Week 5 Discussion Post 1 Document

What is the government's role in healthcare? How does the government impact healthcare

organizations?



Thereareseveralrolesforthegovernmentinhealthcare.AsthelargestinsurerwithintheAmerican

Healthcaresystemthegovernmenttodayisasignificantpayerwithinhealthcare,providingaccessto

healthcareforthoseonthemargins,especiallythepoorandtheelderlythroughMedicaidand

Medicarerespectively.Sincetheestablishmentoftheseprogramsinthe1960stheUSgovernment

hascontinuedtodramaticallyexpanditsroleandaccountsfor45.2%ofhealthcarepaymentsasof

2016(Johnson&Waltson,2021).Thegovernmentplaysaroleinhealthcareasasignificantinsurer

withinhealthcare,helpingtoestablishstandardsandregulationsforcareinordertobenefitpatients

andthecommunitiesserved,andincentivizinghealthcaresystemstoreducecostsandadapttonew

technologiesandinnovations.



Aspartofthissystemthegovernmenthasaroleinregulatingandshapinghowhealthcareis

deliveredandreportedinhospitalsthatparticipateingovernmentinsurancereimbursement

programs.Boththeseprogramsgavethegovernmentasignificantopportunitythroughitsroleasa

financerofhealthcaretodemandgreatertransparencywithinhealthcareandbeginnegotiating

costswithinhealthcare.Aspartofthistheybegantolimitreimbursementforparticularprocedures

andhaveincreasinglypassedregulationtoimprovethequalityofcareandensurethatfraudand

wasteareminimizedwithinhealthcare(Oliver,2014).Thismovementtowardqualityhasledthe

governmenttoincentivizeorganizationstoembracenewtechnologieslikeelectronicmedicalrecord

systemswiththeintentionofincreasingtransparencywithinhealthcare,promotingbestpractices,

andensuringthatprovidersareforthrightandtruthfulaboutthecaretheydoprovide(Bowie,

2014).



How does health insurance impact healthcare delivery?



WithintheUnitedStates,healthcarehasbecomeanincreasinglycomplexendeavor.Overtheyears

theintegrationoftechnologyandtheprofessionalizationofcarepracticeshaveincreasedthecost

associatedwithhealthcareandhasnecessitatedtheneedofacomplexpayersystemthatisreliant

onhealthinsuranceformostindividualstomeetmostofthecostofexpensivetreatmentsandcare.

WhilethegovernmenthasincreasinglybroadenedwhomeetsthequalificationsforMedicaidand

Medicaregovernmenthealthinsuranceplans,thereisawidearrangementofemployersponsored

healthcareplansthataremanagedbyprivatebusinessesandagencieswhoviewhealthinsuranceas

anadditionalbenefitandincentivefortheirworkforce(Johnson&Waltson,2021).Healthinsurance

agencieshavenecessitatedtheneedforrobustreportingandbillingstructureswithinhealthcare

systemstohelpjustifyreimbursementforcareandcoverageprovided.Thishasexpandedthe

amountofadministrativeFTEsthatareneededwithinhealthcareinordertodevelopedreportout

thisinformation(Bowie,2014).



Duetotheincreasingcostsassociatedwithcare,healthcareinsuranceagencieshavebegunworking

withhealthcaresystemstoexplorenewarrangementsforpaymentmodelsforcareprovided,inan

efforttoincreasethequalityandreducetheofcare.Traditionalpaymentmodelshaveoften

providedreimbursementforcarebasedonafeeforservicemodel,wherethehealthsystemswere

reimbursedforthequantityofcareprovided.MedicareandMedicaidhassoughttoreducecosts

andincentivizehealthcareagenciestodevelopandadaptbestpracticesthatreducelengthofstays

andpossiblyrewardhighperformingsystemswithabundledpaymentmodel.Inthismodel

healthcaresystemsarereimbursedasetamountforaprocedure(suchasakneereplacement)

basedonnationalaverages(Johnson&Waltson,2021).Thegoalofthistypeofpaymentmodelis

toencouragehealthsystemstoreducetheamountofspendtheyneedforproceduresandeliminate

theincentiveforunnecessarychargeslikeadditionaltesting,etc.Healthsystemsarealso

incentivizedtomakesurethecareprovidedmeetstheneedsofthepatientanddoesnotleadto

readmissionsasthewholebundledcostofcareincludes30daysfollowingtheprocedure.Thisis

oneexampleofhowhealthinsurancecompaniesareattemptingtoinfluencethedeliveryofcare

andreducecostsassociatedwithhealthcare.



