People have come to appreciate the importance of having medical insurance, especially in emergency cases. In response to this need by consumers, many insurance providers have flooded the market hence presenting a host of choices for the people. This essay seeks to find out whether PPO, HMO, or PHO is more advantageous to the consumer. It will also discuss how the United States can assist those who are uninsured with healthcare and whether reforms in healthcare ought to be a primary concern in the forthcoming elections. It will finally describe how a nurse can facilitate a great continuity of care and help in the simplification of the current confusion many elderly feel in the healthcare system.
Several insurance products are administered or provided by several payers, trusts, employers, and insurance companies. They include; Preferred Provider Organization (PPO), Health Maintenance Organizations (HMOs), and Physician Hospital Organization (PHO) (Rickel & Wise, 2000).
Usually, many providers seek to contract multiple products yet it would be better if the consumers were able to choose from the various products. This would minimize the confusion brought about by the agreements and the difficult terms involved. The three basic groups on the payer side mentioned above vary in their degree of risk for medical costs for the consumers. An HMO that is contracting for professional services can decide to pass on part of its risk to another party or otherwise take the risk but with an attempt to minimize the number of services utilized, prices to be paid, and hence the cost. In hospital transactions, the HMO strives to get an aggressive contracted rate which is normally per diem, and at the same time offering benefits that are limited in the case of out-of-network utilization. If the patient offers to pay more due to choice, then the extra pay ought to go to the hospital which has created the demand for the services. This is not the case in most instances.
PPO, on the other hand, seeks to offer discounts if the hospital accepts to be placed in the preferred network. The consumers can therefore demand a lot of incentives from the PPO if their in-network provider is to be chosen. Patients, who happen to be members of the PPO can identify with the insurance company at any time of admission into the hospital.
The HMO can enter into transactions with physicians through the PHO. This involves insurance for risks associated with professional services. When the strength of the PHO is greater, it implies that there will be more risk and hence it will attract a higher percentage of premiums. The problem with these contracts is that different funding pools are used for different services provided depending on definitions of situations.
From the above discussion, it is evident that the best product for the consumer, if given a choice, would be to use the PPO hospital transactions since they have a direct influence on the incentives given by the insurer. The best can be made by mutual understanding among the parties concerning their motivations, operational limitations, and strengths. The PPO, unlike the HMO, accepts a prepaid fee for its consumers (Rickel & Wise, 2000).
A significant number of citizens in the US are uninsured, about 47 million of them (Harrington, et al., 2004). Due to this fact, the federal government enacted the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires that all emergencies be treated regardless of whether the patients can pay their bills or not. This move is viewed as a form of ‘safety net’ especially for the uninsured. The problem is that most hospitals went uncompensated by the government hence rendering the act ineffective. The United States should increase its yearly income towards insuring the uninsured as well as financing the EMTALA. It should also provide universal healthcare coverage regardless of political inclination.
The health care reform has raised a lot of debate in the United States, especially in the previous presidential election. The major point of diversion is whether to make healthcare affordable or guarantee healthcare coverage for all (Dean, et al., 2009). This health care debate will remain to be an issue in the upcoming election campaigns depending on the success of the current proposals by the Obama administration which seeks to provide universal healthcare coverage. The Act is currently awaiting approval by the Senate.
To ensure greater continuity of health care and minimize the confusion that several elderly people feel towards the healthcare system in the United States, nurses should play a central role. They can facilitate this by encouraging and participating directly in the provision of home healthcare services to the ever-increasing number of the elderly population, even in their rural areas (White, 2004). Generally, they can facilitate extended care, primary care, public health, and home care especially for the vulnerable groups, and hence more nurses will be needed in the future if this is to succeed due to the increasing demand for access to health care services.
This essay has illustrated the magnitude of the need for healthcare insurance for the citizens of the United States, both young and old. We have also learned that for a healthy population, there should be meaningful health care reforms.
References:
Dean, H., Volsky, I. & Shakir, F. (2009). Prescription for real health care reform: How to achieve affordable medical care for every American. Chelsea Green Plc.
Harrington, C., Estes, C. L., & Craw, C. (2004). Health care policy: Reform and crisis in the U.S. health care system (4th ed.). Sudbury, MA: Jones & Bartlett Plc.
Rickel, A. U., & Wise, T.N. (2000). Understanding managed health care: Introduction for the health care professionals. Karger Plc.
White, L. (2004). The Foundations of nursing (2nd ed). Cengage Learning.