Financing Healthcare
Introduction
The modern health insurance began as hospital insurance during the Great Depression, when increased cost of hospitalization posed a threat to the economic progress of both hospitals and individuals. Hospital insurance was supported by the American Hospital Association. The association also aided in mobilization and organization of hospital plans into the Blue Cross Network.
History of Private Health Insurance and Managed Care
In the United States, private health insurance, which was initially referred to as voluntary health insurance, started to spread and evolve in the 1920s. It resulted in discussions in Congress regarding the reforms required to meet the needs of the elderly, the poor, the underserved (Shmueli et al., 2016). During the era of the Second World War, health insurance was employer-based. As a result of the freezing of wages, the loss of salary increases was compensated by health insurance Managed care and its roots in the twentieth century. During this period, lumber, mining, and railroad companies arranged for their medical services or approached medical groups, with whom they signed contracts, to offer care to their employees. In the 1980s, most employees opted for managed care to manage the increasing cost of offering employees benefits of health care. In the 1990s, there was a huge increase in the enrollments of managed care. Currently, the majority of the Americans who are privately insured, and those who have government-sponsored insurances, such as Medicaid and Medicare programs, are protected by a particular form of managed care (Shmueli et al., 2016). Various managed care plans are currently being applied. They include health maintenance organization, preferred provider organization, point of sale service plan, and exclusive provider organizations
Protection of the Privately Insured
Specific federal laws protect those who have private insurers. The Affordable Care Act is one of those legislations. AC uses various techniques, including subsidies, mandates, and insurance exchanges, to ensure that healthcare services are available at affordable costs. It ensures that employees of firms are covered for other comorbidities that they have regardless of their gender. Another federal law is the Consolidated Omnibus Budget Reconciliation Act (COBRA). This law offers continuous medical coverage with the aim of offering financial security to those who are prone to losing their insurance due to job loss.
Moreover, it can cover for the spouses and also children. Another legislation is the Hospital Readmissions Reduction Program (HRRP). This law has aided in the reduction of the readmissions of the insured through the improvement of the quality of healthcare being offered by the providers of healthcare and the reduction of costs of treatment. This law achieves through penalizing those health care facilities that display high levels of readmission of patients.
Consumer-Driven Healthcare
Consumer-driven healthcare is a care plan whereby the patients manage their health care rather than ceding control to other parties involved. Through this plan, patients are empowered to express their preferences and priorities and to determine trade-offs between other functions of their money and health care rather than letting other people make these choices for them (Fine et al., 2016). In consumer-driven healthcare, the policyholders possess personal health accounts which they use to pay for their expenses directly. Examples of such accounts include health reimbursement arrangement (HRA) or health saving account (HSA). In this system, people choose their health insurance programs and can tag them along as they change their jobs from one location to another. For this system, the amount that the employer uses in health insurance does not belong to the organization but rather the employee (Fine et al., 2016). If an employee is not contented or impressed with the health plan of the company, the employees can redirect those funds to buy their insurance.
Consumerism has impacted the view of healthcare consumers regarding approach in the care of patients and payment of the offered services. Unlike in the past, through this approach, patients are determined to be actively involved in their care process, unlike when they were passive. The consumer-driven approach has impacted the health care system significantly (Fine et al., 2016). There is a rise in the number of retail clinics, concierge medicine, the use of generic drugs, hospitals owned by specialist physicians, and a reduction of the usage of beds in the emergency departments.
Though this approach has many advantages, some demerits have also been linked to it. Health consumers are now facing more out-of-pocket costs before the insurers kick in to share the costs. Tools that aid patients in determining costs, clinical quality, and patient satisfaction, which ultimately influence the health care facilities they choose, are not available. Thus most patients do not make medically-based decisions since they believe other insurance plans linked with established and well-equipped facilities are aimed at increasing the pay of physicians and not offering the desired quality of insurance benefits.
Nursing Opportunities
Hospitals and health care facilities that have subscribed to private insurers are offering some patients home-based care, especially those with chronic diseases. This creates a niche for the nurses since they are involved in providing home-based care, especially the family nurse practitioners. Moreover, these facilities strive to offer quality healthcare services to invite more clients. Thus, nurses are needed in various departments, including the emergency department, theatre department, and acute care department (Fine et al., 2016). Nurses can also work in the facilities in departments dealing with payments and insurance. They are vital in advising patients on the benefits of them subscribing to their insurance plans and the health care service they are likely to join. Opportunities are also created for specialist nurses in the private insurance system. Most of the private insurers target the developing hospitals to increase market them and even expand their outreach. For such facilities to attract patients through the provision of quality health, nurses who have specialized in the various departments are employed, thus creating opportunities for the nurses.
Some of the hospitals where private insurance is used have medical equipment and facilities that nurses are conversant with (Shmueli et al., 2016). Moreover, some of these facilities require personnel to carry out various laboratory tests for their patients. This creates a need for nurses since there are professionally certified to perform those functions. Nurses also have opportunities for nurse educators in the private insurance system. Most of the patients using insurance are those having chronic illnesses and are on life-long medications. These patients are at a high rate of developing complications. Thus nurses educate them on the various mechanisms of coping with the diseases such as lifestyle modifications and advise them on the different insurance plans they should subscribe to receive quality healthcare
Conclusion
Health is a vital aspect of life. One of the challenges that Americans face is accessing quality health care and being able to pay for the costs related to healthcare. The managed care approach was incorporated to ensure that the healthcare costs are reduced, and the quality provided has increased. There are federal laws that have been put in place to ensure those insured by the government and private insurers are also protected. Over the years, the insurance approach has changed to a consumer system. Consumers of healthcare are now being involved in making decisions regarding the payment plan for the care they are receiving. This consumer-driven approach has its advantages and disadvantages. The growth of private insurance has created many opportunities for nurses. Nurses are now working as nurse educators, nurse collaborators research, nurses, and acute care nurses in the various institutions using private insurance. Nurses are expected to work with other professionals in healthcare as a team to improve patient outcomes.
References
Fine, R. L., Yang, Z., Spivey, C., Boardman, B., & Courtney, M. (2016, July). Early experience with digital advance care planning and directives, a novel consumer-driven program. In Baylor University Medical Center Proceedings (Vol. 29, No. 3, pp. 263-267). Taylor & Francis.
Shmueli, A., Stam, P., Wasem, J., & Trottmann, M. (2015). Managed care in four managed competition OECD health systems. Health Policy, 119(7), 860-873.