efr ch13 ethicsinternational_sr2.4

Copyright © Springer Publishing Company, LLC. All Rights Reserved.

CHAPTER 13: ETHICAL ISSUES AND INTERNATIONAL HEALTH CARE SYSTEMS• Analyze a current health care concern using the

ethical principles of autonomy, justice, beneficence, and nonmaleficence

• Explain how nurses can avoid the risk of at least two types of health care fraud

• Compare the health care financing of one other country to the U.S. health care system

• Summarize at least three concerns shared by many countries in the world related to health care quality, access, and costs

1


PRINCIPLES OF BIOETHICS

• Autonomy: The right of individuals to make their own decisions about their care

• Justice: Equal or fair distribution of health care benefits and risks

• Beneficence: Health providers must do good and provide the most benefit possible

• Nonmaleficence: Health providers must avoid or minimize harm

2


IS FRAUD A PROBLEM? 2011 UPDATE• Office of the Inspector General: 92% of U.S.

nursing facilities employ at least one person with a criminal conviction

• CMS estimates FY 2010 improper payments for Medicare fee-for-service and Medicare Advantage of almost $48 billion, 9.4% of the estimated total $509 billion spending– This does not include the Medicare D drug

program

3


FINANCIAL FRAUD• Intentional deception or misrepresentation designed to obtain

something of value held by another

• 1996 Health Insurance Portability & Accountability Act (HIPAA): health care fraud is knowingly and willingly executing, or attempting to execute, a scheme to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money owned by, or under custody or control of, any health care benefit program

• Includes filing false claims, offering and receiving kickbacks, and other schemes to divert money from the government

• Medicare and Medicaid are frequent targets of fraud

4


FINANCIAL ABUSE• Often difficult to distinguish from fraud• Methods or practices that are unnecessarily

costly, improper, or at odds with customary practice

• Exploitation of vulnerable clients such as the elderly by family, caregivers, or criminals

• Example: neglect of nursing home patients; phone solicitation offering cash giveaway in exchange for cash outlay

5


FRAUDULENT PRACTICES

• Billing for services not rendered • Misrepresenting the diagnosis to justify

payment (DRG upcoding)• Soliciting, offering, or receiving inducements

to influence future purchases (kickbacks)• Billing for separate parts of a single procedure

(unbundling) • Falsifying documents to justify payment

6


MORE FRAUDULENT PRACTICES• Providing services more often than indicated

(over-utilization or “churning”) • Billing for unnecessary services • Making single visits while billing for multiple visits • Exhausting insurance benefits for one family

member then billing for another (looping) • Falsifying the credentials of a provider to bill at a

higher rate (phantom billing) • Billing Medicare and a private insurer for the

same treatment or procedure (double billing) 7


8

Type of System PluralisticNational Health

InsuranceNational Health

Service

Principal Features

Some uninsured citizens and foreign residents; government and non-government providers; multiple government and non-government funding streams

Universal coverage; government and non-government providers; often national and provincial budgets

Universal coverage; largely government providers; funding largely government with some self-pay

Typical Problems

Uninsured populations

Health care rationing

Health care rationing

Examples of Countries

United States Canada, Japan, many European nations

Great Britain

Source: Adapted from V.G. Rodwin, in Kovner & Jonas, 1999.


U.S. HEALTH CARE PERFORMANCECompared to other industrialized countries:•Proportion of elderly and rate of health care employment is not the highest—these would account for higher health care costs•% GDP for health care expenditures is the highest•Per capita health care expenditures are the highest

9


DISPARITIES IN GLOBAL HEALTH CARE FINANCING “Low- and middle-income countries account for only 18% of world income and 11% of global health spending. Yet 84% of the world’s population live in these countries and they bear 93% of the world’s disease burden.”

WHO, The World Health Report 2000, pg. 7

10


APPROACHES TO HEALTH CARE RATIONING

11

ApproachStrict controls limiting the health

care budgetControls based on specific

priorities Target Does not target specific diseases or

interventionsOften provides an affordable "basic" or "essential" package of interventions

Principal Features

Most common approach; most frequently used in countries with national health budgets

Social, political, and cost-effectiveness criteria used to determine priorities

Typical Problems

Resources managed according to politics, often favoring the higher income citizens at the expense of the poor

Providers respond to demand for services outside the approved package; limitations to cost-effectiveness criteria

Examples of Countries

Pre-1990 National Health System in the United Kingdom, some European Union countries, some developing nations

The Netherlands, New Zealand, Norway, Sweden, Oregon (U.S.), Mexico, Bangladesh, Columbia, Zambia

Source: Adapted from WHO, World Health Report 2000.


SOME GLOBAL HEALTH CONCERNS• Shortage of nurses and other health care

professionals• Aging populations• Quality of health care services and patient

satisfaction • Economic downturn• Medical tourism

12


HEALTHSPROCKET AUGUST 10, 2012• Ranking of Selected Countries by % of Patients Rating Their Doctor 9 or 10 (1-10 scale)

• Top Ten Countries with Most Hospital Beds per 10,000 Population

• Top Ten Countries with Most Physicians per 10,000 Population

• Top 25 countries with the world's best healthcare systems

• The US ranks at the bottom of 19 industrialized countries in preventable deaths

• How the Performance of the U.S. Health Care System Compares Internationally

• Six Country Comparison: Hospital Satisfaction Level

• Six Country Comparison: Consumers Rating Their Health System Failing

• Six Country Comparison: Consumers Rating Their Health System Excellent

• Six Country Comparison: Public Health Care Spending % of Total Health Expenditure

• Health Expenditures per Capita - Seven Selected Countries

• Commonwealth Fund Overall Quality Ranking of Seven Nations' Healthcare Systems

13

efr ch13 ethicsinternational_sr2.4

Documents

health care expenditures

health care financing

health providers

current health care

higher health care costs

care justice

world health report

rate of health careemployment