Is Gaming The System?

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

In many ways, the hospital system in America is set up mirroring our government. They are similar in the way that checks and balances have been set in place to ensure the best possible care is delivered to patients. With these checks and balances there are three main bodies; the governing board, medical staff, and executive management (Showalter, 2017). The duties and responsibilities of each body many times is to oversee and continually check the others. A prime example of this system can be seen through the case of Moore v. The Board of Trustees of Carson-Tahoe Hospital, which took place in Nevada and was heard before the Supreme Court of the state in 1972 (Moore v. Board of Trustees of Carson-Tahoe Hospital, 1972). Specifically, in this case, the duty of the governing board to “exercise reasonable care in selecting and retaining medical staff” is questioned in contrast with the right of the physician to have “due process… when disciplinary action is taken” (Showalter, 2017). In hopes of changing a decision by the governing board, and attempting to reverse the decision of a lower court, the appellant, Dr. Moore, brought the case against Carson-Tahoe Hospital (Moore v. Board of Trustees of Carson-Tahoe Hospital, 1972).

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

Since we know this may not always be the case, this is how lawmakers create laws with the hope that it will discourage people from not adhering to the rules. According to Pozgar & Santucci (2016), the case of Patrick v. Burget is a direct violation of the Sherman Antitrust Act where physicians conspired to terminate another doctor’s hospital privileges which would ultimately have an adverse reaction to his practice. The creation of the Sherman Antitrust Act is to prevent similar incidences from occurring and deter individuals from trying to monopolizing the system for personal gain. The new contracts are effective to some degree although laws are in place they cannot control everyone actions. These improvements have provided some resolution regarding the integrity of health care professionals however there is always room for improvement. As the health care industry progresses and the new laws are in place with stricter guidelines, the more health professional that are compliant will reduce the number of law

He was not biased towards any particular solution; he was more so concerned with the harmony of privacy and the sharing of said private information. Westin also states for example, the government requiring personal information in order to properly provide protection. With HIPAA the same applies except HIPAA is a non-discriminating system of properly sharing information and only used for the patient care at a given point of time. After the patient has been discharged their file becomes sealed. Employers were losing money by providing insurance to employees hoping for them to use their preferred healthcare units. Of course, no one wants their coworkers knowing about their personal health and HIPAA allows protection in this case. Now that most hospitals have switched to electronic charting they can better monitor who is looking at a specific patient’s information base off employee logins. Patient information is not only closely monitored, but an individual can also be hit with a big fine even by accidentally sharing confidential information about a patient. I work at the University of Arkansas for Medical Science in their information technology department and even though I do not deal with any patients directly, I still am trained to be compliant with the Health Insurance Portability and Accountability Act. Being trained about the Health Insurance Portability and Accountability Act helps me to understand the importance of privacy as a patient of the University of Arkansas for Medical Science and as someone who is able to look into another person’s file. “Health information privacy has fundamental importance in us society.”

According to Roger Feldman, Blue Cross Professor of Health Insurance on the University of Minnesota, one of the main motives that medical fraud is this type of general exercise is that almost all of the parties concerned discover it favorable in some way. Many physicians see it as necessary to offer satisfactory care for their sufferers. Many sufferers, even though disapproving of the concept of fraud, are sometimes extra inclined to simply accept it when it impacts their own hospital treatment. Program administrators are regularly lenient on the problem of insurance fraud, as they want to maximize the services in their providers.[17]

From a personal standpoint I believe that the excessiveness of litigation is hurting the field of healthcare due to the affects in many different areas. It reduces access that patients need. Due to the misuse and disloyal antics of people making false accusations to self gain we will continue to see a rise in healthcare. I do not feel that all accusations are false, but I do believe that litigation has become successful due to dishonesty. In order for there to be financial distress for us all as a country we must flow diligently with each other. From a malpractice standpoint they need to ensure that their patients are taken care of to the best of their ability and that they are taking the precautions needed to ensure no

Finding out that people blame doctors for when their patient commits a crime puts my mind in utter disbelief. The law of patient confidentiality clearly states that the physician must keep all information a patient informs them in confidence, unless it acquires serious medical care, but if the doctor breaches the confidentiality by informing a third party without the patient’s consent, he or she could be sued. Doctor-patient confidentiality is based on the belief that a person should not be worried about seeking medical treatment in alarm that his or her problem will be shown to others. The objective of the relationship between the patient and their doctor is to make patients feel as comfortable as possible by providing them with any information they way need about their symptoms. This helps the doctor to make a correct diagnosis, and overall helping the patient feel comfortable enough to trust their doctor so that they may receive the best care. Once a physician takes a patient on, they must keep all the patient says and does in confidence; moreover, he cannot inform any third party of the patients wellbeing, but there are some exceptions like if the patient intends on causing harm to oneself or other or if it is an issue in a lawsuit. The court system claims A patient must have full confidence that their doctor will be able to keep all his or her medical issues private which helps the patient trust their physician. The professional duty of confidentiality not only covers

Health insurance fraud is what drives up health insurance premium costs, wastes taxpayer’s money, but can also endanger beneficiaries or leave them uninsurable. In 2015, Medicare Strike Force reported over $700 million in false billing by doctors, nurses, other licenses medical professionals, laboratories, and individuals (FBI.gov). This is a staggering figure that is only getting worse. In this fictitious federal case I will be describing the criminal offender, the crime that was committed, the charge handed down by law enforcement, and the judicial process from the beginning of the criminal case to the sentencing of Dr. Richard Heartman, an internal medicine physician.

