Discussion 4

Discussion 4

I have to respond to the following statements of my classmates. Please provide 150-200 words to each statement with a reference to each if applicable.


Re: Discussion Starter

posted by CALEB SCHULTZ at Feb 04, 2015, 2:51 PM

Last updated Feb 04, 2015, 2:51 PM 


There are typically three type of sources, they are private insurance, Medicaid, and Medicare. In all reality as it should not affect the type of care delivered, it does. Also I think depending on the type of insurance a person has highly depends on the type of tests or health care that is given. There are multiple reasons I believe this and they are one, some insurance’s will not cover certain tests or procedures two, depending on which type of organization and setting physicians will not order or attempt to provide particular services because they know they will not get reimbursed for it and three, HMO, POS, or Medicaid insurances require authorizations and this typically prolongs treatment and or services. Also this can cause denials of payments and coverage on millions of dollars a year. To not say that the type of insurance changes the type of treatment patients receive would be naive. It is a direct correlation to how an organization is paid and thus how they provide treatment. Previous discussion I have mentioned PA’s and NP’s as providers in some emergency rooms and this is cost saving technique however in all honesty they are not physicians and does that mean the patients are not getting the care they should? Or how about when a PA cannot perform a specific technique and has to await for a physician to do procedure or help assist prolonging care…that affects delivery of care too…Just food for thought?


Re: Discussion Starter

posted by WANDA LANE at Feb 03, 2015, 9:41 PM

Last updated Feb 03, 2015, 9:41 PM 


Private insurance, Medicaid, and Medicare are three sources of financing for a health care organization.  Private insurance is voluntary and usually offered by the insureds employer.  Medicare is offered by the federal government to those 65 and older, in end-stage renal failure, or the disabled.  Medicaid is overseen by states and is designed to assist those in lower income brackets.

In a 2001 survey by presented in the journal Health Affairs of randomly selected telephone subscribers, it was determined that  “Medicare beneficiaries are generally more satisfied with their health care than are persons under age sixty-five who are covered by private insurance” (Davis, Schoen, Doty, & Tenney, 2003).  Those surveyed report “fewer problems getting access to care, greater confidence about their access, and fewer instances of financial hardship as a result of medical bills” (Davis, Schoen, Doty, & Tenney, 2003).

I know from personal experience that private insurance is more costly than Medicaid.  When my children and I were enrolled in TennCare (Tennessee’s version of Medicaid), I had no copays, no deductibles, and no out-of-pocket expenses.  When I was able to purchase insurance through my employer, I had all of those costs, and it was quite a shock to my pocketbook.  With TennCare, I had fewer choices of providers, but the costs savings far outweighed the limited access.  I felt it was important to not rely on the government, but when I receive the bills for deductibles and copays I wonder if it was worth the switch to private insurance.

As someone who wants to be a manager in a health care organization, it is necessary that I understand the nuances of all types of financing.  In addition, I must determine what is best for my clients as well as for my employees.


Re: Discussion Starter

posted by Debbie McKeever at Feb 04, 2015, 4:35 PM

Last updated Feb 04, 2015, 4:35 PM 


The three sources of financing for a health care organization are private insurance, Medicaid, and Medicare. Private insurance includes a variety of health plans, such as group insurance, self-insurance, managed care plans, individual private health insurance, etc. Each type of financing can affect how health care organizations deliver care mainly based on the reimbursement for care. According to Shi & Singh (2012), “The payment function has two main facets: (1) the determination of the methods and amounts of reimbursement for the delivery of services and (2) the actual payment after services have been rendered” (p. 226). For example, Medicare developed the resource-based relative value scale (RBRVS), which determines the reimbursement fee based on the time, skills and intensity of the service provided. Another example is one that managed care organizations use. They use fee schedules and capitation. According to Shi & Singh, (2012) “Capitation removes the incentive for providers to increase the volume of services to generate additional revenues” (p. 228). This basically means that a physician’s cannot order unnecessary tests just to receive extra reimbursement. Some physicians will also steer clear of ordering expensive or unnecessary tests just for this same reason.

My health care organization is not-for-profit. We try and ask the doctors not to order medication that is going to cost $1000, rather they order a generic brand or something that works the same but is half the cost. Health care financing only covers so much and then the rest is either out of pocket for a patient or the organization/physician loses money


Re: Discussion Starter

posted by Debbie McKeever at Feb 05, 2015, 4:32 PM

Last updatedFeb 05, 2015, 4:32 PM 


Regulatory agencies make organizations follow specific rules and regulations. Any new health care delivery model would need to go through of process in which different groups decide whether or not it is going to be effective and if it would benefit the organization and the public. An example of this would be new technologies that are being developed. If the effectiveness of a product does not exceed the cost then there is a chance the product will not be approved. This also goes for new technology in delivering services. For example, the electronic health records. If the information being delivered was unable to prove the patient records were going to be delivered safely it would not have passed HIPAA compliance regulations. In health care organizations like a hospital, if they decide to implement a new technology, they must be able to prove how it will be safe for staff, patients, and the overall organization. Organizations need to develop internal policies when they take on new approaches to the delivery of health care.

At my workplace we wanted to change an area of our skilled nursing facility from a recreation center to a physical therapy center. This involved our architect to investigate all of the requirements needed. From what I learned about this, we would need to extend one of our doorways to meet ADA requirements for transporting residents from one building to another. We also needed to eliminate two of the three exits in the area because they would be blocked by equipment and you cannot block a fire exit. There are little details on implementing new models that are considered big details when it comes to compliance of state, federal, and government regulations.


Re: Discussion Starter

posted by WANDA LANE at Feb 04, 2015, 8:55 PM

Last updatedFeb 04, 2015, 8:55 PM 



As a health care leader, I must be aware of local, state, and federal rules and regulations.  Everyone has a “piece of the pie” so to speak, and as such, health care delivery in the United States is complicated and cumbersome.  Accordingly, health care organizations must employ lawyers to interpret the regulations, accountants to manage the finances, IT engineers to protect the privacy of patient records, and a myriad of other skilled professionals.  I believe most, if not all, health care leaders would agree the system needs to streamlined and simplified, but where to start?  Creativity is stifled in this environment, and it becomes almost impossible to develop new delivery models.  Man hours are invested in understanding the rules and regulations of health care delivery and time itself becomes a hindrance.  It is almost as if the regulatory agencies do not want any changes in the system.  I am not a believer in conspiracies, but this is a dilemma that lends itself to those types of theories.  Any thoughts?

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