Ethical Issues In Managed Care

Background- The scenario in question involves a 77 year old widowed woman, Mrs. Zwick. Mrs. Zwick had a mild stroke, and was admitted and hospitalized as a inpatient for five days to ensure her condition was mitigated. After the five days, Mrs. Zwick was transferred to a skilled nursing facility for rehabilitation. However, Mrs. Zwick was uncomfortable, and tests revealed that she had manifested a hospital-acquired urinary tract infection. This infection was serious enough to require IV antibiotics and extended care for an addition forty days in the nursing facility. Upon discharge, Mrs. Zwick was prescribed several medications and had to get a walker. Due to her age and circumstances, Mrs. Zwick is enrolled in Medicare A, B and D she is not able to handle her bills and paperwork, so her daughter helps out. Mrs. Zwick and her daughter both were unaware that the urinary tract infection was considered a hospital-acquired condition all the nursing staff told them was that it had to be medicated.

Managed Care is a system of health care in which patients agree to visit only certain doctor and hospitals, and in which the cost of treatment is monitored by a managing company. David, a clinical supervisor of one pad was responsible for the clinical supervision of eight clinical case managers. On typically day, he receives around 40 phone messages about clients that are in need of his services. His job is to field calls from mental health providers seeking authorization to provide treatment for clients. There are those who believe that managed care is simply another example of corporate America discovering a means to increase profits for shareholders of insurance companies, at the expense of individuals seeking mental health treatment. (pg.

In addition, the article highlighted the issue of litigation and policy context under the Employee Retirement Income Security Act’s (ERISA’s) preemption provision. It stated that “when a law or legal action involves the administration of plan benefits, such as a state law mandating certain benefits or a patient’s challenge to the denial of a plan benefit, ERISA preemption is triggered” (Jacobson, 1999). Therefore, the states block the litigation against the managed care organizations. Lastly, the courts and public policy have been a challenge of the implementation of cost containment initiatives. Some prominent commentators have been arguing for years that health care delivery should be guided by market principles as determined through contractual

Preventive care. Individuals may not have to pay a copayment, co-insurance, or deductible to receive recommended preventive health services, such as screenings

Pharmaceutical companies play a significant role in controlling costs within the healthcare industry. Prescription drugs are now the fastest growing segment of medical costs. One of the reasons that our health insurance rates are high is because we are funding other people’s high-cost medications. Since 1970’s, the pharmaceutical industry has produced remarkable treatments for diseases so rapidly. Many patients with different diseases used to suffer long-term stay in the hospital; with fast-progressed medication, many diseases can be cured at home.

Given that there are five professionals, eight paraprofessionals, and a host of patients that utilize the health care services, it is necessary to address this ethical problem with the utmost care. Austin, Schirick, and Jones (2013) cautions that using assistive staff in the health care setting is an area that warrants ongoing monitoring. This manner must be addressed reasons. Firstly, the other professionals in the office could be victims of this type of behavior in the future. For this reason, it is necessary to address this concern immediately. Secondly, there is the possibility that this has happened before this particular incidence. It was by chance that this incident was recognized by the nurse practitioner (ANP) as the patient brought the bottle into the office. Thirdly, Stephanie could give the other paraprofessionals the idea that this is acceptable behavior.

The training will includes healthcare codes of ethics for managed care and five ways to improve ethics in the managed care organization.

A philosophy of an organization helps differentiate themselves from their competitors and set a foundation for future success. It also helps shape an organization by presenting the goals they want to accomplish with specific activities. To improve this, many organizations understand the important of sharing values and goals and realize employee recognition. This helps staff from moving forward toward success of the organizations. Chapter 4 introduces “Codes of Ethics in Health Services.” Code of ethics is a guideline for healthcare professionals to accomplish and serve as a member of a society. Similar to other professions, managers have their own code of ethics in maintaining their duties and responsibilities. They also use the codes for ethical decision-making in dealing with ethical issues. Chapter 5 deals with “Organizational Responses to Ethical Issues.” It provides assistance for managers and organizations in their decision making. It is manager’s duty to figure out the problem and resolve it (Darr, 2011,

Many mental health counselors work with managed care organizations (MCOs) to provide services to clients. While managed care guidelines determine how counselors deliver services and what they will be reimbursed for, many counselors are upset with how limiting the guidelines are. It is a challenge for counselors when insurance reimbursement is denied because the MCOs are not honoring DSM codes (Braun & Cox, 2005). Therefore, counselors tend to submit inaccurate diagnoses that are reimbursable for their clients can receive services and they can be paid. However, this can lead to ethical and legal dilemmas for counselors. Braun and Cox (2005) address this issue in their article “Managed Mental Health Care: Intentional Misdiagnosis of Mental Disorders.”

