not enrolled (“The state of health insurance”, 2001). The Healthy Families Program is an option for low-income families, as well. This provides low cost health care for children. Healthy Families Program covers low income children until their 19^th birthdays; low income being defined as those who earn only 100%-250% of the FPL. This has minimal paperwork and is State as well as Federally subsidized. This type of program does not over-lap No-Cost Medi-Cal programs (“The state of health insurance”, 2001). However, only 70% of the uninsured who are eligible for this program are enrolled.

What is an ACO and how does it work?

An ACO is an accountable Care Organization. It is  a legal organization that with a tax id and consist of a group of participants working to ensure proper care for Medicare beneficiaries and  unitinges the whole health system. It generates efficient process while decreasing duplicate process. The overall goal is improved cost controls. Hospitals, private practices,  and specialties can participate. (Valenta 2011). An ACO is based on local accountability, shared savings, and measurement of performance.

What is value-based purchasing?  Describe how this is expected to impact the rising cost of healthcare in the US. 

This is something initially required by the Affordable Care Act and is a quality incentive program that aims to build on the quality of caring for patients. This the care that is paid for rewards better value and better patient outcomes. Because of this, healthcare is becoming more and more expensive since people would typically want to receive the best possible care available.

What is the SGR and why is it important?

The SGR is the sustainable growth rate, this is important because it is the factor that determines medical reimbursement rates for hospitals. During the last years, this has exceeded and in turn physician payments were greatly reduced. For the public, this is very important because it determines what they pay for.

What does the term “population health” mean?  How can implementation of the Chronic Care Model improve population health? 

” Population Health is the status of a category of people with respect to their well being and the determinants of that status.” (Green 736) The Chronic Care model has six components. These are Community programs, Health system, Self management support, Dekivery system design, Decision support, and Clinical information systems.(Kovner 232-234)

If you were going to design the “perfect” (or a better) healthcare system for the U.S. 

The first module would consist of preventative health, educating the population on healthy living, rewarding members for maintaining healthy lifestyles and not punisihing those who become ill despite their good efforts. Mandatory physicals each year will help catch and treat illnesses. There would be no penalties for pre-existing illneses. The conversion to ICD-10 will help narrow down diagnosis and treatments which will ensure smoother claims processing.  I would base my fundamental principle on health care prevention. Drugs and alcohol, poor diets, and sedentary lifestyles.

The Healthcare facilities do not always have the capacity to respond to an increased number of uninsured/ underinsured persons, which can happen due to an increase in persons admitted (Tanner, 2007).  There are two fronts on which response to change is possible. The main intake of uninsured patients is in the emergency rooms. The capacity of the emergency room can be increased to accommodate more patients. Currently there are five bed fast rack minor care area, this should be increased to eight beds, two full-service trauma rooms should be increased to four, two obstetrics/gynecology rooms need to be increased to four and the two cardiac treatment rooms should be increased to six. There is no need to increase the all-private room, the uninsured cannot afford them.

The other front on which the Healthcare facilities can respond is to subsidize the unpaid portion of the underinsured/uninsured patients. The two methods that can be used to subsidize are increased donations or government grants, this is what the new health care reform bill is for. The other method of mitigating risks is to introduce a system of advance payment for the underinsured. If the patients are made to pay their estimated costs in advance, the risk of loss from non-payment by underinsured is reduced.

There are many ways in which we can improve health care and make it equal for all, uninsured or not. There can be internal and external changes. Yet, when we look at the system, it all boils down to one thing – money. Because the uninsured cannot afford health care, they do not get treated, and this poses as a problem for our country’s overall health. Instead of fixing things one by one, we can tackle the overall problem seen in health care and open up the system for everyone, especially those hard-working Americans who do not have access to health care due to financial restraints. The country will definitely benefit from the Affordable Care Act, if passed.

References

Improving Health Care Access for the Uninsured and Underinsured (2004). Human Services Advisory Committee. A Report presented to the Dakota County Board of Commissioners.

The State of Health Insurance in CA: Recent Trends, Future Prospect (2001). UCLA Center for Health Policy Research.

Kaye, D.(2004), Uninsured Risks: Meeting the Special Challenges of an Organization Facing Potentially Destructive Damage, The Geneva Papers on Risk and Insurance, 29(3); p. 503-511.

Mahar, M. (2009). Counting the Uninsured. Healthbeat. Retrieved on Nov 28, 2010 from http://www.healthbeatblog.com/2009/09/counting-the-uninsured-1.html

Newport, F & Mendes, E. (2009). About One in Six U.S. Adults Are Without Health Insurance.  Gallup. Retrieved from http://www.gallup.com/poll/121820/one-six-adults-without-health- insurance.aspx

Tanner. L, (2007), “Boom Times in Denton County”,  Dallas Business Journal, Retrieved from: http://www.bizjournals.com/dallas/stories/2007/06/11/focus2.html on June 12, 2008.

Wakefield, M. (2010). Change Drivers for nursing and health care. Nursing Economics Health Publication.