Making healthcare affordable is among the goals that have proven elusive and unattainable for successive U.S. governments. While other developed nations have had impressive success in delivering quality care to their people, the US continues to struggle. The struggle is being experienced despite the initiatives that have been implemented in an effort to contain the cost of care. Expanding insurance coverage is among these initiatives. It is true that this initiative has made health insurance accessible to millions of Americans who previously lacked coverage. However, this and other initiatives have not had a significant impact on healthcare costs. To understand why the cost of care in the US remains high, it is important to scrutinize the various financial and economic forces which shape the delivery of healthcare in the country.
Funding Sources
The US healthcare system is complex. Employers, the government and private firms all play critical roles in facilitating the delivery of care. Providing funding for medical services is among the issues that bring these stakeholders together. In the US, the government is the main source of funding for healthcare. In 2015, the government allocated more than $1 trillion to healthcare (Walker, 2015). It is expected that as the healthcare needs of the American people become more complex, the government will be forced to spend higher amounts on healthcare. Medicare and Medicaid are some of the programs that the government has established for the purpose of paying for medical services (Walker, 2015). Private insurance and out-of-pocket payments are other sources of funding. In the US, there are dozens of private insurance companies which help Americans pay for services received. In some cases, individuals are forced to pay for care out of pocket. This is particularly true for uninsured Americans or those whose cost of care exceeds the amount covered by private insurance.
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Reimbursement Methods
No discussion on the financial issues surrounding healthcare in the US would be complete without a look at reimbursement methods. Essentially, these methods refer to the approaches used to compensate practitioners and healthcare facilities for the care that they deliver. Fee-for-service is the traditional reimbursement model (Butler, 2017). Basically, through this model, practitioners deliver service in exchange for direct and immediate payment. The main drawback of this model is that practitioners can deny payment to patients who are unable to raise the required fee. Accountable care organization (ACO) is another reimbursement model (Butler, 2017). This model is rather new and its primary purpose is to promote accountability and patient outcomes. Medicare patients are this model’s primary focus. Merit-based incentive payment system (MIPS) is yet another model (Butler, 2017). Through this model, practitioners and facilities receive rewards for delivering quality and affordable care. It is worth noting that most of these models stem from acts which were enacted with the goal of improving healthcare quality while minimizing cost. For example, the ACO model is the result of the Affordable Care Act.
Economic Factors
The delivery of medical services does not occur in a vacuum. There are various economic factors which influence the cost and quality of care that the American people receive. Availability and cost of insurance, and the performance of the economy are some of these factors. It is understood that the strength of a country’s economy determines its capacity to offer medical insurance and affordable care. Middle and low-income countries tend to struggle in their quest to deliver insurance and medical services (Adebayo et al., 2015). Despite being a high-income country, the US joins these nations in struggling to cover all its people. Today, millions of Americans lack medical insurance. Most of these people are poor and from minority communities. In recent years, the US economy has witnessed significant changes. Expansion is perhaps the most important change that the economy has undergone. The government has attempted to ensure that the expansion of the economy is reflected in the amount invested in healthcare. Healthcare expenditure has been on an upward trend and this is expected to continue as the county’s economy continues to expand. It is indeed surprising that despite increased investment in healthcare, the cost of care in the US remains high. One could argue that the key to addressing the issues that the US healthcare system faces is expanding coverage and focusing healthcare reform on poor and marginalized communities.
Business Influences
Private enterprises are among the stakeholders whose impact on the US healthcare system is most profound. The main function that the enterprises perform is working with employees to establish medical insurance schemes. Furthermore, the enterprises make contributions to insurance programs that are operated by third party insurance companies. For the most part, businesses have facilitated the expansion of medical insurance and the delivery of affordable care. However, the structure and recent developments in the US business environment have had adverse impacts on healthcare. The business environment is rather unstable and cannot be relied on to offer constant employment (Kaletsky, 2016). In the US, medical insurance is designed such that individuals who are employed gain access to employer-funded insurance schemes. Instabilities in employment mean that interruptions arise in private insurance. If the US is to deliver medical insurance to the millions who are still uncovered, it needs to improve the business environment. The economy should be strong enough to support full employment and encourage investment. As it is, the business environment is simply too volatile and unstable to facilitate private insurance satisfactorily.
Cost Containment and Role of the Nurse
The US appears to have all the resources and expertise needed to deliver quality and affordable care. Yet, the nation continues to struggle with high cost of care. Other developed nations have leveraged their economic strength to provide their people with medical services which enhance their health. For the US to rise to the level of these nations, it needs to implement reforms. Cost containment should be the primary objective of the reforms. The medical community should lead the implementation of these reforms. Refraining from delivering care that is unnecessary and which offers little benefit is among the measures that can be instituted. Unnecessary services account for a significant portion of the cost of care in the US (Walker, 2015). Adopting models which help to reduce the cost of care is another measure that the medical community should implement. The ACO model is among the frameworks which have proven effective in reducing the cost of care. By applying this model, practitioners and institutions are incentivized to deliver quality care at low cost. The task of containing the cost of care cannot be left to medical practitioners. Such other stakeholders as legislators also have roles to play. Legislators need to increase funding for such programs as Medicare and Medicaid. While these programs do not necessarily seek to keep the cost of care low, they make medical services affordable.
In the discussion above, medical practitioners have been identified as the parties who should be in the fore front of the implementation of measures designed to minimize healthcare costs. While the entire medical community has a role to play, nurses are particularly needed to ensure that the cost containment initiative yields success. There are numerous roles that nurses can and should play. Having discussions with patients regarding unnecessary services is among the roles that nurses have (Walker, 2015). Nurses are also expected to understand applicable laws and healthcare policies. They need to give special focus to policies and guidelines which affect such issues as deductibles and co-payments (Dzubak, n.d). If they are unable to contain costs, nurses should at least strive to offer the best possible quality of care.
In conclusion, the US continues to face serious hurdles in its quest to protect the health of its people. While other developed nations have managed to offer universal coverage and quality care to their people, millions of Americans remain without insurance cover and are therefore unable to access quality care. There is no question that the US needs to institute reforms urgently. Focus should be given to building the economy and supporting businesses. The medical community should also participate in this initiative. Nurses should be actively involved since they hold the key to transforming healthcare in the US.
References
Adebayo, E. F., Uthman, O. A., Wiysonge, C. S., Stern, E. A., Lamont, K. T., & Ataguba,J. E. (2015). A systematic review of factors that affect uptake of community-based health insurance in low-income and middle income countries. BMC Health Service Research. DOI: 10.1186/s12913-015-1179-3
Butler, M. (2017). Money troubles: changing reimbursement models shake up physician andOutpatient healthcare industry. Journal of AHIMA, 88 (9), 14-17.
Dzubak, J. (n.d). Healthcare today: a review of reform, and how it impacts nurses. Ohio Nurses Review, 93 (1), 6-7.
Kaletsky, A. (2016). What volatile markets say about the world economy. The Guardian.Retrieved June 16, 2018 from
https://www.theguardian.com/business/2016/feb/01/what-volatile-markets-say-about-the-world-economy
Walker, S. (2015). As healthcare costs continue to rise, providers weigh care’s expense And effect. ONS Connect, p. 57.