Quality health care is an issue in America for everyone, despite our numerous tests and advances in technology. In his article, “Overkill,” Atul Gawande argues against a common assumption that our healthcare system is the best because of these medical advances. In fact, Gawande claims that our health care provides much unnecessary care that often causes harm and that costs a lot . He follows that claim by redefining “low-value care” as “no-value care” and provides considerable scientific data along with his own experience with his own patients to support his claim. He also states logical reasons by referring to expert authorities who critique our health care by viewing it from an economic perspective: like talking about information asymmetry where a doctor is more informed than the patient, thus the doctor has more power over the patient. All of these emphases strongly defend his controversial claim. But what stands out most is how Gawande uses several stories showing vastly different outcomes, depending on how informed the patient and doctor are including offering non invasive treatments. We need to explore how his unusual storytelling strategy exposes how surgeons and patients should care more about quality than the mere quantity of tests and what alternatives are available to change the unnecessary over testing and over-diagnosis which prevent good health care.

Medical fraud and abuse is a huge contributing factor in the rise of healthcare costs in the United States. Although there are many definitions of fraud and abuse, according to Cigna and HIPPA, Medical fraud is false representation of a substance, device or therapeutic system as being beneficial in treating a medical condition, diagnosing a disease, or maintaining a state of health. Medical Abuse is defined as any action that intentionally harms or injures another person. It also involves actions that are inconsistent with accepted, sound medical, business or fiscal practices. Abuse directly or indirectly results in unnecessary costs to medical programs through improper payments. Insurance fraud occurs when companies

(Jones and Jing) Though citizens might not see the effects of health care fraud directly, everyone is impacted in one way or another either through increased taxes, high insurance costs, or the inability to afford health care coverage. While we all hear about major frauds in the system, a majority of the frauds are small and usually go through undetected, unreported, or seriously underreported. (Sparrow) These small frauds add up to be a huge problem. There is a large spectrum of frauds in the health-care systems ranging from the theft of a wheelchair, to organized crime groups that steal patient information and bill for phantom services in multimillion-dollar schemes. (Jones and Jing) In many cases, the fraud is minor but all the small scams add up to an enormous loss to the public. For example, the frequent occurrences of forging of a doctor’s signature on a prescription accounts for billions of dollars lost each year. (Jones and Jing) One of the most common crimes involves billing for services that were never performed. This involves a health care provider submitting a false claim to be paid for a patient that was never treated or adding on services to a patient. For example a doctor may obtain names of other people such as a patients spouse or child who are covered by insurance and put in a claim for them as well as the actual patient. (FBI) Another common fraudulent activity involves upcoding of services. This is when a healthcare

One reason a stigma is placed on forms of managed care, such as health maintenance organizations (HMO), is a highly publicized practice of providing material incentives to doctors to control the amount of costly tests and medications the doctor prescribes. Before providing these material incentives the HMOs would force the doctor to sign a gag rule, preventing the physician from disclosing any information pertaining to the unethical practice. Since the doctors who participated in the bribery can not speak about the practice, there is no way to tell the impact of this practice, but one can assume that many patients received diminished treatment of illnesses, possibly resulting in harm.

Medical ethics have indirectly regulated the patient-doctor relationship for thousands of years. Today’s health care policies are primarily designed to politically regulate that relationship in accordance to medical ethics with a great focus on the patient’s best interest. Recently, however, the emergence of many physician-owned specialty hospitals has ignited a controversial debate over the legitimacy of their entitlement to receive Medicare and Medicaid reimbursement; especially with their higher prices than their competitor public hospitals offering the same services. It was not until 2006 when supported data proved that physician-owned specialty hospitals function differently from equivalent public hospitals.This paper discusses the

These crooks are the possible cause of ruining the reputation of the most trusted and appreciated professionals of our society – physicians. Healthcare fraud can be committed in a variety of ways, but three of the most widely used are described below. The first and most widely known, is billing services that were never endured by using general patient information. When giving personal information out, many hand it over to the front desk assistant at the local doctor. These appear to be people are some of the most known to scam the information and bill patient’s payments that never took place. Keep in mind that when handing over information, the handler is a trusted individual with a good reputation. On the other hand, many are scammed for the opposite; otherwise known as “upcoding,” where patients are billed more expensive services that were actually done. In fact, according to USA.gov a new study showed that 7 percent of identity fraud victims this year reported identity thieves stole their health insurance information, rising up from just 3 percent last year (Federal Bureau Investigation, 2010). This includes the latest scam, called “unbundling,” where scammers con bills and bill each step of a procedure as if it were a separate making the individual pay even more money, leaving devastating effects for the victim. All of which have a common goal of making taxpayers, insurance companies, and