Case study ch 9
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California State University, Los Angeles *
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3140
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Medicine
Date
Dec 6, 2023
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docx
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Uploaded by jaselynledesma31
1.
The reason that the healthcare insurer, Anthem, implemented the “avoidable ER” policy
was to avert their policyholders from going to the emergency room for reasons that
weren’t meant for the ER. The new implemented policy caused a lot of controversy and
fear within the policyholders. “Critics say patients shouldn’t be forced to self-diagnose,
warning that the new policies will encourage people to avoid seeking care for serious
medical conditions out of fear that their claim will be denied” (Small, 2018). This has
caused individuals to stop going to the doctors which is a bad thing because when they
have symptoms, they will google the symptoms in order to avoid the whole denial of a
claim. “Most people pay additional amounts for healthcare beyond the cost of their
health insurance premiums” (Walston, 2021). Many individuals would overuse the
emergency room in order to not pay the deductible or copay which was one of the
factors that played into executing the “avoidable ER” policy.
2.
The avoidable ER policy is an example of managed care because it is a benefit that offers
additional assistance in receiving the medical treatment you require to maintain your
health but also arranges for the treatment you receive from several physicians. The most
common managed care would be Health Maintenance Organization (HMO). “In an HMO,
only network providers are available to the patient, so specialists, hospitals, pharmacies,
imaging centers, and laboratories are preselected and credentialed and contracted by
the HMO. In the case of an HMO with a gatekeeper model, coverage will only be
available for care and services authorized by their PCP” (Giardino & De Jesus, 2022). The
HMO lowers your costs, and you can only see providers in your small region which
contributes to the cheap cost of care. “Almost all insurance products are based on a
managed care model that directs patients to networks of providers and reviews and
manages cost and use” (Walston, 2021). This demonstrates that manage car are
beneficial towards healthcare insurance and provide the best opportunity for a low cost
with good care.
3.
There are many solutions to minimize costs but ensure access and quality for example
reducing administrative cost, focusing on preventive care, eliminating unnecessary test
and procedures, and lastly, controlling the cost of prescription drugs.
“We must reduce
the cost of health care in the US. We can do this by developing a health care system that
emphasizes prevention rather than disease management. To do this we must encourage
more physicians to be adult generalists and we must provide them with new skills”
(Dalen, 2010). Nowadays when one goes to the doctors, anything that is being done,
cost a lot and many of the time they don’t provide you with good care. Private and
government insurances are switching healthcare service payment methods from fee-for-
service to value-based. “Value-based payment seeks to improve quality while promoting
cost-efficient care. This is done by altering incentives to focus on value by rewarding
better health outcomes and lower spending” (Walston, 2021). Value-based payments
seem like a step towards a solution to cut costs while maintaining quality and
accessibility for patients. All in all, if healthcare insurances focus on what’s best for their
ensurees, they might get more individuals to enroll.
Word Count: 539
Dalen, J. E. (2010, March).
We can reduce US health care costs - the American Journal of
Medicine
. The American Journal of Medicine .
https://www.amjmed.com/article/S0002-
9343%2809%2901115-2/fulltext
Giardino, A. P., & De Jesus, O. (2022, October 24).
Managed care - statpearls - NCBI bookshelf
.
National Library of Medicine.
https://www.ncbi.nlm.nih.gov/books/NBK564410/
Small, L. (2018, February 16).
Anthem alters controversial er coverage policies
. Fierce
Healthcare.
https://www.fiercehealthcare.com/payer/anthem-er-coverage-policy-changes
Walston, S. L., et al., (2021). Healthcare in the United States: Clinical, Financial, and
Operational Dimensions (Ebook)
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