Conflict Of Interest In Ataged Care : Conflict Of Interest In Managed Care

"In the past two decades or so, health care has been commercialized as never before, and professionalism in medicine seems to be giving way to entrepreneurialism," commented Arnold S. Relman, professor of medicine and social medicine at Harvard Medical School (Wekesser 66). This statement may have a great deal of bearing on reality. The tangled knot of insurers, physicians, drug companies, and hospitals that we call our health system are not as unselfish and focused on the patients' needs as people would like to think. Pharmaceutical companies are particularly ruthless, many of them spending millions of dollars per year to convince doctors to prescribe their drugs and to convince consumers that their specific brand of drug is needed in

The payment system in the healthcare industry has appealed to specialty care providers, they make a higher income than the primary care physician. The physicians are attracted to specialty care, and the individual feels that specialty care is better. If physicians were all paid well, in order to pay for their education and then continued quality training, we would not be confronting the lack of primary care doctors who are available to treat the general needs of the population (Fisher, 2013). Just as the physicians seem to be treated differently in our health system so are the patients. Using a multi-tiered system of health care where some insurance gives out a higher payment to physicians, some patients seem to be wanted while others are less well received, this leads to an “everyone for himself or herself ethic” within our medical system (JAMA, September).” The design of the system is flawed in reference to the primary care physician and with the patient who has insurance which pays less, the way to reorient both is to make the pay scale more competitive for both. The primary care physician should be able to make money and cover this educational expenses and the patient should have insurance that will equate to

The health facility in this case study experienced several problems and issues beyond possible solution efforts by the time. One of the main problems is based on the perfect way of handling the various challenges attributed to a shift from the hospital’s fee-for-service in the case of managing care environment. Besides, some local physicians were loyal to Dr. William and had the necessary flexibility and availability to assist the doctor in various ways, but today they are no longer available to assist the doctor towards the achievement of his medical and societal mission. The physicians were always available and loyal to the doctor and they could volunteer their efforts especially in cases of physician shortages in the health center. The physicians cannot afford the time they once used for volunteering activities in the health facility to assist Dr. Williams (Swayne, 2008). The reason behind this problem is that the physicians have now been employed by various managed health care organizations. Others have been involved in various contractual agreements such that the partners prohibit them from working with the health care facility. Although the health care facility has a few small groups or individuals offering primary care, these individuals and small groups are still struggling to survive in the industry. As such, the majority of them cannot

3. (TCO C). Some physicians and for-profit healthcare organizations in your area are refusing to treat Medicare and Medicaid patients for a variety of reasons. These controversial decisions present not only a major breakdown in the healthcare delivery system but also in the financing of healthcare for many individuals across the nation. Delineate at least three reasons that physicians have for refusing to participate in these governmental programs, as well as the impact this practice has on other areas of the healthcare delivery system. (Points : 25)

Critics believe that the present functioning of managed-care is degenerative to health care. Managed-care firms control costs by requiring patients to use a “network” of approved doctors and hospitals, and by reviewing the actions of doctors. Patients have to pay more to visit a doctor who does not participate in the “network.” Managed-care firms second-guess doctors, considering only the costs. Patients are often prevented from visiting specialists to reduce costs. A managed-care company might insist that its doctors prescribe inexpensive generic drugs instead of commercial products. Many patients must, also, receive the insurer’s approval before undergoing treatments or operations. HMOs have been criticized for refusing to pay when a patient goes

Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a)reduce adverse outcomes, b)deter patients from filing medical malpractice claims, or c)provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated liability can be pre-empted. (David M. Studdert, et al., 2005) Diagnostic defensive medicine practices have a much greater impact on costs that do therapeutic defensive practices. One study conducted by American Academy of Orthopedic Surgeons, showed assurance behavior reported by 92 percent of physician respondents involves ordering test (particularly radiological imaging) performing diagnostic procedures through CT scans, x-rays, MRI studies, ultrasound studies, laboratory testing and referring patients for consultation. The ordering of unnecessary tests can lead to diminishing quality of care and produce emotional distress and necessitate additional invasive or hazardous procedures.

Many physicians in family practice have solo practice settings and receive fees based on services. A study by Hunter et al (2004) showed that many family physicians opposed capitation and patient rosters because many believe that capitation will lead to loss of autonomy. The competition for patients may increase under capitated payment and physicians would move to less serviced areas to attract more patients under their team (Hunter et al., 2004). Another research from Cohen, Ferrier, Woodward, & Brown (2001), found that only five percentage of Ontario family physicians believed that primary care reform will have a positive effect on them. Many family physicians were concerned about changes in practice

Health maintenance organization’s (HMOs) use of the primary care physician (PCP) as the “gatekeeper” initially had MCOs view restrictions as a negative approach to patients’ choices. However, some necessary steps have started to be implemented which reduce unnecessary utilization by enforcing some restrictions.

Understanding the forces affecting physicians discusses the extreme struggles private practice physicians have obtained. The increase in malpractice insurance and benefit costs, horizontal or declining revenue, and the extreme requirements to obtain EHR are contributing factors. Private practice physicians have looked for ways to work with hospitals and other health organizations. There are three offerings that were designed to meet the needs of physicians: “independent physician programs, employed

Some patients mistakenly believe they are not allowed to shop around when it comes to their healthcare. However,

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.

Medical dominance is a concept within the Australian health care system which majorly impacts general practitioners (GPs), through giving them power over the associated economics and business of health services. This is specifically exemplified in their role within the health care system under the Medicare Benefits Schedule (MBS), wherein they act as the primary care service providers in Australia. With reference to the private sector, the position of power given to GPs is exemplified through their control over the client bases of other health professionals. This control generates both disadvantages and advantages for GPs. Disadvantages include the inevitable production of poor professional relationships within multidisciplinary teams, due

The main concern of doctors is that patient safety could be jeopardized as well as the quality of care. Some physicians fear that NPs and PAs will make more mistakes because of their lack of education. Some suggest that they may order more tests than necessary due to lack of confidence in their diagnosis. There is accusations that the reason physicians are against independent practice is because they are afraid they will lose business and an issue of professional pride. “This is not primarily a question of lost income to family practitioners. The main concern is an erosion of clinical expertise, which may result in a decrease in overall quality of care,” according to Dr. Dorio, an interventional radiologist in Florida (Page, 2014). Other physicians

Lack of Trust: A sense of lack of trust was identified among the various key players of healthcare system: patients, doctors, and insurers.

see beyond lobbyists’ trying to ensure that doctors and insurance companies remain in control rather than setting up a patient centered system