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Paying Hippocrates*
Published in David B. Friend, HealthCare.com, 2020
As the financial pressure mounts from these capitated systems, the economic incentives could potentially overwhelm the moral, ethical, and legal duties to care for patients. While it is assumed that the threat of malpractice will induce physicians to continue to care for their patients properly, this threat is an extremely poor substitute for well-thought-out compensation practices and quality control.
Balancing Quality with Costs in Managed Care Settings
Published in A.F. Al-Assaf, Managed Care Quality, 2020
James C. Benneyan, Vivian Valdmanis
Therefore, it is useful to review briefly the relationship between costs and service delivery as a function of the types of reimbursement methodology used. Under historical fee-for-service reimbursement systems, physicians had economic incentives to provide all the care available irrespective of medical benefits. For example, in economic jargon, this meant that physicians might treat patients until no further benefit is accrued without regards to the cost of resources used for this treatment. Hence, the costs of providing the last unit of care could be much greater than the benefit of that care for the patient. However, physicians were paid for all services rendered and patients who were insured faced little or no out-of-pocket costs. Both parties, therefore, had little financial incentive to decrease the use of unnecessary health care services and, aside from ethics and a professional concern for patients’ well-being, its critics have argued are strong incentives to increase this use.
Medicare
Published in Kant Patel, Mark Rushefsky, Healthcare Politics and Policy in America, 2019
Each category is assigned a treatment rate. Hospitals are reimbursed according to these rates. There are economic incentives in the form of rewards and punishments built into the system. If a hospital spends more money than the preestablished rate for a particular diagnostic treatment, the hospital must absorb the additional cost. If the hospital spends less money than the preestablished rate, it is still paid the preestablished rate and can keep the overpayment as profit. The HCFA (now the CMS) within the HHS was assigned the responsibility of establishing the DRG payment schedule. To safeguard against reduction in quality of care as a result of the PPS, Congress assigned PROs the responsibility of monitoring the quality and appropriateness of care for Medicare patients. If a PRO finds inappropriate or substandard care, the hospital may be denied Medicare payment. If a pattern of inappropriate or substandard care is discovered, the hospital’s Medicare provider agreement may be terminated.
Clinical Ethics as a Profession?
Published in The American Journal of Bioethics, 2019
The issue of specialized knowledge can be easily linked to a second feature which is typically attributed to professions: professional autonomy. On the individual level professional autonomy warrants the right to exercise expert judgment without undue influences by forces from outside the profession. This component is currently discussed, for example, with respect to of economic incentive structures in health care and their impact on physicians’ clinical decision making. In addition there is a collective aspect of professional autonomy which, for example, extends to the right to self-legislation which professional associations have with respect to certain aspects of their occupational activities. If the idea of professional autonomy is now transferred to Clinical Ethics Support as a potential profession questions arise with respect to the authoritative status and the demarcation of the field of expertise which can be attributed to the clinical ethicist. “Autonomy” as a normative term needs to be much further developed to make sense of it with respect to the provision of Clinical Ethics Support. Current understandings of professional autonomy bear the risk of being misleading if they unilaterally highlight the ethics consultant’s right to make decisions without interfering influences. On the collective level it needs to be further analyzed how much self-determination must be given to professional ethics societies to enable them to fulfill their function for the welfare of patients, relatives and health care staff.
Organizational influences on the use of low-value care in primary health care – a qualitative interview study with physicians in Sweden
Published in Scandinavian Journal of Primary Health Care, 2022
Gabriella Lang, Sara Ingvarsson, Henna Hasson, Per Nilsen, Hanna Augustsson
Economic incentives as well as local and central policies can lead to unintentional LVC and LVC reductions across the health-care system; given these consequences, a whole-system approach is necessary. Thus, potential consequences should not be considered for only one unit but for the entire system [60–62]. Furthermore, primary care physicians could work with managers to identify the LVC activities they have, prioritize the ones that can be reduced, and develop the strategies to allow them to be reduced [5,66]. Physician-management cooperation could help enable the development and testing of physician-proposed LVC-reducing strategies, as many of their suggested strategies require higher-level support for their implementation.
Effect of inadequate care on diabetes complications and healthcare resource utilization during management of type 2 diabetes in the United States
Published in Postgraduate Medicine, 2022
Benjamin Lewing, Shubhada Sansgiry, Susan M. Abughosh, Lincy S. Lal, Ekere J. Essien, Sujit S. Sansgiry
There are several implications of this study that should be highlighted. First, the presence of inadequate T2D care is a pervasive issue that may have severe economic costs and burden on individuals with T2D. The 49% prevalence of receiving inadequate pharmacologic therapies is especially alarming. Further, it is apparent that inadequate care occurred in each patient group: inadequate care is an issue that persists regardless of an individual’s income level, education level, insurance type, and other demographics variables that were examined. This study estimated an additional 0.256 emergency healthcare visits during the following year on average if guidelines-based laboratory tests are not given to adults with T2D, which highlights the importance of careful monitoring of diabetes. The cost aspect of implementing guidelines is a major issue that both clinicians and patients are concerned with. The current study demonstrates that the cost of implementing diabetes care guidelines is offset in the cost savings to total healthcare. There is an economic incentive to be guideline adherent, even for categories of care beyond medications. While the generalizability of the current study is limited to the T2D population, the methodology could be adapted to other chronic conditions that also are adversely affected by non-adherence to evidence-based guidelines. Future studies can build on the current in a variety of ways. The current study only examined individuals during a one-year baseline period and a one-year follow-up period. A longer follow-up could highlight additional health consequences of inadequate T2D care. This study focused on the health outcomes of five different categories of inadequate care, comprising a total of nine individual processes of care; however, additional studies could examine the effects of high amounts of inadequate care, such as multiple processes of inadequate care present compared to fully adherent care. Additional research could consider the specific reasons for the additional hospitalizations that were seen among those with inadequate laboratory tests. Another area of inadequate diabetes care that could be examined is adherence to chronic kidney disease (CKD) screening guidelines. A recent study by Folkerts et al. showed about 20% of newly diagnosed diabetes patients in a US administrative claims database were nonadherent to screening guidelines[52]. Recently published research by Ueki et al. indicated intensive multifactorial intervention following detection of CKD could confer significant reduction in kidney events[53]. Finally, this study could be repeated within a different data set or using additional years of data to increase the confidence in results.