Healthcare reform has been challenge for many people of the great United States of America. There are sick people who are dependent on their healthcare benefits to aid in the recovery of an illness or just remain in the most stable condition possible. One of the hot topic issues that exists within healthcare reform is the cost of healthcare which includes insurance, medication, and other expensive, but necessary parts. The Trump administration has chosen another path for underinsured, low to average income citizens of the U.S. The ethical issues created by latest healthcare reform are an extension

Health insurance costs are often raised to balance out the potential costs posed by risk factors. This is because insurance companies have to, on average, spend more money to help highly prone individuals. While this practice makes sense financially, it raises some questions ethically. Three risk factors that often lead to companies raising monthly fees are tobacco usage, obese individuals, and people with genetically inherited conditions.

Nurses are constantly challenged by changes which occur in their practice environment and are under the influence of internal or external factors. Due to the increased complexity of the health system, nowadays nurses are faced with ethical and legal decisions and often come across dilemmas regarding patient care. From this perspective a good question to be raised would be whether or not nurses have the necessary background, knowledge and skills to make appropriate legal and ethical decisions. Even though most nursing programs cover the ethical and moral issues in health care, it is questionable if new nurses have the depth of knowledge and understanding of these issues and apply them in their practice

I talked with a couple of mental health professionals within the local area in which I live, I asked each of them form their perspective weather or not they work with insurance companies, what are the advantages of insurance panels, what are the struggles. One of the mental health care professional stated that some of the disadvantage being involved with insurance panels is the enormous amount of paper work that involved that must be prepared. This was one of her most frustration in work with insurance planes other than waiting to paid especially when it come third party payer. Also, the amount of wages which is non-negotiable, because the insurance company set their own pay rates which is considerably less that

As a health care provider, I believe physicians do have the right to refuse certain procedures do to morals or religious beliefs. I have seen as a physician had stated to me "fire" a patient. The reasons he gave were that the patient never showed up for her prenatal visits. A letter was sent to the patient many times about coming to prenatal visits, but she never showed up. When the patient didn't respond, she was let go from that physicians practice. The physician felt morally that he couldn't provide the optimum care for the patient, and it was in the patients best interest to get her care elsewhere. Another physician suggested the patient go to another hospital for care because she wanted only women caring for her, for religious reasons, and only male physicians were working that day. The patient and her husband talked about it and decided to stay, and they ended up loving the care they received from the male physicians. I have also seen many doctors refer early second trimester abortions to a physician that could accommodate the patient. Most

Everyday, healthcare professionals are faced with ethical dilemmas in their workplace. These ethical dilemmas need to be addressed in order to provide the best care for the patient. Healthcare professionals have to weigh their own personal beliefs, professional beliefs, ethical understandings, and several other factors to decide what the best care for their patient might be. This is illustrated in Mrs. Smith’s case. Mrs. Smith is an 85 year old who has suffered from a large stroke that extends to both of her brains hemispheres which has left her unconscious. She only has some brain stem reflexes and requires a ventilator for support. She is unable to communicate how she wishes to proceed with her healthcare. Mrs. Smith’s children, Sara and Frank have different views regarding their mother’s plan of care. The decision that needs to be made is whether to prolong Mrs. Smith’s life, as Sara would like to do, or stop all treatments and care, as Frank feels his mother would want. In the healthcare field, there are situations similar to this case that happen daily where moral and ethical judgment is necessary to guide the decision that would be best for the patient. The purpose of this paper is to explore and discuss, compare and contrast the personal and professional values, ethical principles, and legal issues regarding Mrs. Smith’s quality of life and further plan of care.