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Healthcare Insurance

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Introduction

Healthcare management, also identified as healthcare administration, is experiencing fast

growth due to the need to improve healthcare outcomes, improve service delivery, and increase

technology integration in healthcare. Healthcare management helps maintain oversight over

healthcare systems, hospitals, and public health system by ensuring the smooth operation of

healthcare departments, efficient dissemination of information, hiring qualified professionals,

efficient resource utilization, and achieve specific healthcare outcomes. Therefore, this paper

evaluates the development private health insurance plans and managed care, the government

policies that protect individuals covered by private healthcare insurance plans, the development

of consumer driven care, and the opportunities that nurses can realize from the private healthcare

industry.

Discuss the history of private health insurance and managed care and how it involved the

healthcare industry?

Managed care traces its roots back to the 19th century, the start of World War II. The first

program was the health maintenance organization (HMO), and the second was the Blue Cross

and Blue Shield (BCBS) plan. HMO combined several healthcare delivery systems and functions

of insurance, while BCBC exclusively used private practising physicians and existing hospitals.

Based in Tacoma, Washington, the Western Clinic was the first healthcare institution to offer

prepaid medical services as early as 1910 (Fox & Kongstvedt, 2018). The institution offered a

broad range of medical services to its members and charged every individual $0.50 every month.

The institution offered medical services to lumber mill owners and their employees. The program

assured clinics of a consistent flow of revenues and patients. In 1929, Michael Shadid, a

managing director, started a rural farmers' cooperative health program in Oklahoma's Elk City.
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The farmers bought shares worth $50 each, which was used to finance the development of a new

healthcare facility and to offer discounted medical care (Fox & Kongstvedt, 2018). The medical

society opposed Dr Shadid's idea. The union withdrew his membership and also threatened to

cancel his medical license. However, after 20 years, the court vindicated him allowing him to

continue offering the services. The Farmers' Union took control of the healthcare programs and

the institution in 1934. In the same year, two physicians, Clifford Loos and Donald Ross, started

a prepaid contract that provided comprehensive health coverage to over 2,000 employees

working in a local water company. Over the next years, several group health associations offered

prepaid healthcare plans to their customers, also identified as health maintenance organizations

(HMOs).

In 1973, the Nixon-led government established the Health Maintenance Organization Act

to contain the increasing cost of healthcare programs and facilitate universal healthcare plans.

The policy required healthcare service providers to establish and expand HMOs. The policy also

required employers with more than 25 employees to offer HMO to their employees by furnishing

their health insurance coverage (Fox & Kongstvedt, 2018). The policy aimed at increasing

competition between healthcare service providers by improving outpatient options compared to

hospital-based treatment. Further, the policy encouraged the development of for-profit healthcare

institutions in the not-for-profit-dominated healthcare industry. In 1972, Congress allowed

Medicare payments to healthcare institutions offering free-standing ambulatory services for

kidney dialysis. The relaxation of healthcare services encouraged physicians to open outpatient

centres and group practices specializing in rehabilitation, fitness and wellness, births, surgery,

and diagnostic imaging. Moreover, insurance plans increased from around 200 in 1983 to over

1,500 in 1991 (Fox & Kongstvedt, 2018).

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Identify the key federal laws that protect individuals who are enrolled in private insurance.

Several federal laws exist to protect patients enrolled in private insurance plans. Among

them is the healthcare quality improvement act established in 1986 that was developed to track

physicians with a recent history of adverse actions and malpractices. The law restricts such

physicians from relocating their operations to other regions, protecting other medical

practitioners and patients (Shaw et al., 2019). The physicians' malpractice is reported and

recorded in the National Practitioner Data Bank, such as their name, name of the associated

hospital, amount of malpractice payment, and description of the malpractice claim. Another law

that protects health insurance recipients is Medicare. Medicare was established in 1965 and

offered by Social Security Administration to monitor and control government funding. Medicare

incorporates a network of healthcare services and hospital insurance for American citizens over

65 years (Shaw et al., 2019). Individuals below 65 years covered by the policy include those

under Social Security benefit and those in need of kidney transplant or dialysis. Medicare

beneficiaries receive care by liaising with organizations that contract with Medicare. Medicare

does not cover all medical expenses. However, individuals can purchase additional insurance

plans to offset the differences.

Health Insurance Portability and Accountability Act (HIPPA) is another law that protects

American employees in two broad categories: Title I and Title II. According to Title I of HIPPA,

employees can change their jobs without maintaining their insurance covers. This option enables

employees to receive care even when they have pre-existing conditions (Shaw et al., 2019).