How can we reduce the number of uninsured people while maximizing quality and access and

minimizing costs?



Reducingthenumberofuninsuredpeopleissomethingthatisimportantforthecontinued

functioningandsustainabilityoftheAmericanhealthcaresystem.Whenanuninsuredindividual

comestoouremergencyroomsandhospitalsthecostofthatcare,especiallyforemergentand

necessaryprocedures,willbeabsorbedbythehospitalorhealthcareentitywithwhichthepatient

goes.Afewcaseshereandthereareabsorbablebyhealthcaresystems,butbecomesincreasingly

lesssustainablethemorethisexperiencehappens.Asanexample,sincethepassingofEMTALA

within1990through2016,hospitalshaveprovidednearly$576billionofuncompensatedcarethat

theyhavebeenlegallyrequiredto(Weismann&Jorge,2019).



ThegoaloftheAffordableCareActwastoattempttoreducethenumberofuninsuredfolksby

creatingahealthcaremandate,andattemptingtoprovidegreatergovernmentsubsidiestomake

insurancemoreaffordableforfolksorfreeforthoseonthemargins.Accordingtoastudydoneby

FerreiraandGomesin2017,thebestwaytoreducethenumberofuninsuredisthroughworkingto

continuetoprovidelowcostorfreehealthinsurancetotheuninsured.Whilealotofeffortshave

focusedonreducingthecostofhealthcare,therealityisthatreducingthecostofhealthcarehasa

broadbenefitforallacrosstheboardintermsofhealthcoverage,butdoesnotfocusandutilize

fundstoprovidemaximumcoverageandsupportforthosewhoareuninsured(Ferreira&Gomes,

2017).



Thus,itwouldappearthatmovingtowardasabasicminimumsomeformofgovernmentinsurance

forallfolksisthemosteffectivewayforreducingthenumberofuninsured.Aswehaveseen

throughthehistoryofgovernmentinvolvementinhealthcare,thegreatertheirroleasafinancial

providerwithinhealthcare,thegreatertheopportunitytoinfluenceandregulatequalityand

increaseaccesstothoseonthemargins.Whileattimesthismayappeartobeinefficient,thecostof

thecarefortheuninsuredarebornbythecommunitiesandhealthcareentitiesthatservethe

uninsuredandovertimehaveledtotheclosureandreductionofaccesstocareforcommunities.

ThistypeofproposaltowardhavingatleastabasicuniversalhealthcareplanthroughouttheUnited

Statesisonethatisdivisiveamongthegeneralpopulation(Weismann&Jorge,2019).



References:

Bowie,M.J.(2018).EssentialsofHealthInformationManagement:PrinciplesandPractices(4thed.).

CengageLearning

Ferreira,P.C.,&Gomes,D.B.P.(2017).Healthcarereformormoreaffordablehealthcare?Journal

of Economic Dynamics and Control,79,126–

153.https://doi-org.ezproxy.snhu.edu/10.1016/j.jedc.2017.03.011



Johnson,K.&Waltson,S.(2021).Healthcare in the United States: Clinical, Financial, and Operational

Dimensions.HealthAdministrationPress.



Oliver,T.(2014).Guide to U.S. Health and Health Care Policy.CQPress.

Weismann,M.F.,&Jorge,I.(2019).TheRegulatoryVisionofUniversalHealthcareintheUnited

States:Strategic,Economic,andMoralDecision-Making.University of Pennsylvania Journal of

Business Law,21(3),647–705.

Students also viewed