Health Insurece – Research Paper Example

American health care system is the highest rated health care provider yet most expensive system due to the system through which that care is financed. Medicare and Medicaid both are government resources which promise to provide healthcare to people by paying for their health problems. The services, coverage and eligibility of both health welfare programs are different. Managed care is the major health services program subsequent to the arrival of Medicare to reduce the cost of health care services for patients. Managed care plans are health insurance plans frequently involves unreasonable limits on visits with health care providers and medical facilities. The plans network is divided into the restrictive plans and flexible plans to decide coverage area and the amount. As per the client’s plan, the cost is more or less (U.S. National Library of Medicine, 2009). The managed care plans are mainly divided into three types: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS). HMOs shells out only for within the network, PPOs also makes part payment for outside network and POSs offers flexibility to choose between the two care plans (U.S. National Library of Medicine, 2009). The various programs included under managed care are: motivate physicians and patients to recheck the need for specific costly services, select and fix health care providers, restrain inpatient admissions and lengthy stay, control high-cost health care cases etc. (U. S. National Library of Medicine, 2009).
Gatekeeping system was eliminated by a Harvard Community Health Plan in 1998. This led to direct entry to specialists on visits to primary care physicians. It has been reported that major changes were not observed for availing specialty services by adults in the first 18 months of omission of gatekeeping system. This decision was supposed to be in patient’s and physician’s favor, and against many health plans for controlling the costs and coordinating care. The use of specialty services by commercially insured adult members of a group-model health maintenance organization were not affected by getting rid of gate keeping system (Ferris et al., 2001). The assessment of emerging healthcare technologies in terms of safety, efficacy and cost effectiveness is becoming a real challenge to adopt proper health insurance plan and reimbursement. Mental Health Parity Act and Insurance Portability and Accountability Act passed in 1996 has not addressed overall quality care and comprehensiveness of employer given insurance (
The development in health insurance plans has affected quality of care, access to care, the physician/ patient relationship, and informed patient choice. According to a preliminary evaluation of health insurance coverage in the 2008 American Community Survey it has been reported that 84.9 percent people have health insurance coverage; and 15.1% people are uninsured. Among insured people, 69.6 percent had private health insurance and 25.5 percent had public coverage (Turner, Boudreaux & Lynch, 2009). 45 million uninsured U.S. citizens are actually become high risk individuals due to absence of source of care, and delays in diagnosis and treatment. Thus lack of proper health care can lead to poor health, and might increase mortality. This might result in further diseases development such as detection of cancer in late stages.
Many proposals are on the list to cover maximum Americans and apply universal health insurance plan. Wyden and Bennett’s "Healthy Americans Act" proposal has given new direction from employer-based insurance. The government’s pay-or-play stance on employer based insurance, Medicaid expansion through the State Childrens Health Initiative, more affordable regional health insurance plans are the positive steps in the health insurance coverage reform (Dorn, 2009). The efforts are on the way to avoid disparity among disproportionately paid doctors and fragmented care by proposing combination of fee-for-service (FFS) model for physicians and bundled payment schemes that cover an entire episode of care (Dorn, 2009). For correct reimbursement of insurance plans and qualitative patient care three reorganization of health care delivery models such as Integrated Medical Groups, Patient-centered Medical Homes, and Accountable Care Organizations are also under consideration. The “individual mandate,” strategy proposed by the Clinton and the Mayo’s proposals to secure uninsured people might in the future would lead to universal health insurance plan (Manchikanti, 2008).
Healthcare system reforms are important from the point of view of solving issues related to access, cost, and quality. To tackle with the root cause of the issue, it is important to identify the fallacies in the current health care system & understand potential change initiatives. Since the cost factor is the major problem, it is necessary to emphasize preventive care, qualitative medical practice which results in positive health outcome, alteration in reimbursement system, and push coordinated and integrated systems of care (Karpf, Lofgren, & Perman, 2009). The goal of reform is to deliver efficient care with the reduced cost which is same as managed care model with limits on spending.
Dorn, Spencer D. (2009). United States Health Care Reform in 2009: A Primer for Gastroenterologists: Conclusions Clin Gastroenterol Hepatol. 2009;7(11):1168-1173
The History of Health Insurance In The United States. From:
Manchikanti, Laxmaiah (2008). Health Care Reform in the United States: Radical Surgery Needed Now More Than Ever. Pain Physician 2008; 11:13-42
Ferris, T. G., et al. (2001). Leaving Gatekeeping Behind ? Effects of Opening Access to Specialists for Adults in a Health Maintenance Organization. New England Journal of Medicine 345 (18), 1312-1317.
U.S. National Library of Medicine, last updated: 11 June 2009. Managed care
Turner, Joanna; Boudreaux, Michel; and Lynch, Victoria (2009). A Preliminary Evaluation of Health Insurance Coverage in the 2008 American Community Survey. September 22, 2009. From:
Karpf, M., Lofgren, R., & Perman, J. (2009). Commentary: Health Care Reform and Its Potential Impact on Academic Medical Centers. Academic Medicine, 84(11), 1472-1475. doi: 10.1097/ACM.0b013e3181bae9a1