Additionally, Title I prevents new employers from developing discriminative policies that limit

employees' health benefits and allowing employees to access previously denied coverage by
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enabling them to customize their plan beyond the employer's provided cover. The Title II of

HIPPA was designed to protect electronic medical records and monitor medical health officers'

sharing and use of medical records (Shaw et al., 2019).

Briefly discuss consumer-driven healthcare and the empowerment of the healthcare

consumer.

Consumer-driven health is a healthcare practice that involves setting up health plans of

low premiums, use a savings account, and high deductions. These plans aim to reduce costs for

employers, encourage employers to make informed decisions on healthcare practice, and enrol

more employees to access insurance services (Parkinson, 2020). These health insurance plans

help employers shift part of the health costs to the employees. Tax exemptions and high

deductions on savings account mean that both employees and employers spend less money on

health services upfront. However, if the employee falls sick frequently, they would incur most of

the expenses. A plan made of lower deductibles means the employer and employees share

expenses more evenly. Consumer-driven health plans are effective as they encourage employees

to seek cost-efficient care (Parkinson, 2020). These plans require employees to effectively

differentiate between unnecessary and necessary care, challenging to most medically untrained

individuals. Effective designing, implementing, communicating, and embracing consumer-driven

care can produce positive outcomes in healthcare. Empowering healthcare consumers involves

informing and availing resources, tools, and other forms of support to healthcare consumers that

encourage transparency of information and include patients in decision-making processes

(Goldstein & Bowers, 2019). Empowering healthcare consumers promote continuous service

delivery to consumers and improves decision-making in healthcare plans.

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Explore the opportunities which have emerged for nurses within the private insurance

market.

The private insurance market has presented nurses with several opportunities. In the

current market, nurses are involved in coordinating care from different healthcare providers,

managing patients with acute care needs, and facilitating the transition of patients from hospitals

into their homes or other places. Nurses offer their services to several veteran institutions in

outpatient and inpatient settings (Fraher, Spetz, & Naylor, 2017). Nurses also work as educators

in university settings where they offer clinical assistance to nursing students. Nurses also find

roles in Geisinger Health System. The Geisinger Health System has experienced significant

change and growth over time and transformed itself into a high-cost medical institution that

ensures high-quality care to patients. Nurses are also involved in redesigning, regulating, and

supporting new policies developing skills to satisfy patient needs and improve the value of

healthcare services (Fraher, Spetz, & Naylor, 2017). Moreover, nurses are engaged in

interprofessional collaboration with physicians, social workers, medical assistants, and

pharmacists to enhance interaction with patients. The healthcare industry also provides

opportunities for nurses by using data and evidence to improve health outcomes and effective

implementation of health interventions.

Furthermore, the current healthcare system facilitates the development of policies and

their implementation. New healthcare policies enable nurses to utilize and improve their skills to

improve patient outcomes (Fraher, Spetz, & Naylor, 2017). Nurses are currently involved in

gathering and entering patient information into electrical health records (EHRs), assessing past

patient records and treatments, discussing medication alternatives, and evaluating patient social

history.
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Conclusion

In summary, the need to improve healthcare outcomes among patients and the role of

nurses in ensuring effective care delivery are mutually exclusive and dependent. Developing

healthcare requires the continuous improvement of plans and policies that promote efficient and

effective care delivery. Therefore, there is a need for more research to develop strategies that

encourage patient-centred care.

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References

Fraher, E., Spetz, J., & Naylor, M. D. (2017). Nursing in a transformed health care system: New

roles, new rules.

Fox, P. D., & Kongstvedt, P. R. (2018). A history of managed health care and health insurance in

the United States. Essentials of managed health care. Burlington, Sixth Edition: Jones &

Bartlett Learning.

Goldstein, M. M., & Bowers, D. G. (2019). The patient as a consumer: empowerment or

commodification? Currents in contemporary bioethics. The Journal of Law, Medicine &

Ethics, 43(1), 162-165.

Parkinson, M. D. (2020). Consumer-Driven Health Care Done Right: Prevention, Evidence-

Based Care, and Supportive Patient-Physician Relationships. doi:

10.1001/virtualmentor.2006.8.3.oped1-0603.

Shaw, F. E., Asomugha, C. N., Conway, P. H., & Rein, A. S. (2019). The Patient Protection and

Affordable Care Act: opportunities for prevention and public health. The

Lancet, 384(9937), 75-82.